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.     

‘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.     

A pattern of post-traumatic demineralization of bone simulating permeative neoplastic replacement: A potential source of misinterpretation

Long bones with a prominent endosteal trabecular pattern, particularly the herringbone configuration, when immobilized, will demineralize in a striking spotty pattern which may simulate neoplastic permeative replacement of bone. The recognition of this phenomenon will obviate needless concern and investigation.     

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.     

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.     

Cerebrovascular doppler examination and cerebral angiography-alternative or complementary?

Summary Obstructions in the extracranial cerebral arteries can be detected noninvasively by directional Doppler ultrasound technique using indirect and direct criteria. The indirect criteria are based on measurement of flow in the common carotid and in the terminal branches of the ophthalmic artery before and after the common carotid artery and branches of the external carotid artery are compressed. With the direct criteria, internal and external carotid artery are differentiated by diastolic flow, and local inhomogeneities of flow (turbulence) are detected. Flow in the vertebral artery is picked up transorally in the oropharynx. The Doppler examination was used in 2230 patients of whom 436 underwent angiography. The results of Doppler and angiography correlated in more than 90% of the cases.     

A nationwide system for computer recording of neuroradiologic examinations

Summary For 2 years the system of recording radiologic examinations connected with the computer called SYBAR has been in operation. The examination methods are coded using the Index of Roentgen Examinations of the Swedish National Medical Board (1970), while the diagnoses are coded according to [4]. The positive experience accumulated so far prompted the authors to project and put in operation the system NEUROSYBAR in order to organize a bank of data of neuroradiologic examinations. This system required the widening of two anatomic fields, skull and contents and spine and contents, according to the Index for Roentgen Diagnoses of the American College of Radiology [1]. The NEURO-SYBAR system was adopted by ten radiologic departments in the country. The complete neuroradiologic data from these departments were collected in one computer center in Lodz.     

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     

Unexpected differences in early thyroidal trapping of iodide and pertechnetate

Compartmental analysis was applied to simultaneously acquired ¹³²I-iodide and ^99mTc-pertechnetate thyroid uptake data. The method allowed for arterio/venous differences in plasma tracer level and for an instantaneous phase of thyroid uptake.Observations in four thyrotoxic patients, before and during antithyroid drug therapy, revealed greater instantaneous uptake of TcO ₄ ^- . The results also revealed that instantaneous uptake of both I^– and TcO ₄ ^– may increase over the first six months of drug therapy. These findings could not be explained by the estimates of unidirectional clearance which were greater for I^- and varied little during the early stages of drug therapy.     

Dose to patients through nuclear medicine procedures in a department in northern Greece

Diagnostic nuclear medicine procedures in a large hospital in northern Greece during 1984–1988 have been surveyed in order to estimate the radiation burden to the patients. The mean effective dose equivalent (EDE) was found to be 1.96 mSv/examination and 2.46 mSv/patient, allowing for the fact that a number of patients underwent more than one examination. Apart from EDE, absorbed dose has been calculated for bone marrow, thyroid, gonads, kidneys and bladder. Patients undergoing multiple examinations have been used to calculate true patient dose distribution as well as patient time-weighted dose distribution. Because of the predominance of renal examinations, 8.5 fatal renal malignancies are expected per 100000 patients.     

The vascular ‘sunburst’ appearance of osteosarcoma: A new angiographic finding

The angiographic analogue of the sunburst, (right angle) periosteal new bone formation in osteogenic sarcoma is described. The angiographic findings in this tumor and their relationship to the pathologic appearance are discussed.     

Reliability of a criterion-based test of athletes with knee injuries; where the physiotherapist and the patient independently and simultaneously assess the patient’s performance

A new criterion-based evaluation test method, has been developed in order to assess the functional ability of athletes with knee injuries, Tests for Athletes with Knee-injuries (TAK). The physiotherapist and the patient assess independently and simultaneously the patients performance. The TAK comprises eight demanding functional activities with emphasis on strength, stability, springiness and endurance. Objectives: To evaluate the inter-rater and intra-rater reliability of TAK between the physiotherapists and the patients assessments. Further, to evaluate the relation between the functional tests in TAK and the isokinetic quadriceps muscle strength. Materials and methods: Fifty-nine subjects were included in the study. Thirty-one were anterior cruciate ligament (ACL) reconstructed, fourteen were ACL-injured not reconstructed and fourteen were healthy athletes. The inter-rater-reliability was evaluated by assessments of 59 subjects carried out by two independent physiotherapists using visual observation. The assessment was rated on a 0–10-point scale according to five elaborate criteria drawn up for each test. Simultaneously, the subjects were asked to rate their own performance on each test using a 0–10-point scale. The intra-rater-reliability of TAK was evaluated by a test–retest of 31 patients. The relation between the physiotherapists and the patients ratings as well as of the patients ratings at two different occasions were evaluated. Isokinetic quadriceps muscle strength was measured in a Biodex dynamometer on all 59 subjects in order to study the relation between quadriceps muscle strength and the results of the functional tests in TAK. Results: Inter-rater-reliability showed good consistency between the assessments of the two physiotherapists in seven of eight tests ( = 0.62–0.78). The intra-rater-reliability was moderate to good ( = 0.43–0.65) in the test–retest study. The consistency of the physiotherapist and the patients assessments differed, but showed good correlation. The consistency of the test–retest study of the patients assessment was low. The correlation between the isokinetic quadriceps muscle strength measured in a Biodex dynamometer and the results of the functional tests was moderate in this study. Conclusions: This criterion-based test method for athletes with knee injuries showed good inter-rater reliability and acceptable intra-rater reliability for the physiotherapists assessment. The consistency of the patients ratings was low. The correlation between isokinetic quadriceps muscle strength and functional tests in TAK was moderate. The validity has not been evaluated in this study but will be done in the future.     

Scintigraphic visualisation of Walker carcinoma-256 in Sprague-Dawley rats by means of 99mTc-labelled monocytes

Labelled macrophages accumulate in Walker carcinosarcoma-256 after in vivo and in vitro stimulation with a lectin and are theretically suitable for scintigraphic tumour detection. At present, routine application of the technique in man is precluded by: (1) the use of PHA, and (2) a labelling method for macrophages with considerable limitations to its application and which results in significant uptake of activity in liver and spleen. However, the purpose of the study was primarily to demonstrate the principle of a possible alternative to the use of labelled monoclonal antibodies for the scintigraphic detection of tumours.     

‘Cold spot’ on bone scan at the site of primary osteosarcoma

A 5-year-old girl presented with a rapidly growing osteosarcoma of the proximal right tibia. The radiographically osteoblastic lesions appeared as a cold on the ^99mTc-MDP bone scan. Possible explantations for this unusual finding on the bone scan are discuessed.     

‘Variant’ angina: Evidence for small vessel coronary artery spasm?

A unique case of variant angina pectoris has been observed in a patient with normal coronary arteries and typical chest pain appearing spontaneously at rest, and repeatedly provoked by ergonovine maleate (0.1 mg iv) associated with large transmural perfusion defects on ²⁰¹Tl-imaging (after ergonovine) and a marked increase in T wave voltage despite no demonstrable spasm of a major coronary artery after the same doses of ergonovine. While saline solution could not provoke chest pain and treatment with a beta-blocking agent increased the frequency of ischemic attacks, a calcium antagonist therapy reduced and eventually eliminated the attacks. Thus, this case provides evidence for yet another aspect of a variant form of angina pectoris: small vessel coronary artery spasm.     

An unusual bone change in acromegaly

A case of acromegaly is reported showing a layer of bone capping the humeral and femoral heads apparently as the result of new bone formation by the articular cartilage.     

Dystrophic intracranial calcification: CT evidence of ‘cerebral steal’ from arteriovenous malformation

Summary Two cases of dystrophic intracranial calcification due to arteriovenous malformations (AVM) are reported. The characteristic distribution is in the watershed areas and away from the AVM. Deposition of calcium on ischaemic brain tissues as a result of cerebral steal by the AVM is the probable pathogenetic mechanism.     

A new method of STR interpretation using inferential logic -development of a criminal intelligence database

Abstract A short tandem repeat (STR) system consisting of seven multiplexed loci has recently been introduced in the UK to support a National strategy to create large DNA databases for criminal intelligence purposes. The process uses automated sequencers, employing dye-labelled primers. Identification of tetrameric loci such as HUMTH01 are straightforward. Sizing windows are estimated by running a series of control allelic ladders on several gels and unknown samples are designated if they fall within a defined window. However, utilisation of complex STRs (eg. D21 S 11) characteristically have common variants which differ by just 2 bp. In addition, rare alleles are encountered which may differ by just 1 by from a common variant. To assist with the identification of alleles, we have introduced a series of allelic ladders, so that direct comparisons with unknown samples can be made on the same gel. To designate an allele, it should be within 0.5 by of an allelic ladder marker. Not all alleles (in particular rare alleles) can be included within an allelic ladder, however their expected positions can be easily calculated by reference to existing alleles in the ladder. Measurement of band shift is also a useful diagnostic tool. A series of guidelines are described to enable reliable allelic identification. These guidelines can be converted into computer programmes, which form the basis of an expert system.     

A new method for quantification of image distortion due to pile-up in scintillation cameras

Characterization of the count-rate performance of scintillation cameras should include not only the specification of count losses. At high count rates, there is also an image distortion due to the mispositioning of pile-up events. In this paper a simple and clinically relevant procedure to quantify this distortion is presented. The images of a square uniform technetium-99m phantom at high and low count rates are used. The fraction of the total counts being correctly positioned is determined as the peripheral count density divided by the total average count density. This ratio, corrected for the camera non-uniformity at low count rates, is called the positioning ability. According to the National Electrical Manufacturers' Association (NEMA), the system count rate performance with scatter should be reported as the measured count rate giving 20% count losses. In this paper it is suggested that this measure be complemented by a measure of the fraction correct positioned events at this count rate. This fraction, the high count rate positioning ability', can be easily and accurately measured using our method. The method has been tested on two different scintillation cameras. For one of them the high count rate positioning ability was determined as 91% at a measured count rate of 30000 s^–1 with 20% count losses. For the other camera, the corresponding figures were 88% at 59000 s^–1 and close to 100% at 38000 s^–1, before and after the installation of a new pile-up rejection circuit, respectively. Offprint requests to: C. Ceberg     

Design and application of finite impulse response digital filters

The finite impulse response (FIR) digital filter is a spatial domain filter with a frequency domain representation. The theory of the FIR filter is presented and techniques are described for designing FIR filters with known frequency response characteristics. Rational design principles are emphasized based on characterization of the imaging system using the modulation transfer function and physical properties of the imaged objects. Bandpass, Wiener, and low-pass filters were designed and applied to ²⁰¹T1 myocardial images. The bandpass filter eliminates low-frequency image components that represent background activity and high-frequency components due to noise. The Wiener, or minimum mean square error filter sharpens the image while also reducing noise. The Wiener filter illustrates the power of the FIR technique to design filters with any desired frequency reponse. The lowpass filter, while of relative limited use, is presented to compare it with a popular elementary smoothing filter.This study was supported in part by National Institutes of Health Grants No. HL17646 and HL13851.