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2.
Chest ; 108(4): 1164-6, 1995 Oct.
Article in English | MEDLINE | ID: mdl-7555134

ABSTRACT

We describe a case of pulmonary artery aneurysm in which clinical clues and conventional imaging suggested a lung tumor, and the actual nature of the lesion was discovered at the time of thoracotomy. This case shows the importance of an awareness of this condition in the formulation of a differential diagnosis for a lung mass.


Subject(s)
Aneurysm, Infected/diagnosis , Lung Neoplasms/diagnosis , Pulmonary Artery , Aneurysm, Infected/surgery , Carcinoma, Renal Cell/diagnosis , Carcinoma, Renal Cell/surgery , Diagnosis, Differential , Female , Humans , Kidney Neoplasms/diagnosis , Kidney Neoplasms/surgery , Lung Neoplasms/secondary , Lung Neoplasms/surgery , Middle Aged , Nephrectomy , Pulmonary Artery/diagnostic imaging , Radiography , Remission, Spontaneous , Thoracotomy
3.
J Thorac Cardiovasc Surg ; 106(6): 1202-7, 1993 Dec.
Article in English | MEDLINE | ID: mdl-8246561

ABSTRACT

Although there is convincing evidence that prophylactic administration of high doses of the monoclonal antibody OKT3 predisposes patients to an increased prevalence of early posttransplantation malignancy, particularly posttransplantation lymphoproliferative disease, it is indeterminate whether polyclonal antilymphocyte globulin poses a similar hazard. We reviewed the outcome of 112 consecutive cardiac transplant recipients who received uniform immunosuppression, including induction therapy with antilymphocyte globulin, and were prospectively followed-up for a median duration of 41.5 months (range 1 to 81 months). No patients had posttransplantation lymphoproliferative disease. Nine malignant neoplasms (8%) were detected from 6 to 70 months after transplantation. Four patients with cutaneous neoplasms were alive and well at the time this article was written. Three patients died of disseminated adenocarcinoma 6 months, 17 months, and 60 months after transplantation. One patient was undergoing treatment of Kaposi's sarcoma at the time this article was written, and another was undergoing treatment of transitional bladder cell carcinoma. Actuarial survival for all patients was 88% at 1 year and 79% at 5 years. Moderate doses of induction antilymphocyte globulin may facilitate rapid reduction of maintenance cyclosporine and steroid doses, thereby decreasing the duration of intense immunosuppression and lowering the risk of posttransplantation lymphoproliferative disease. Testing this hypothesis would require the development of reliable and reproducible in vivo assays to prospectively assess immune status.


Subject(s)
Antilymphocyte Serum/therapeutic use , Heart Transplantation/adverse effects , Neoplasms/etiology , Adolescent , Adult , Antilymphocyte Serum/adverse effects , Female , Graft Rejection , Heart Transplantation/immunology , Heart Transplantation/mortality , Humans , Immunosuppression Therapy , Lymphoproliferative Disorders/etiology , Male , Middle Aged , Neoplasms/immunology , Prospective Studies , Retrospective Studies , Survival Rate , Treatment Outcome
4.
J Cardiovasc Surg (Torino) ; 33(6): 746-53, 1992.
Article in English | MEDLINE | ID: mdl-1287016

ABSTRACT

Allograft coronary artery disease (ACAD) is the major factor limiting long-term survival of cardiac transplant recipients (CTRs). Although cyclosporine based triple drug immunosuppression has not decreased the occurrence of ACAD, some preliminary data suggests that prophylactic antilymphocyte preparations may reduce the incidence of this problem. All CTRs at Henry Ford Hospital have uniformly received prophylactic Minnesota Antilymphocyte Globulin (ALG), thereby providing a unique opportunity to investigate this hypothesis. One hundred three CTRs were followed for a median duration of 34 months with annual angiograms begun one year after transplant. Patients who died without an angiogram were considered to have ACAD based on autopsy results or if their death was clinically suspicious. Ninety-two patients underwent at least one angiogram. Fourteen patients had abnormal angiograms. Nine patients were identified as having ACAD by non-angiographic criteria. Five had autopsy proven disease, 3 died suspiciously, and 1 underwent successful re-transplantation for ACAD. By Kaplan-Meier analysis, the risk of developing ACAD was 12% in 1 year, 16% in 2 years, 22% in 3 years, 26% in 4 years, and 29% in 5 years. Risk of ACAD increased with older recipient's age, higher triglyceride levels, and diabetes, but was not affected by active CMV infection, number of acute rejection episodes, and HLA mismatching. These results suggest that prophylactic ALG reduces the occurrence of ACAD.


Subject(s)
Antilymphocyte Serum/therapeutic use , Coronary Artery Disease/prevention & control , Heart Transplantation , Adult , Aged , Coronary Artery Disease/etiology , Coronary Artery Disease/mortality , Female , Graft Rejection , Heart Transplantation/adverse effects , Heart Transplantation/mortality , Humans , Male , Middle Aged , Prospective Studies , Risk Factors , Survival Analysis , Transplantation, Homologous
5.
J Heart Lung Transplant ; 10(5 Pt 1): 750-6, 1991.
Article in English | MEDLINE | ID: mdl-1958682

ABSTRACT

Magnetic resonance imaging with and without gadolinium (Gd)-DTPA has been shown to enable detection of coronary occlusive ischemic injury and heart transplant rejection. This study was performed to examine findings on magnetic resonance images associated with ischemic injury after heart transplantation in rats. Magnetic resonance imaging was performed immediately before death in 22 rats, between 1 and 90 days after isogeneic (Lewis grafts, Lewis host; or Fischer graft, Fischer host) heterotopic heart transplantation. Ischemic injury, characterized histologically by cellular infiltration or myocyte necrosis, correlated inversely with graft duration. It was graded as moderate to severe in 5 of 5 rats killed at 1 to 2 days, and in 0 of 9 animals killed at greater than or equal to 30 days. T2-weighted myocardial signal intensity (TR = 2.3 seconds; TE = 90 milliseconds) correlated inversely with graft duration and was significantly greater in grafts with moderate or severe histologic abnormalities than in grafts with absent or minimal changes. GD-DTPA-induced myocardial enhancement was judged on T1-weighted images (TR = 0.5 seconds, TE = 25 milliseconds). Areas of intense enhancement were present in all seven grafts with severe histologic abnormalities, but in only 3 of 15 grafts with absent to moderate histologic abnormalities. In conclusion, after heart transplantation in rats, ischemic injury causes increased T2-weighted signal intensity and Gd-DTPA-induced T1-weighted signal enhancement--findings similar to those described in transient coronary occlusive ischemia and in graft rejection. Abnormalities seen on magnetic resonance images during the first few posttransplant weeks may represent ischemic injury rather than rejection.


Subject(s)
Coronary Disease/pathology , Heart Transplantation/adverse effects , Magnetic Resonance Imaging , Myocardium/pathology , Animals , Contrast Media , Coronary Disease/etiology , Gadolinium , Gadolinium DTPA , Magnetic Resonance Imaging/methods , Organometallic Compounds , Pentetic Acid , Rats , Rats, Inbred F344 , Rats, Inbred Lew
6.
Henry Ford Hosp Med J ; 39(3-4): 245-50, 1991.
Article in English | MEDLINE | ID: mdl-1804831

ABSTRACT

In recent years, advances in surgical techniques and perioperative management of cardiac surgical patients have facilitated more aggressive operative treatment of many serious and even catastrophic complications of acute myocardial infarction (MI). In addition, improved understanding of the natural history of these complications has helped to optimize the indications for and timing of surgical intervention. The role of emergency revascularization for postinfarction angina, evolving acute MI, cardiogenic shock after acute MI, and failed percutaneous transluminal angioplasty has expanded with overall satisfactory to excellent results. Surgical treatment of mechanical with overall satisfactory to excellent results. Surgical treatment of mechanical complications of acute MI such as free-wall rupture, acute ischemic mitral insufficiency, and ventricular septal defect also is undertaken earlier and more aggressively. Although the mortality rates for these conditions remain higher than desired, salvage of many previously doomed patients now is a reality.


Subject(s)
Coronary Artery Bypass , Myocardial Infarction/surgery , Acute Disease , Angina Pectoris/etiology , Angina Pectoris/surgery , Angioplasty, Balloon, Coronary , Heart Aneurysm/etiology , Heart Aneurysm/surgery , Heart Rupture, Post-Infarction/surgery , Humans , Mitral Valve Insufficiency/etiology , Mitral Valve Insufficiency/surgery , Myocardial Infarction/complications , Shock, Cardiogenic/etiology , Shock, Cardiogenic/surgery
8.
J Heart Transplant ; 9(1): 11-3, 1990.
Article in English | MEDLINE | ID: mdl-2313414

ABSTRACT

Total lymphoid irradiation can prolong concordant cardiac xenografts. The effects of total lymphoid irradiation in a discordant xenograft model (guinea pig to rat) were studied with and without adjuvant pharmacologic immunosuppression. Inbred Lewis rats were randomly allocated to one of four groups. Group 1 (n = 6) served as a control group and rats received no immunosuppression. Group 2 (n = 5) received triple-drug therapy that consisted of intraperitoneal azathioprine (2 mg/kg), cyclosporine (20 mg/kg), and methylprednisolone (1 mg/kg) for 1 week before transplantation. Group 3 animals (n = 5) received 15 Gy of total lymphoid irradiation in 12 divided doses over a 3-week period. Group 4 (n = 6) received both triple-drug therapy and total lymphoid irradiation as described for groups 2 and 3. Complement-dependent cytotoxicity assay was performed to determine if a correlation between complement-dependent cytotoxicity and rejection-free interval existed. Rejection was defined as cessation of graft pulsation and was confirmed by histologic test results. Only groups 1 and 2 showed a difference in survival (group 1, 6.9 +/- 1.0 minutes; group 2, 14.2 +/- 2.7 minutes, p = 0.02). Although total lymphoid irradiation did decrease complement-dependent cytotoxicity, linear regression revealed no correlation between complement-dependent cytotoxicity and graft survival (coefficient of correlation, 0.30). Unlike concordant cardiac xenografts, total lymphoid irradiation with or without triple-drug therapy does not prolong graft survival.


Subject(s)
Graft Rejection/radiation effects , Heart Transplantation/immunology , Lymphatic Irradiation , Animals , Cytotoxicity, Immunologic/radiation effects , Graft Survival/radiation effects , Guinea Pigs , Immunosuppressive Agents/therapeutic use , Rats , Rats, Inbred Lew , Transplantation, Heterologous/immunology
9.
Biomed Pharmacother ; 44(7): 359-64, 1990.
Article in English | MEDLINE | ID: mdl-1980085

ABSTRACT

Since the inception of aortocoronary bypass surgery, many technical advances have been rapidly achieved. Early experience was limited to reversed saphenous vein grafting of single vessel coronary artery disease. Multiple grafts to several vessels soon became commonplace and sequential grafting techniques were developed. Expanded use of the internal mammary artery resulted after analysis of superior patency rates achieved with this conduit. Use of alternative conduits such as upper extremity veins, allogenic veins, synthetic graft material (polytetrafluorethylene), radial artery, splenic artery, and gastroepiploic artery have been explored. Apart from the gastroepiploic vessel, none of these alternative conduits have been suitable. A grat deal of effort has been directed at the mechanisms of saphenous vein occlusion including technical considerations, early thrombosis, intimal hyperplasia and graft atherosclerosis. Platelet inhibition and lipid reduction have shown promise in improving patency rates. Further work in these areas should lead to even better results.


Subject(s)
Coronary Artery Bypass/methods , Coronary Vessels/transplantation , Coronary Artery Bypass/trends , Humans , Myocardial Revascularization , Saphenous Vein/transplantation
10.
Ann Thorac Surg ; 48(6): 829-34, 1989 Dec.
Article in English | MEDLINE | ID: mdl-2596918

ABSTRACT

Right atrial cardioplegia has been advocated as a simple method of delivering retrograde cardioplegia. Passive distention of the right heart inherent with right atrial cardioplegia has been shown to impair right ventricular function in a canine model of global ischemia. This study was designed to compare right ventricular performance after right atrial cardioplegia administered intermittently (n = 5) and continuously (n = 5) with coronary sinus retrograde cardioplegia (n = 5) and aortic root cardioplegia (n = 8) in a canine model of acute right ventricular ischemia and reperfusion. Right ventricular performance was assessed using the load-independent relationship of end-systolic pressure versus dimension (myocardial fiber length). Right ventricular performance was well preserved after reperfusion in those dogs protected with intermittent right atrial cardioplegia (95% of control). Results with continuous right atrial cardioplegia (66% of control) and coronary sinus retrograde cardioplegia (40% of control) demonstrated diminished postreperfusion right ventricular performance. Right ventricular performance in the group protected with aortic root cardioplegia was significantly impaired after reperfusion when compared with all retrograde groups (34% of control, p less than 0.05). In this model, postreperfusion right ventricular performance was preserved in the right atrial cardioplegia groups despite passive ventricular distention. All methods of retrograde cardioplegia resulted in superior preservation of right ventricular performance when compared with standard aortic root cardioplegia.


Subject(s)
Heart Arrest, Induced/methods , Myocardial Reperfusion Injury/prevention & control , Myocardial Reperfusion , Animals , Dogs , Echocardiography , Heart Atria , Myocardial Contraction , Stroke Volume
11.
Circulation ; 78(5 Pt 2): III87-94, 1988 Nov.
Article in English | MEDLINE | ID: mdl-3052922

ABSTRACT

To date, no noninvasive tool has gained widespread acceptance as an adequate substitute for endomyocardial biopsy for the diagnosis and grading of cardiac transplant rejection. We examined the potential role of magnetic resonance imaging with gadolinium (Gd)-diethylenetriamine penta-acetic acid (DTPA) image enhancement for the diagnosis of cardiac graft rejection. We studied 15 rats with heterotopic cardiac transplants, nine of which received no immunosuppression, and six of which received cyclosporine, azathioprine, and methylprednisolone. The animals underwent magnetic resonance imaging, which was immediately followed by sacrifice (2-12 days after transplant). Myocardial image enhancement was assessed on T1-weighted images performed before and after administration of Gd-DTPA, 0.5 mmol/kg. Histological specimens were graded I, II, or III to indicate increasing severity of rejection. In the absence of rejection, Gd-DTPA induced mild homogeneous myocardial enhancement. Ten of 11 cases with Grade II or III rejection manifested one or more areas of intense myocardial enhancement. The extent and distribution of intense myocardial enhancement corresponded to the severity and distribution of histological rejection. Quantitative myocardial enhancement, expressed as the ratio of maximal signal intensity after Gd-DTPA to signal intensity before Gd-DTPA administration, separated Grade I animals (1.61 +/- 0.27; mean +/- SD) from Grades II (2.89 +/- 0.58) and III (3.10 +/- 0.77; p less than 0.01) animals. In conclusion, cardiac transplant rejection is characterized by intense T1-weighted image enhancement after administration of Gd-DTPA. Magnetic resonance imaging with Gd-DTPA thus has potential application in the clinical diagnosis of cardiac transplant rejection.


Subject(s)
Graft Rejection , Heart Transplantation , Magnetic Resonance Imaging , Organometallic Compounds , Pentetic Acid , Animals , Contrast Media , Gadolinium DTPA , Image Enhancement , Myocardium/pathology , Rats , Rats, Inbred Lew
13.
Ann Thorac Surg ; 45(6): 595-602, 1988 Jun.
Article in English | MEDLINE | ID: mdl-3288140

ABSTRACT

The efficacy of retrograde coronary sinus cardioplegia (RCSC) administered through the right atrium compared with aortic root cardioplegia (ARC) has not been examined critically in patients undergoing coronary artery bypass grafting (CABG). Twenty patients having elective CABG were randomized prospectively to receive cold blood ARC (Group I, 10 patients) or cold blood RCSC (Group II, 10 patients). Patient demographics were similar in both groups. Ventricular function was assessed preoperatively by radionuclide ventriculography and postoperatively by simultaneous hemodynamic and radionuclide ventriculographic studies with volume loading. There was no change in ejection fraction (EF) (preoperative versus postoperative value) in Group I (50 +/- 6% versus 53 +/- 6%) but in group II, at similar peak systolic pressure and similar left ventricular end-diastolic volume index (LVEDVI), LVEF improved significantly (49 +/- 6% versus 60 +/- 12%, p less than 0.05). Postoperative ventricular function (stroke work index versus EDVI) for the left ventricle and right ventricle were similar in both groups. Evaluation of postoperative LV systolic function (end-systolic blood pressure versus end-systolic volume index) and diastolic function (pulmonary capillary wedge pressure versus EDVI) were also similar in both groups. Retrograde coronary sinus cardioplegia is as effective as ARC for intraoperative myocardial protection, and provides excellent postoperative function in patients undergoing elective CABG.


Subject(s)
Coronary Artery Bypass , Heart Arrest, Induced/methods , Blood , Clinical Trials as Topic , Female , Heart/diagnostic imaging , Heart Atria , Humans , Intraoperative Care/methods , Male , Middle Aged , Myocardial Contraction , Perfusion , Prospective Studies , Radionuclide Imaging , Random Allocation , Stroke Volume
14.
Ann Thorac Surg ; 45(4): 449-50, 1988 Apr.
Article in English | MEDLINE | ID: mdl-3355290

ABSTRACT

A benign tracheoesophageal fistula occurring as a complication of Barrett's ulcerative esophagitis is described. Surgical control of gastroesophageal reflux resulted in healing of the fistula, obviating the need for a resective procedure or esophageal exclusion. Although Barrett's ulcer has been reported as a cause of acquired esophagorespiratory fistula, to our knowledge, the important role of reflux control in the management of this difficult problem has not been discussed.


Subject(s)
Barrett Esophagus/complications , Esophageal Diseases/complications , Gastroesophageal Reflux/surgery , Tracheoesophageal Fistula/etiology , Aged , Barrett Esophagus/diagnostic imaging , Gastroesophageal Reflux/complications , Humans , Male , Radiography , Tracheoesophageal Fistula/diagnostic imaging , Ulcer/complications
16.
Ann Thorac Surg ; 40(4): 385-7, 1985 Oct.
Article in English | MEDLINE | ID: mdl-3876814

ABSTRACT

Fibrin glue derived from pooled human blood is an effective sealant for high-porosity vascular grafts and a valuable topical hemostatic agent in heparinized patients. Use of this agent in the United States is prohibited because of potential transmission of hepatitis B, acquired immunodeficiency syndrome, and other serologically transmitted illnesses. We have developed a cryoprecipitation technique that allows preparation of fibrin glue from single-donor fresh frozen plasma. Use of this agent presumably entails no greater risk of disease transmission than intravenous administration of single-unit fresh frozen plasma. This report describes our early clinical experience with this material. Fibrin glue was used as a sealant for porous woven Dacron tubular prostheses and cardiovascular patches in 19 patients. The fibrin glue sealant has also been employed to control bleeding from needle holes and small anastomotic tears in 22 patients. No patient in this series had a bleeding complication from a suture line or graft treated with fibrin glue. This experience indicates that like fibrin glue from pooled blood, fibrin glue from single-donor plasma is effective as a graft sealant and topical hemostatic agent. Preparation of fibrin glue from single-donor plasma is simple and economical, and may provide cardiothoracic surgeons in the United States with a widely available, valuable hemostatic adjunct.


Subject(s)
Cardiac Surgical Procedures , Factor XIII , Fibrinogen , Hemostasis, Surgical , Plasma , Thrombin , Tissue Adhesives , Blood Donors , Drug Combinations , Fibrin Tissue Adhesive , Humans
17.
Circulation ; 72(3 Pt 2): II237-40, 1985 Sep.
Article in English | MEDLINE | ID: mdl-3896557

ABSTRACT

Despite the introduction of cyclosporine immunosuppression, infectious morbidity and mortality in cardiac transplant recipients has remained high. To decrease infectious complications, lower doses of cyclosporine and oral prednisone than previously reported were used for maintenance immunosuppression in 22 operative survivors of orthotopic cardiac transplantation. Twelve infections occurred in 10 patients followed 8 +/- 5 months. Fifty-five percent of patients had no infectious complications. There were no deaths. Seven infections required hospitalization for a mean of 12 days. Infection rate per patient for the first 3 months after transplantation was 0.23 compared with a range of 0.82 to 1.06 in series previously reported in which higher doses of steroids were used. Lowered doses of steroid can be used for maintenance immunosuppression and treatment of rejection with acceptable short-term results. With such a protocol, a low incidence of controllable infectious complications with no deaths has been observed.


Subject(s)
Bacterial Infections/etiology , Heart Transplantation , Virus Diseases/etiology , Adolescent , Adult , Anti-Infective Agents/therapeutic use , Bacterial Infections/drug therapy , Bacterial Infections/surgery , Child , Child, Preschool , Cyclosporins/therapeutic use , Drug Administration Schedule , Follow-Up Studies , Graft Rejection/drug effects , Humans , Methylprednisolone/therapeutic use , Middle Aged , Prospective Studies , Virus Diseases/drug therapy
18.
Surgery ; 97(6): 750-5, 1985 Jun.
Article in English | MEDLINE | ID: mdl-3873716

ABSTRACT

Fibrin glue is used widely in Europe as a tissue sealant and hemostatic agent. The European glue is prepared commercially from pooled human blood. It is not available in this country because of the risk of transmission of hepatitis B, acquired immune deficiency syndrome, and other blood-transmitted diseases. We describe a cryoprecipitation technique for preparation of fibrin glue from single-donor fresh-frozen plasma. This technique enables the glue to be made in large quantities with no greater risk of disease transmission than with that from the transfusion of single-unit fresh-frozen plasma. We have found that the glue is a useful tool in surgery. By helping to control difficult bleeding, its use can decrease the need for blood transfusions and shorten operating room time. It also is effective as a means to pretreat highly porous vascular prostheses that currently are used infrequently because of bleeding. These porous grafts offer potential advantages in handling, suturing, and long-term patency. This new technique of fibrin glue preparation may make this useful surgical adjunct as readily available in this country as it is in Europe.


Subject(s)
Factor XIII/isolation & purification , Fibrinogen/isolation & purification , Thrombin/isolation & purification , Tissue Adhesives/isolation & purification , Chemical Precipitation , Cryoprotective Agents , Drug Combinations/isolation & purification , Fibrin Tissue Adhesive , Freezing , Humans , Plasma
20.
Cancer ; 52(1): 51-60, 1983 Jul 01.
Article in English | MEDLINE | ID: mdl-6850545

ABSTRACT

One hundred and one soft tissue sarcoma patients from an adjuvant chemotherapy study of the Surgery Branch, National Cancer Institute who had received greater than or equal to 430 mg/m2 (range, 430-600 mg/m2) of doxorubicin were followed for evidence of cardiomyopathy. Fourteen patients developed clinical congestive heart failure attributable to doxorubicin. Nine of these fourteen were evaluated by radionuclide angiography (RNA), and all were abnormal with mean ejection fraction both at rest and exercise less than 30%. Sixty-one asymptomatic patients were studied at least once with RNA. In this asymptomatic group, 13 of 61 patients (21%) had abnormal resting left ventricular function. Exercise studies identified an additional 19 abnormal individuals (31%). Overall incidence of cardiomyopathy, as evidenced by RNA, in the asymptomatic group was 52%. By including the fourteen symptomatic patients, the incidence of cardiomyopathy detected either clinically or by RNA in the 75 evaluated patients was 46%. Comparison of patients by age (less than 40 versus greater than 40) revealed a highly significant difference in the incidence of cardiomyopathy (P less than .001). Fourteen of 36 patients (38%) less than or equal to 40 had either clinical or RNA evidence of cardiotoxicity while 32 of 39 (82%) individuals greater than 40 demonstrated cardiomyopathy. No significant difference was seen in those asymptomatic patients in whom RNA was performed less than or equal to 12 months as compared with greater than 12 months after the end of doxorubicin treatment. In the entire group there was no apparent improvement in cardiomyopathy with time, but results suggest that left ventricular function in the group older than 40 years does deteriorate. The cardiac function of patients younger than age 40 appeared to remain stable or possibly improve with time after the completion of treatment. Sex, tumor location, and radiation treatment were not associated with an increased risk of cardiomyopathy. These results emphasize the dangers of full-dose doxorubicin therapy. This high incidence of cardiomyopathy became apparent because of our ability to prospectively evaluate a large group of patients with prolonged life expectancy that received adjuvant doxorubicin chemotherapy after surgery.


Subject(s)
Doxorubicin/adverse effects , Heart Diseases/chemically induced , Sarcoma/therapy , Soft Tissue Neoplasms/therapy , Adolescent , Adult , Age Factors , Angiography , Doxorubicin/administration & dosage , Female , Heart Diseases/diagnostic imaging , Heart Failure/diagnostic imaging , Humans , Male , Middle Aged , Physical Exertion , Prospective Studies , Radionuclide Imaging , Sarcoma/diagnostic imaging , Soft Tissue Neoplasms/diagnostic imaging , Stroke Volume
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