Dual-Energy Parathyroid 4D-CT: Improved Discrimination of Parathyroid Lesions from Thyroid Tissue Using Noncontrast 40-keV Virtual Monoenergetic Images.

BACKGROUND AND PURPOSE: In parathyroid CT, a noncontrast phase aids discrimination of parathyroid lesions (not iodine-containing) from thyroid tissue (iodine-containing). When thyroid iodine is pathologically diminished, this differentiation is difficult with standard CT. Because the attenuation of an element is maximal near its K-edge (iodine = 33.2 keV), we hypothesized that dual-energy CT 40-keV virtual monoenergetic images will accentuate thyroid iodine relative to standard images, improving the differentiation of thyroid from parathyroid lesions. Our purpose was to test this hypothesis through quantitative assessment of Hounsfield unit attenuation and contrast-to-noise on dual-energy CT standard (70-keV) and 40-keV noncontrast images. MATERIALS AND METHODS: For this retrospective study including 20 dual-energy parathyroid CTs, we used an ROI-based analysis to assess the attenuation of thyroid tissue, parathyroid lesions, and sternocleidomastoid muscle as well as corresponding contrast-to-noise on standard and 40- keV noncontrast images. Wilcoxon signed rank tests were performed to compare differences between 70 and 40 keV. RESULTS: Absolute and percentage increases in attenuation at 40 keV were significantly greater for thyroid gland than for parathyroid lesions and sternocleidomastoid muscle (P < .001 for all). Significant increases in the contrast-to-noise of thyroid relative to parathyroid lesions (median increase, 0.8; P < .001) and relative to sternocleidomastoid muscle (median increase, 1.3; P < .001) were observed at 40 keV relative to 70 keV. CONCLUSIONS: Forty-kiloelectron volt virtual monoenergetic images facilitate discrimination of parathyroid lesions from thyroid tissue by significantly increasing thyroid attenuation and associated contrast-to-noise. These findings are particularly relevant for parathyroid lesions that exhibit isoattenuation to the thyroid on parathyroid CT arterial and venous phases and could, therefore, be missed without the noncontrast phase.

Can Assessment of the Tongue on Brain MRI Aid Differentiation of Seizure from Alternative Causes of Transient Loss of Consciousness?

BACKGROUND AND PURPOSE: Transient loss of consciousness is commonly evaluated in the emergency department. Although typically caused by epileptic seizure, syncope, or psychogenic nonepileptic seizure, the underlying etiology is frequently misdiagnosed. Lateral tongue bites are reportedly a specific clinical finding of seizure. We have observed tongue signal abnormality suggesting bite injury on brain MR imaging after seizures. We hypothesized an association between tongue signal abnormality and seizure diagnosis among patients in the emergency department imaged for transient loss of consciousness. Our purposes were to determine the prevalence of tongue signal abnormality among this population and the predictive performance for seizure diagnosis. MATERIALS AND METHODS: For this retrospective study including 82 brain MR imaging examinations, 2 readers independently assessed tongue signal abnormality on T2-weighted and T2-weighted FLAIR images. Discrepancies were resolved by consensus, and interrater reliability (Cohen κ) was calculated. The final diagnosis was recorded. Proportions were compared using the Fisher exact test. RESULTS: Tongue signal abnormality was present on 19/82 (23%) MR imaging examinations. Interrater reliability was "substantial" (κ = 0.77). Seizure was diagnosed among 18/19 (95%) patients with tongue signal abnormality and 29/63 (46%) patients without it (P < .001). In our cohort, tongue signal abnormality conveyed 97% specificity, 95% positive predictive value, and 63% accuracy for seizure diagnosis. CONCLUSIONS: Tongue signal abnormality was observed in 23% of the study cohort and conveyed 97% specificity and 95% positive predictive value for seizure diagnosis. By assessing and reporting tongue signal abnormality, radiologists may facilitate a timely and accurate diagnosis of seizure among patients imaged for transient loss of consciousness.

The Pharyngolaryngeal Venous Plexus: A Potential Pitfall in Surveillance Imaging of the Neck.

BACKGROUND AND PURPOSE: Among patients undergoing serial neck CTs, we have observed variability in the appearance of the pharyngolaryngeal venous plexus, which comprises the postcricoid and posterior pharyngeal venous plexuses. We hypothesize changes in plexus appearance from therapeutic neck irradiation. The purposes of this study are to describe the CT appearance of the pharyngolaryngeal venous plexus among 2 groups undergoing serial neck CTs-patients with radiation therapy-treated laryngeal cancer and patients with medically treated lymphoma-and to assess for changes in plexus appearance attributable to radiation therapy. MATERIALS AND METHODS: For this retrospective study of 98 patients (49 in each group), 448 contrast-enhanced neck CTs (222 laryngeal cancer; 226 lymphoma) were assessed. When visible, the plexus anteroposterior diameter was measured, and morphology was categorized. RESULTS: At least 1 plexus component was identified in 36/49 patients with laryngeal cancer and 37/49 patients with lymphoma. There were no statistically significant differences in plexus visibility between the 2 groups. Median anteroposterior diameter was 2.1 mm for the postcricoid venous plexus and 1.6 mm for the posterior pharyngeal venous plexus. The most common morphology was "bilobed" for the postcricoid venous plexus and "linear" for the posterior pharyngeal venous plexus. The pharyngolaryngeal venous plexus and its components were commonly identifiable only on follow-up imaging. CONCLUSIONS: Head and neck radiologists should be familiar with the typical location and variable appearance of the pharyngolaryngeal plexus components so as not to mistake them for neoplasm. Observed variability in plexus appearance is not attributable to radiation therapy.

Internal Auditory Canal Diverticula among Pediatric Patients: Prevalence and Assessment for Hearing Loss and Anatomic Associations.

BACKGROUND AND PURPOSE: Internal auditory canal diverticula are focal lucencies along the anterior-inferior aspect of the internal auditory canal fundus. Studies in adults report conflicting data on the etiology and clinical relevance of this finding. We would expect a pediatric study to help elucidate the significance of internal auditory canal diverticula. The primary goals of this study were to determine the temporal bone CT prevalence of diverticula among pediatric patients and to assess possible hearing loss and anatomic associations. MATERIALS AND METHODS: For this retrospective study including 283 pediatric temporal bone CTs, 4 neuroradiologists independently assessed for diverticula. Discrepancies were resolved by consensus. One neuroradiologist assessed for an enlarged vestibular aqueduct, labyrinthine dysplasia, cochlear cleft, and otospongiosis. Patient demographics, audiologic data, and pertinent clinical history were recorded. One-way analysis of variance and the Fisher exact test were used to assess possible associations between diverticula and specific patient characteristics. RESULTS: Diverticula were observed in 42/283 patients (14.8%) and were more commonly bilateral. There was no significant association with age, sex, hearing loss, enlarged vestibular aqueduct, labyrinthine dysplasia, or cochlear cleft. A statistically significant association was observed with otospongiosis (P = .013), though only 1 study patient had this disease. CONCLUSIONS: Internal auditory canal diverticula are a common finding on pediatric temporal bone CT. In the absence of clinical or imaging evidence for otospongiosis, diverticula likely fall within the range of a normal anatomic variation. Familiarity with these findings may prevent neuroradiologists from recommending unnecessary additional testing in pediatric patients with isolated internal auditory canal diverticula.

Prolapse of Orbital Fat through the Inferior Orbital Fissure: Description, Prevalence, and Assessment of Possible Pathologic Associations.

BACKGROUND AND PURPOSE: A few patterns of orbital fat prolapse have been described. Some are associated with disease, and others may mimic a neoplasm. We have observed prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure on MR imaging. The clinical relevance of this finding, if any, is unknown. The purposes of this study were to describe the MR imaging appearance of orbital fat prolapse through the inferior orbital fissure, to estimate the prevalence of this finding, and to assess possible pathologic associations. MATERIALS AND METHODS: For this retrospective study of 228 orbital MR imaging examinations, 3 neuroradiologists independently assessed the presence of prolapse on high-resolution T1-weighted images. Discrepancies were resolved by consensus, and interobserver agreement was calculated. Patient demographics, indications for imaging, and pertinent clinical history were recorded. One-way analysis of variance and the Fisher exact test were used to assess possible associations between prolapse and specific patient characteristics. RESULTS: Orbital fat prolapse through the inferior orbital fissure was observed in 20/228 patients (9%). This finding was unilateral in 11 patients (55%) and bilateral in 9 patients (45%). There was no significant association with age, sex, obesity, Graves disease, hypercortisolism, prior orbital trauma, proptosis, or enophthalmos. Interobserver agreement was 90%. CONCLUSIONS: Prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure is a relatively common finding on orbital MR imaging that has no identified pathologic association. Neuroradiologists should recognize this finding so as not to report it as pathologic.

Trochlear Groove and Trochlear Cistern: Useful Anatomic Landmarks for Identifying the Tentorial Segment of Cranial Nerve IV on MRI.

BACKGROUND AND PURPOSE: The trochlear groove and trochlear cistern are anatomic landmarks closely associated with the tentorial segment of cranial nerve IV. The purposes of this study were to describe the MR imaging appearances of the trochlear groove and trochlear cistern and to test our hypothesis that knowledge of these anatomic landmarks facilitates identification of cranial nerve IV in routine clinical practice. MATERIALS AND METHODS: For this retrospective study, consecutive MR imaging examinations of the sinuses performed in 25 patients (50 sides) at our institution were reviewed. Patient characteristics and study indications were recorded. Three readers performed independent assessments of trochlear groove, cistern, and nerve visibility on coronal images obtained by using a T2-weighted driven equilibrium radiofrequency reset pulse sequence. RESULTS: Interobserver agreement was 78% for visibility of the trochlear groove, 56% for the trochlear cistern, and 68% for cranial nerve IV. Following consensus review, the trochlear groove was present in 44/50 sides (88%), the trochlear cistern was present in 25/50 sides (50%), and cranial nerve IV was identified in 36/50 sides (72%). When the trochlear groove was present, cranial nerve IV was identified in 35/44 sides (80%), in contrast to 1/6 sides (17%) with no groove (P = .0013). When the trochlear cistern was present, cranial nerve IV was identified in 23/25 sides (92%), in contrast to 13/25 sides (52%) with no cistern (P = .0016). CONCLUSIONS: The trochlear groove and trochlear cistern are anatomic landmarks that facilitate identification of cranial nerve IV in routine clinical practice.

Comparison of the fermentative alcohol dehydrogenases of Salmonella typhimurium and Escherichia coli.

The adhE gene, encoding the fermentative alcohol dehydrogenase, from Salmonella typhimurium (Genbank accession number U68173) was cloned and sequenced. The Salmonella AdhE protein has 619/878 (70%) amino acid residues identical to the AdhE protein of Escherichia coli. Salmonella AdhE was synthesized only anaerobically. It was present in higher amounts when cells were grown on reduced substrates such as sorbitol, instead of glucose. Growth on glucuronate, which generated no net nicotinamide-adenine dinucleotide reduced (NADH) during metabolism, showed the lowest AdhE levels. Analysis of fermentation products by in vivo nuclear magenetic resonance showed that the proportion of ethanol was highest with sorbitol, intermediate with glucose and negligible with glucuronate. The Salmonella enzyme had a lower Michaelis-Menten constant (Km) for alcohol substrates than AdhE of E. coli although both enzymes displayed a similar Km for nicotinamide-adenine dinucleotide (NAD+). Although AdhE of E. coli was inactive with alcohols longer than four carbons, the Salmonella enzyme was still active with alcohols up to eight carbons.

Regulation of the thdF gene, which is involved in thiophene oxidation by Escherichia coli K-12.

The thdF gene of Escherichia coli encodes a 48 kD protein which is involved in the oxidation of derivatives of the sulphur-containing heterocycle thiophene and which appears to be induced during stationary phase. In this work the upstream regulatory region of the thdF gene was isolated by polymerase chain reaction and inserted in front of the lacZ structural gene. Examination of the resulting thdF-lacZ operon fusions showed that expression of the thdF gene increased as E. coli entered the stationary phase. However, the expression of thdF was not dependent on RpoS (KatF), the stationary phase sigma factor. The thdF gene was subject to substantial catabolite repression by glucose and its expression was also greatly decreased in the absence of oxygen. The thdF-lacZ fusions were not significantly affected by elevated temperature or medium of high osmolarity, nor by mutations in thdA, fadR, arcA, arcB, or fnr. Both multicopy, plasmid-borne fusions and single-copy fusions gave similar results in all of the above cases except that the plasmid-borne fusions still showed substantial expression in the absence of oxygen. The heterocyclic compounds thiophene carboxylic acid, furan carboxylic acid and proline increased expression of the thdF gene by 2- to 3-fold, but only during the stationary phase. Tryptophan, indole, and several indole derivatives had no effect.

A pilot study of the anti-CD20 monoclonal antibody rituximab in patients with refractory immune thrombocytopenia.

We conducted a prospective pilot phase I/II clinical trial to evaluate the toxicity and response rate of the chimeric anti-CD20 monoclonal antibody, rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceutical Corporation, San Diego, CA), in the treatment of patients with immune thrombocytopenic purpura. Patients with a clinical diagnosis of idiopathic thrombocytopenic purpura who had failed corticosteroid therapy and whose platelet count was less than 75,000/microL were eligible for the study. Rituximab was administered in a dose-escalation fashion using doses ranging from 50 to 375 mg/m2 weekly for 4 weeks. Thirteen patients have been enrolled on the trial to date and 12 have completed the full course of treatment. No unusual toxicity was noted in this patient population. None of the three patients at the lowest dose level achieved a clinical response. Three of nine patients (30%) who have received rituximab at doses close or equal to the full dose have shown an objective clinical response (two complete responses, one partial response). The study is currently ongoing, and conclusions regarding the overall response rate, clinical parameters that influence response, surrogate markers of response, and the underlying mechanism of response remain to be addressed. The current study should provide answers to a number of important questions regarding the role of rituximab in the treatment of this and other autoimmune disorders.

Comparison of two methods for accurate measurement of modulation transfer functions of screen-film systems.

The modulation transfer function (MTF) of a screen-film system can be measured by two methods, i.e., a slit method with Fourier transform on the line spread function and a square-wave response function (SWRF) method. However, it is still uncertain whether MTFs obtained by the two methods are identical. In this study, MTFs of relatively sharp and unsharp screen-film systems were measured by using the two methods. The slit method provided slightly greater MTF for the relatively sharp system than the SWRF method. However, MTFs of the unsharp system obtained with the two methods were comparable. Generally, the slit method tends to provide reliable results for unsharp systems, whereas the SWRF method is favorable for sharp systems. Accuracy and consistency of these measurements were examined by comparison of experimental and theoretical edge responses derived from the measured MTFs. However, the difference in edge responses obtained by the two methods was relatively small compared with the variation of the measured edge responses, and thus results were considered inconclusive as to whether either of the methods can provide more accurate MTFs. International interlaboratory comparison indicated that the variation in the measured MTFs at six different institutions was relatively large for both methods. However, the MTFs of two screen-film systems measured by the slit method appear to agree with those by the SWRF method within the variation expected from the interlaboratory comparison.

Evaluation of resolution and sensitometric characteristics of an asymmetric screen-film imaging system.

The authors compared asymmetric and conventional screen-film systems for chest radiography. The new imaging system, with asymmetric construction of the screens and film, has image quality characteristics substantially different from those of available screen-film combinations. This asymmetric screen-film system consists of a thin (high-resolution) front screen and a high-contrast emulsion, a thick (lower-resolution) back screen and a low-contrast emulsion, and technology that reduces the crossover exposure and prevents light from the front screen from exposing the back emulsion and vice versa. With this system, density, contrast, and resolution can be increased in selected regions while maintaining density and contrast in the rest of the image. Also, the resolution of this system varies as a function of density. Preliminary image quality and sensitometric studies indicate the new system is superior for chest radiography because it provides better visualization of mediastinal, retrocardiac, and diaphragmatic regions while yielding better contrast and resolution in lung parenchyma.

Noise power spectrum analysis of a scanning microdensitometer.

We have analyzed the principal sources of noise in a commercially available 2-D scanning microdensitometer which we use to estimate the noise power spectra of radiographic films. Two kinds of noise have been observed. One source, associated with the glass platen of the instrument, is correlated from scan to scan. This source of noise limits our ability to measure the NPS of film samples at low sample optical densities. The other major noise source is uncorrelated from scan to scan and increases exponentially with sample optical density. We have measured both of these component noise sources as well as the total instrument noise as a function of instrument density and spatial frequency. A method for minimizing the effects of instrument noise on estimates of the noise power of film samples is described and demonstrated.

Analysis of the detective quantum efficiency of a radiographic screen-film combination.

Detective quantum efficiency provides a useful measure of the imaging efficiency of imaging systems. Methods for measuring the exposure and the spatial-frequency dependence of the contrast transfer function, the noise power spectrum, and the detective quantum efficiency are developed for x-ray imaging systems. These are applied to a high-resolution screen-film combination exposed to a 30-kV-peak x-ray spectrum. The major component sources of screen-film noise in this system are identified and quantified. These are interpreted in terms of a simple model to predict the screen-film noise power spectrum and detective quantum efficiency. Reasonable agreement is found between model predictions and experimental measurements.

Status of the physician-patient privilege.

While in most states information physicians obtain from the about patients is confidential and cannot be disclosed without the patient's permission, a recent California Supreme Court decision affirms that when the doctor reasonably believes his patient can cause violent harm to third persons, he had an overriding duty to warn the third parties and appropriate authorities. Such possible violent harm may be direct, such as physical assult, or indirect, such as an automobile accident resulting from driving while taking certain drugs. The duty to break the privilege of confidentiality does not apply when the injury is likely to be self-inflicted or involve only property damage.

The pregnant worker: who bears the burden?

The article reviews the history of pregnancy disability legislation and links the recent Congressional action to include pregnancy discrimination under Title VII to women's increasing labor force participation.