Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia

To evaluate the level of concurrence between radiologist reports and the diagnosis of community-acquired pneumonia (CAP) in patients discharged from an emergency department (ED), a retrospective chart audit of patients discharged with a diagnosis of pneumonia or possible pneumonia from the ED during a 2-year period was conducted. Emergency physician (EP) and radiology report (RR) diagnoses were categorized as pneumonia, possible pneumonia, non-pneumonia and normal, and categories from each were compared. 815 charts were analyzed. Of 671 EP diagnoses of pneumonia, 304 (45.3%) RRs reported pneumonia and 82 (12.2%), possible pneumonia. Of 815 EP diagnoses of pneumonia or possible pneumonia, 426 (52.3%) RRs were in agreement, while 216(26.5%) were of diagnoses other than pneumonia and 173 (21.1%) were read as normal. EPs and radiologists frequently disagree on whether a patient has pneumonia or not. Perhaps it is time to revisit the gold standard status of plain chest X-ray.Presented at the 9th International Conference of Emergency Medicine, Edinburgh, Scotland, 17–21 June, 2002.     

Technical parameters influencing the severity of injury of front-seat,belt-protected car passengers on the impact side in car-to-car side collisions with the main impact between the front and rear seats (B-pillars)

Summary Authentic car-to-car side collisions (n = 30) with the main impact area at the B-pillar were analyzed to find technical parameters corresponding with the injury severities of the front seat, belt-protected car passengers on the impact side. EES (Energy Equivalent Speed) and Av (delta v, change in velocity) were highly significant predictors of the severity of thoracic and abdominal injuries and total injury severity coded according to the Abbreviated Injury Scale (AIS). At an EES or v 40 km/h all front-seat car passengers on the impact side sustained a total injury severity of Maximum AIS (MAIS) 4 and died. Although a passenger could survive the crash without injury to one or more body regions up to the highest EES- and Av-values, at EES or v 40 km/h fatal injuries were sustained in at least one body region. At an EES 35 km/h or a Av 15 km/h no front-seat car passenger on the impact side remained uninjured.     

Evaluation of knee ligament injuries with the IKDC form

Various scoring systems have been proposed to quantify the disability caused by knee ligament injuries and to evaluate the results of treatment. None of these systems has found worldwide acceptance, mainly because all scoring systems attribute numerical values to factors that are not quantifiable, and then the arbitrary scores are added together for parameters not comparable with each other. For these reasons a group of knee surgeons from Europe and America met in 1987 and founded the International Knee Documentation Committee (1KDC). A common terminology and an evaluation form was created. This form is the standard form for all publications on results of treatment of knee ligament injuries. It is a concise one-page form. It includes a documentation section, a qualification section and a evaluation section. For evaluation there are four problem areas (subjective assessment, symptoms, range of motion and ligament examination). These are supplemented with four additional areas that are only documented but not included in the evaluation (compartmental findings, donor site pathology, X-ray findings and functional tests). The form can be used pre- and postoperatively and at follow-up. It has been specified that in any publication the minimum follow-up time for shortterm results should be 2 years, for medium-term results 5 years and for long-term results 10 years. The largest part of the sheet is the qualification section. It is called qualification section rather than scoring section because no scores are given. Each parameter is qualified as normal, nearly normal, abnormal or severely abnormal. This qualification is less subjective and emotional than very good, good, fair and poor. No knee and no knee function can be better than normal, and it is rather doubtful whether any knee, once operated on, can ever be normal again. For evaluation, the parameters of the four problem ares subjective assessment, symptoms, range of motion and ligament examination, are qualified for the group qualification. The worst qualification within the group gives the group qualification. The worst group qualification gives the final evaluation. If the knee is abnormal in any of the problem areas, it cannot be a normal knee. For chronic knee conditions there is also the possibility of evaluating the sum of levels of improvement or deterioration of all groups compared with the preoperative evaluation. The committee also recommends that terms describing knee ligament problems should be used according to the definitions of Noyes et al. [32]. The use of the IKDC evaluation form will reveal less favourable results than those evaluated with other current evaluation forms, because a still existing knee problem cannot be hidden with a high numerical score that is added up from other, unrelated parameters. It is to be hoped, however, that the use of this new form will enable us to compare treatment methods in various publications with each other.     

Three-dimensional display of myocardial perfusion detection of ischemic lesions using a new image subtraction method

A recent, commercially available computer program for the three-dimensional (3D) display of single-photon emission tomography (SPET) data was used to study myocardial perfusion in patients with coronary artery disease (CAD). To enable the detection of small ischemic lesions, the authors proposed a new distance-subtraction method: after suitable centering of the axial slices, 3D distance-shaded images of the stress study were subtracted from the corresponding views of the rest study. With this technique, small changes in surface-to-observer distance were highlighted, thus enabling us to detect nontransmural ischemic areas of the myocardium. General characteristics and possibilities of the subtraction technique were tested on a simple myocardial phantom. Some clinical results of the application of this method on CAD patients are presented and discussed. In CAD patients in whom only nontransmural ischemic lesions are present, the subtraction of distance-shaded images is decisive for a correct diagnosis.     

Disco-vertebral destructive lesions (So-called Andersson Lesions) associated with ankylosing spondylitis

Radiological examination of 31 patients with established ankylosing spondylitis revealed 58 disco-vertebral destructive lesions. Careful assessment of their radiological features permitted differentiation into two main types, (1) inflammatory and (2) non-inflammatory. The inflammatory type may represent either an active inflammatory process or a late sequel to such a lesion. In this series 44 lesions were included in this category, with a marked predilection for the lumbar spine. Moreover, all were observed within the first decade following the onset of the disease.The non-inflammatory type reflects an attempt of a stress fracture in the diseased spinal column to repair by connective tissue, causing a pseudoarthrosis. Eleven such lesions were obseved in this series all occurring more than 12 years after the onset of the disease. In a much smaller group of three cases-here termed the ambivalent type — differentiation between the inflammatory and non-inflammatory types could not be established on radiological grounds alone. It is of interest that all three cases occurred within the first year after the onset of the disease.It is suggested that the term Andersson lesion should be used to include all disco-vertebral destructive lesions related to ankylosing spondylitis—be they of inflammatory or non-inflammatory pathogenesis —as the better known term Romanus lesion includes all types of circumscribed marginal destructive lesions of vertebral bodies without involvement of the disc in ankylosing spondylitis.     

Positive 131Cesium scanning in parathyroid adenoma

In a case of primary hyperparathyroidism, a palpable nodule, at the base of the right lobe of the thyroid, proved cool during ^99mTc scanning, but hot when scanned with radiocesium. The uptake of this tracer was higher than the uptake of ⁷⁵Se-selenomethionine after suppression with T₃.The authors discuss the possibility of cases of false-positive radiocesium uptake in extrathyroid nodules, and in particular, the use of this tracer for the detection of parathyroid adenoma by scanning.     

Genetic polymorphism of Alpha-2-HS glycoprotein in Lombardy (Italy)

Summary 2HS-subtypes have been analysed in samples from 700 unrelated individuals from the Brescia area (Italy) by the isoelectric focusing technique and immunofixation. The observed allele frequencies were: 2HS*1= 0.7472; 2HS*2 = 0.2507; 2HS*V = 0.0021.     

Zur Interpretation von postmortalen Digoxinspiegeln: Überprüfung eines „Korrekturfaktors“ für postmortal gemessene Digoxinkonzentrationen im Blut

Zusammenfassung Die Interpretation von postmortalen Serumdigoxinspiegeln wird vor allem dadurch erschwert, daß mit einem präfinalen and postmortalen Anstieg der Digoxinkonzentration im Blut zu rechnen ist. Eriksson et al. (1984) dividierten die postmortal gemessenen Digoxinspiegel im Femoralvenenblut durch 1,5, um den postmortalen Anstieg des Serumdigoxinspiegels zu berüicksichtigen; nach Meinung dieser Autoren weisen postmortale Serumdigoxinspiegel, die nach Division durch 1,5 noch über dem therapeutischen Bereich liegen, auf eine Digoxinüberdosierung hin. Der diagnostische Wert des von Eriksson et al. (1984) vorgeschlagenen Korrekturfaktors wurde überprüft. In 56 Fällen mit dokumentierter Digoxin-Medikation wurde postmortal Femoralvenenblut asserviert und eine Serumdigoxinspiegelbestimmung durchgeführt. In keinem der untersuchten Fälle war klinisch eine Digoxin-Intoxikation diagnostiziert worden. 50% der gemessenen Werte lager oberhalb des therapeutischen Bereichs (0,7 ng/ml bis 2,2 ng/ml). Nach Division der gemessenen Werte durch 1,5 lagen noch immer ca. 20% über 2,2 ng/ml, der höchste korrigierte Wert betrug 4,44 ng/ml. Unter Berücksichtigung des Zeitraums zwischen letzter Gabe und Tod, der individuell unterschiedlichen Digitalisglykosidempfindlichkeit sowie der Komplexität präfinaler und postmortaler Verteilungsvorgänge wurde für unser Untersuchungskollektiv festgestellt, daß eine (unerkannte) Digoxinüberdosierung auch darn nicht wahrscheinlich war, wenn der postmortale Wert nach Division durch 1,5 noch über dem therapeutischen Bereich lag. Der vor Eriksson et al. (1984) vorgeschlagene Korrekturfaktor ist nur vor begrenztem diagnostischem Wert; die korrigierten Werte können allenfalls einen Hinweis darauf geben, in welchem Bereich sich die entsprechende antemortale Serumdigoxinkonzentration bewegt haben könnte. Vor allem korrigierte Werte, die nur wenig über dem therapeutischen Bereich liegen, können den Verdacht auf eine Digoxinüberdosierung nicht mit ausreichender Sicherheit stützen.Ausführliche Darstellung siehe Dissertation St. Ritz, Kiel, Dissertation eingereicht Sonderdruckanfragen an: S. Ritz     

Usefulness of <Superscript>123</Superscript>I-metaiodobenzylguanidine myocardial scintigraphy for predicting the effectiveness of β-blockers in patients with dilated cardiomyopathy from the standpoint of long-term prognosis

Purpose The usefulness of ¹²³I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy in predicting the effectiveness of -blocker therapy in dilated cardiomyopathy (DCM) was investigated from the standpoint of long-term prognosis.Methods The subjects were 53 DCM patients in whom -blockers had been successfully introduced and used for 6 months or longer. When symptoms were stable before the introduction of -blockers and for up to 1 year thereafter, MIBG myocardial single-photon emission computed tomography was performed and the images analysed to obtain the extent score (EXT), severity score (SEV) and washout rate (WR). At the same time, echocardiography was performed to measure left ventricular ejection fraction (LVEF). Thereafter, patients were placed under observation for an average of 1,314±986 days, with the occurrence of cardiac events as the endpoint.Results The degree of improvement in WR after introduction of -blockers was a significant predictor of cardiac events. In fact, none of the patients whose improvement in WR was valued at 10 or higher had cardiac events. Accordingly, using improvement in WR of 10 as the cut-off value, the patients were divided into two groups, improved and unimproved. There were significant differences between the groups in respect of early EXT, early SEV and WR before the introduction of -blockers . As regards predictors of WR improvement, multivariate logistic regression analysis demonstrated that early EXT, WR and LVEF were significant predictors.Conclusion This study shows that, from the standpoint of long-term prognosis, DCM patients who would benefit the most from -blocker therapy are those with low early EXT and early SEV and high WR before -blocker introduction regardless of LVEF values.     

Sclerotic changes of the manubrium sterni

Six females with nearly identical sclerotic and hyperostotic changes of the manubrium sterni are reported. Malignancies, bacterial inflammatory processes, and Paget disease, which were first suspected, could be excluded. The youngest patients also had sclerotic changes of other bones, including the lumbar spine, the pubic bone, and the clavicle, and may be classified as having chronic recurrent multifocal osteomyelitis (CRMO). The two oldest patients had ossification of the costoclavicular ligament(s) and may be classified as having inter-sterno-costo-clavicular ossification (ISCCO). One had only hyperostotic and sclerotic changes as seen in sterno-costo-clavicular hyperostosis (SCCH). The pathogenesis of these uncommon diseases is unknown, but they are all frequently associated with pustulosis palmoplantaris and have similar clinical courses and laboratory abnormalities. None of the present patients had HLA-B₂₇. The similarity of the radiological abnormalities of the manubrium sterni suggests that the diseases themselves may be similar, but with different courses depending on age, CRMO being present in children and young adults and ISCCO or SCCH in older adults.     

A pragmatic approach to metal artifact reduction in CT: merging of metal artifact reduced images

The purpose of this study was to improve metal artifact reduction (MAR) in X-ray computed tomography (CT) by the combination of two artifact reduction methods. The presented method constitutes an image-based weighted superposition of images processed with two known methods for MAR: linear interpolation of reprojected metal traces (LI) and multi-dimensional adaptive filtering of the raw data (MAF). Two weighting concepts were realized that take into account mean distances of image points from metal objects or additional directional components. Artifact reduction on patient data from the jaw and the hip region shows that although the application of only one of the MAR algorithms can already improve image quality, these methods have specific drawbacks. While MAF does not correct corrupted CT values, LI often introduces secondary artifacts. The corrective impact of the merging algorithm is almost always superior to the application of only one of the methods. The results obtained with directional weighting are equal to or in many cases better than those of the distance weighting scheme. Merging combines the advantages of two fundamentally different approaches to artifact reduction and can improve the quality of images that are affected by metal artifacts.Symbols LI linear interpolation algorithm - MAF multi-dimensional adaptive filtering algorithm - MAR metal artifact reduction - f(x, y) object function at (x, y) - F(), F() normalized filter function in the direction of the coordinates and - I primary X-ray intensity - I₀ transmitted X-ray intensity - N_D number of detectors per detector row - p attenuation - p(,), p(,) projection data (fan and parallel geometry) - p_th lower threshold of the attenuation of adaptive filtering - p_max maximum value of the attenuation of adaptive filtering - (x, y) image point - projection angle in fan geometry - angle within the fan relative to the central ray - , , z, , minimum functions for adaptive filtering - projection angle in parallel geometry - orthogonal distance of a ray to the center of rotation in parallel geometry     

Partial volume summation: A simple approach to ventricular volume determination from CT

Summary The accurate determination of ventricular volume from computed tomography (CT) is not a trivial problem. The direct approach of measuring the area within a visually determined boundary or contour level and multiplying by the nominal slice thickness may be subject to large errors because such boundaries are not, in general, well defined. When the ventricles are filled with a high-contrast material such as metrizamide, we may use the technique of partial volume summation, a simple but accurate, clinically applicable method which may be performed on a standard DeltaScan-50 or similar system.     

Das Problem der a-priori-Wahrscheinlichkeit bei Verwendung der Essen-Möller-Formel zur Berechnung der Vaterschaftswahrscheinlichkeit

Zusammenfassung Die Annahme der a-priori-Wahrscheinlichkeit, daß Nichtväter und wahre Väter gleichhäufig zur Begutachtung gelangen, wird an Hand von 408 Aktenfällen bestätigt.Die Berechnung der Vaterschaftswahrscheinlichkeit bietet, insbesondere bei Mehrverkehrsfällen, wertvolle Hinweise für die Vaterschaft oder Nichtvaterschaft eines Probanden, Hinweise, die durch die Angabe der Vaterschaftsausschlußchance aufgrund der Mutter-Kind-Konstellation nicht erbracht werden können. Auf Beziehungen zwischen der Vaterschaftsausschlußchance und der Vaterschaftswahrscheinlichkeit wird hingewiesen.

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The assumption of prior probability computing the plausibility of paternity by the Essen-Möller equation and its problem

Summary Among objectivists the assumption of firsthand probability, that non-fathers and true-fathers are being given an opinion on with equal frequency, yields to a rejection in calculating the probability of fatherhood according to Essen-Möller. By means of 408 cases it is shown, that this assumption does meet the actual situation. Non-fathers and true-fathers are observed equally frequent. Calculation of fatherhood probability renders a valuable reference to paternity or nonpaternity of a subject in cases of multiple intercourses. These references cannot be brought on by the statement of the exclusion chance of fatherhood based on the mother-child-constellation. The relationship between the exclusion chance and the probability of fatherhood is pointed out.

     

Synchronous development of breast cancer and chest wall fibrosarcoma after previous mantle radiation for Hodgkin’s disease

Survivors of Hodgkins disease are at increased risk of developing a second malignant neoplasm, including breast carcinoma and sarcoma. We report the first case of synchronous development of chest wall fibrosarcoma and breast carcinoma after mantle radiotherapy for Hodgkins disease. Mammographic, sonographic and MR features are demonstrated.     

The value of bone imaging in multiple myeloma

In a series of 20 patients with a proven diagnosis of myeloma, both full radiographic skeletal surveys and full ratio-nuclide bone images were performed. When these were compared, they showed that (i) imaging underestimated the number of areas involved by 50%, but there were no false negative whole images when compared with the radiology, (ii) large lytic areas on X-ray show as cold areas on the bone image but small ones show as normal, (iii) images that show areas of increased uptake (hot) are almost always associated with fracture, and (iv) patients with bone pain very commonly had hot images corresponding to the region of pain.4th year medical student     

Quantification of left ventricular volume in gated equilibrium radioventriculography

We have developed a simple method for measuring left ventricular volume based on semi-automated analysis of 40° left anterior oblique images obtained with a standard scintillation camera after equilibrium of an intravenous injection of 20 mCi of technetium-99m in vivo labeled red blood cells. The essence of the method is the use of the dimensions and radioactivity within a segment of aorta to convert observed left ventricular count rates to volume. Four assumptions were made: 1) the aortic arch is nearly parallel to the collimator face when a patient is in the proper left anterior oblique position; 2) a segment at the top of the aortic arch, approximately 1 cm wide, is a right cylinder, 3) the edges of the aorta can be delineated as the lines where the second derivative of a cross sectional profile equals zero; 4) left ventricular and aortic arch counts undergo the same attenuation because they are nearly the same distance from the chest wall in the proper left anterior oblique position. By measuring the counts and volumes of two regions of known shape, one in the middle, the other at the edge of the aortic arch, and calculating their differences a background-independent volume count ratio (v/C) can be obtained. The left ventricular and diastolic volume (LVEDV) is calculated with the equation: LVEDV=(/C) LVEDC, where LVEDC represents left ventricular end diastolic counts. Twenty-six patients were evaluated by equilibrium radio- and contrast-ventriculography, the latter analyzed by planimetry. The radionuclide method yielded an end diastolic volume that correlated well with contrast ventriculography (r=0.96, Y=0.91 X+21 ml). In addition to its simplicity and objectivity, a major advantage of this method of determining ventricular volume is that it does not require a blood sample.This work was supported in part by USPHS Grant Nos. HL 20674 and GM 10548     

Impact of CT in the neurosurgical management of intracranial tumors

Summary A total of 103 brain tumor patients examined with CT, radionuclide brain scan, and angiography or pneumoencephalography, and all surgically verified, were studied to evaluate the impact of CT on the neurosurgical handling of brain tumors. CT alone was usually sufficient for optimal handling of astrocytoma patients, angiography in most meningioma cases, and pneumoencephalography in cases with sellar, suprasellar, and some other midline tumors. Information obtained only through CT sometimes altered the therapy. Sometimes it led to biopsy instead of a meaningless attempt at a radical excision; in other cases it permitted a radical excision otherwise not possible.     

ω-123I-Hexadecanoic acid metabolic probe of cardiomypathy

The utility of -¹²³I-hexadecanoic acid myocardial scintigraphy as a metabolic probe of cardiomyopathies was investigated. Sixteen patients with a variety of cardiomyopathies and myopathies that involve cardiac muscle and ten volunteers were imaged in the postabsorptive state in a 40° LAO projection after a standard dose of -¹²³I-hexadecanoic acid. An elimination T_1/2 was calculated from the left ventricular myocardial time-activity curve. An uptake index, corrected for chest wall attenuation, was also computed in 7 of 10 volunteers and 8 of 16 patients.Of the 16 patients, only 2 had distinctly abnormal -¹²³I-hexadecanoic acid myocardial tracer kinetics. The first patient had a metabolic disorder of which cartine deficiency was one component. The second patient had endocardial fibroelastosis, a process which has been linked to disorders which deprive the myocardium of oxygen and energy. Therefore, the cardiomyopathy may have been caused by some abnormality of cardiac metabolism other than carnitine deficiency. Although of limited utility in the overall cardiomyopathic population, -¹²³I-hexadecanoic acid myocardial scintigraphy should be further investigated as a screening test for carnitine deficiency and related metabolic abnormalities in patients at risk.Supported by a Canadian Heart Foundation Research FellowshipSupported by an Australian Heart Foundation Travel Grant     

A simple method for the quantification of benzodiazepine receptors using iodine-123 iomazenil and single-photon emission tomography

Iodine-123 iomazenil (Iomazenil) is a ligand for central type benzodiazepine receptors that is suitable for single-photon emission tomography (SPET). The purpose of this study was to develop a simple method for the quantification of its binding potential (BP). The method is based on a two-compartment model (K ₁, influx rate constant;k ₂, efflux rate constant;V _T (=K ₁/k ₂), the total distribution volumes relative to the total arterial tracer concentration), and requires two SPET scans and one blood sampling. For a given input function, the radioactivity ratio of the early to delayed scans can be considered to tabulate as a function ofk ₂, and a table lookup procedure provides the correspondingk ₂ value, from whichK ₁ andV _T values are then calculated. The arterial input function is obtained by calibration of the standard input function by the single blood sampling. SPET studies were performed on 14 patients with cerebrovascular diseases, dementia or brain tumours (mean age±SD, 56.0±12.2). None of the patients had any heart, renal or liver disease. A dynamic SPET scan was performed following intravenous bolus injection of Iomazenil. A static SPET scan was performed at 180 min after injection. Frequent blood sampling from the brachial artery was performed on all subjects for determination of the arterial input function. Two-compartment model analysis was validated for calculation of theV _T value of Iomazenil. Good correlations were observed betweenV _T values calculated by three-compartment model analysis and those calculated by the present method, in which the scan time combinations (early scan/delayed scan) used were 15/180 min, 30/180 min or 45/180 min (all combinations:r=0.92), supporting the validity of this method. The present method is simple and applicable for clinical use.     

‘Hot’ and ‘cold’ lesions detected by gallium-67 scintigraphy in a pyogenic liver abscess

Most pyogenic liver abscesses appear to be not in a ⁶⁷Ga-citrate study; rarely, a warm or cold area may also be seen. We present a patient with a pyogenic liver abscess that had both cold and hot areas in the ⁶⁷Ga-citrate study. This striking finding is probably related to the different stages of evolution of the abscess.