Calciphylaxis on Technetium Bone Scan: Two Case Reports.

Calciphylaxis is a rare but feared condition thought to related to derangements in calcium and phosphorus metabolism. The syndrome has a predilection for obese women receiving dialysis for chronic renal failure (1, 2). Patients develop painful violaceous lesions in the subcutis, which can lead to ulceration and wound-related sepsis. In severe cases, amputation is required for the gangrenous involved extremity (3). We present two cases of calciphylaxis with similar clinical presentations and physical findings.

Phaeochromocytoma with central nervous system manifestations.

A 35-year-old Samoan male presented with intermittent headaches and hypertensive episodes for several months. A subsequent left adrenal gland phaeochromocytoma was discovered and surgically excised. An MRI of his brain demonstrated periventricular, basal ganglia, and centrum semi-ovale infarction. We suggest that catecholamine excess and neuropeptide Y may contribute to intracerebral haemorrhage and infarcts associated with phaeochromocytomas. Additionally, our surgical approach in removing the phaeochromocytoma is discussed.

Las variables clínicas predicen infarto y muerte en la angina inestable / Clinical markers predict myocardial infarction and death in instable angina

Se analizaron 1022 pacientes con angina inestable definida por cambios electrocardiográficos y/o antecedentes coronarios, incluídos en el estudio ENAI (enalapril en angina inestable). Se relacionaron las variables clínicas basales y después de la admisión con la aparición de eventos mayores. Se consideró angina recurrente a la aparición de síntomas con cambios electrocardiográficos o repercusión hemodinámica y angina refractaria cuando ocurría bajo tratamiento completo. Se realizó un análisis diferenciado de la recurrencia isquémica dentro de las primeras 48 horas. La edad promedio fue 62 ñ 11,5; 31,4 por ciento era de sexo femenino, 75 por ciento tenía cambios electrocardiográficos. La prevalencia de recurrencia isquémica fue 22,1 por ciento, 14,8 por ciento dentro de las 48 horas, eventos mayores 42 pacientes (infarto 2,8 por ciento y muerte 1,6 por ciento). En la angina inestable las variables preadmisión, como las características de la angina previa, y los cambios electrocardiográficos, identifican un grupo con mayor riesgo de evolucionar al infarto o muerte

Las variables clínicas predicen infarto y muerte en la angina inestable / Clinical markers predict myocardial infarction and death in instable angina

Se analizaron 1022 pacientes con angina inestable definida por cambios electrocardiográficos y/o antecedentes coronarios, incluídos en el estudio ENAI (enalapril en angina inestable). Se relacionaron las variables clínicas basales y después de la admisión con la aparición de eventos mayores. Se consideró angina recurrente a la aparición de síntomas con cambios electrocardiográficos o repercusión hemodinámica y angina refractaria cuando ocurría bajo tratamiento completo. Se realizó un análisis diferenciado de la recurrencia isquémica dentro de las primeras 48 horas. La edad promedio fue 62 ñ 11,5; 31,4 por ciento era de sexo femenino, 75 por ciento tenía cambios electrocardiográficos. La prevalencia de recurrencia isquémica fue 22,1 por ciento, 14,8 por ciento dentro de las 48 horas, eventos mayores 42 pacientes (infarto 2,8 por ciento y muerte 1,6 por ciento). En la angina inestable las variables preadmisión, como las características de la angina previa, y los cambios electrocardiográficos, identifican un grupo con mayor riesgo de evolucionar al infarto o muerte (AU)

Exercise training and heparin pretreatment in patients with coronary artery disease.

The purpose of this study was to evaluate whether combined treatment with a cardiovascular exercise rehabilitation program and low doses of heparin can induce changes in ergometric parameters of ischemia in patients with coronary artery disease (CAD). Heparin may potentiate the development of new vessels promoted by ischemia and therefore may produce important clinical improvement. Thirty-six patients with stable CAD and evidence of myocardial ischemia on exercise testing were randomized into three groups: a control group (n = 11) received the usual medical treatment; another group (n = 11) underwent three exercise sessions per week during 12 weeks; and a third group (n = 14) undertook this exercise program and also received calcium heparin 12,500 IU subcutaneously 20 to 30 minutes before each exercise session. Pretreatment and posttreatment exercise tests were compared. Patients who underwent the rehabilitation program had an increase in exercise duration and workload at the onset of 1 mm ST-segment depression, but only patients who received calcium heparin showed a significant increase in rate-pressure product at the ST-segment ischemic threshold (p = 0.035). This result suggests that higher levels of myocardial oxygen consumption were now tolerated, a change that may be related to an improvement in myocardial perfusion.

Glenohumeral ligaments and shoulder capsular mechanism: evaluation with MR arthrography.

PURPOSE: To evaluate the efficacy of magnetic resonance (MR) arthrography in identification of the glenohumeral ligaments (GHLs) and to determine the location of abnormalities of the GHL, joint capsule, and labrum. MATERIALS AND METHODS: MR arthrograms were evaluated retrospectively in 46 patients with a history of shoulder instability, impingement syndrome, or pain of unknown cause. Imaging findings were correlated with surgical observations. RESULTS: The superior, middle, and inferior GHLs were identified on MR arthrograms in 39 (85%), 39 (85%), and 42 (91%) of the 46 patients, respectively. In diagnosis of tears of the superior, middle, and inferior GHLs, MR arthrography had a sensitivity of 100%, 89%, and 88% and a specificity of 94%, 88%, and 100%, respectively. CONCLUSION: Findings at MR arthrography can help accurate identification and demonstration of the integrity of the GHL and labrum and can help in staging of abnormalities. The large number of abnormalities depicted in the middle and inferior GHLs suggests that both might be important in the maintenance of glenohumeral joint congruity.

Partial thickness supraspinatus tears: diagnosis by magnetic resonance arthrography.

Two patients, with clinical symptoms of advanced impingement syndrome, presented for radiologic evaluation. The magnetic resonance (MR) images of each patient were interpreted as representing a full thickness tear of the supraspinatus tendon. Magnetic resonance arthrography was performed on both patients to further determine the extent of the tear. Using this technique, both patients were diagnosed correctly as having partial thickness tears; one on the articular surface and the other on the bursal surface of the tendon. This information is useful in surgical planning and in patient outcome.

Prognostic value of clinical variables for recurrent ischemic events after acute myocardial infarction.

Recurrent ischemia after acute myocardial infarction (AMI) has been largely associated with a poor prognosis. This study was carried out to analyze the relationship among different clinical variables and both postinfarction angina and reinfarction after AMI. A total of 452 consecutive patients (mean age 58.2 +/- 12 years) were admitted to the coronary care unit and were studied prospectively. More than half of the patients received some type of thrombolytic therapy. Death occurred in 45 patients (9.9%) during hospital stay. Postinfarction angina was diagnosed in 81 patients (17.9%) and reinfarction in 22 (4.9%). Patients who developed reinfarction had a high mortality rate (45.5%) compared with those who did not develop such an event (8.1%) (p < 0.0001; odds ratio: 9.4; 95% confidence interval 3.5-25.4). On the other hand, postinfarction angina had no significant association with mortality. Multivariate analysis revealed that a history of angina (> 1 week) was predictive of the occurrence of postinfarction angina and that the use of fibrinolytic treatment, prodromal symptoms, and postinfarction angina were significantly related to reinfarction. We conclude that several simple clinical variables are clear independent predictors of postinfarction angina and reinfarction following AMI and should be taken into account in routine clinical practice or when planning intervention trials.

Colonic sphincters revisited: simulators of organic disease.

Barium enema examinations establish the presence of neoplastic or inflammatory disease in the colon. Areas of narrowing commonly encountered appear to represent organic disease. These areas are in expected locations throughout the colon and have been described. Not much attention had been given to these areas in recent literature, however, which has led to unnecessary colonoscopies and even surgeries. The sphincters of Rossi, Balli, and Payr-Strauss are involved in nerve reflexes; the sphincters of Hirsch, Moultier, and Busi are a thickening of longitudinal and circular muscle fibers. Cannon's sphincter is an overlap of the superior and inferior mesenteric nerve plexuses. When an area of narrowing is encountered where a known sphincter is located, insufflation of more air, changing patient position, administering 2 mg of glucagon intramuscularly or 0.5 mg to 1 mg intravenously will aid in the distinction between a sphincter and organic disease.

Detection and staging of chondromalacia patellae: relative efficacies of conventional MR imaging, MR arthrography, and CT arthrography.

OBJECTIVE: Chondromalacia patellae is a condition characterized by softening, fraying, and ulceration of patellar articular cartilage. We compare the sensitivity, specificity, and accuracy of conventional MR imaging, MR arthrography, and CT arthrography in detecting and staging this abnormality. SUBJECTS AND METHODS: Twenty-seven patients with pain in the anterior part of the knee were prospectively examined with MR imaging, including T1-weighted (650/16), proton density-weighted (2000/20), T2-weighted (2000/80), and spoiled two-dimensional gradient-recalled acquisition in the steady state (SPGR/)/35 degrees (51/10) with fat saturation pulse sequences. All were also examined with T1-weighted MR imaging after intraarticular injection of dilute gadopentetate dimeglumine and with double-contrast CT arthrography. Each imaging technique was evaluated independently by two observers, who reached a consensus interpretation. The signal characteristics of cartilage on MR images and contour abnormalities noted with all imaging techniques were evaluated and graded according to a modification of the classification of Shahriaree. Twenty-six of the 54 facets examined had chondromalacia shown by arthroscopy, which was used as the standard of reference. The sensitivity, specificity, and accuracy of each imaging technique in the diagnosis of each stage of chondromalacia patellae were determined and compared by using the McNemar two-tailed analysis. RESULTS: Arthroscopy showed that 28 facets were normal. Grade 1 chondromalacia patellae was diagnosed only with MR and CT arthrography in two (29%) of seven facets. Intermediate (grade 2 or 3) chondromalacia patellae was detected in two (13%) of 15 facets with T1-weighted and SPGR MR imaging, in three (20%) of 15 facets with proton density-weighted MR imaging, in seven (47%) of 15 facets with T2-weighted MR imaging, in 11 (73%) of 15 facets with CT arthrography, and in 12 (80%) of 15 facets with MR arthrography. Grade 4 was detected in three (75%) of four facets with T1-, proton density-, and T2-weighted MR imaging, two (50%) of four facets with SPGR MR imaging, and four (100%) of four facets with MR and CT arthrography. Thus, all imaging techniques were insensitive to grade 1 lesions and highly sensitive to grade 4 lesions, so that no significant difference among the techniques could be shown. CONCLUSION: All imaging techniques studied had high specificity and accuracy in the detection and grading of chondromalacia patella; however, both MR arthrography and CT arthrography were more sensitive than T1-weighted, proton density-weighted, and SPGR with fat saturation MR imaging for showing intermediate grades of chondromalacia patellae. Although the arthrographic techniques were not significantly better than T2-weighted imaging, the number of false-positive diagnoses was greatest with T2-weighted MR imaging.

Diffuse venous malformation with intraosseous involvement.

A young boy with a large venous malformation of his left arm and hand was evaluated for Maffucci's syndrome. Initial hand films were remarkable for cystic bony lesions suggestive of enchondromas. Additional roentgenograms and magnetic resonance imaging studies showed the bony abnormalities were the result of a venous malformation infiltrating bone. Magnetic resonance imaging is a useful diagnostic tool in differentiating enchondromas from vascular anomalies. Venous malformations infiltrating bone should be included in the differential diagnosis of Maffucci's syndrome.

Chronic ankle instability: evaluation with MR arthrography, MR imaging, and stress radiography.

PURPOSE: To compare the efficacy of conventional magnetic resonance (MR) imaging, MR arthrography, and stress radiography in the detection of lateral collateral ligament abnormalities in patients with chronic ankle instability. MATERIALS AND METHODS: Seventeen patients with chronic lateral ankle instability underwent stress radiography, MR imaging, and MR arthrography after intraarticular injection of gadopentetate dimeglumine. Imaging findings were correlated with surgical findings. RESULTS: The anterior talofibular (ATF) ligament was torn in 14 patients, and the calcaneofibular (CF) ligament was torn in 10. MR arthrography was more accurate and sensitive in the detection of ATF tears than was MR imaging or stress radiography (P < or = .05). Associated injuries were detected with both MR imaging and MR arthrography. CONCLUSION: MR arthrography is a sensitive technique for detecting and staging tears of the lateral collateral ligaments.

A review of the radiographic manifestations of gout.

Hyperuricemia and gout are found in high percentages of the Pacific Island population. As local clinicians and radiologists are more likely to have patients with either the diagnosis or suspicion of gout, a pictorial review of the common radiographic manifestations is presented especially for their information.

Choledochal cyst complicating pregnancy: antepartum diagnosis with MRI.

Choledochal cyst presenting during pregnancy is a rare condition, associated with potentially life-threatening complications for both the mother and developing fetus. Clinical symptoms are nonspecific, and radiographic evaluation is complicated by the presence of the gravid uterus. The authors describe a 34-year-old pregnant female presenting in the third trimester with obstructive jaundice and a right upper quadrant mass. Multiplanar and multisequence imaging with MR established the antepartum diagnosis of choledochal cyst, avoiding the use of ionizing radiation during pregnancy.

Magnetic resonance imaging with computed tomography of a renal leiomyoma.

Renal leiomyoma are rare, benign tumors of the kidney. There is little information about the imaging of these tumors with modern modalities. We present a case of computed tomographic (CT) and magnetic resonance (MR) imaging of a large renal leiomyoma.

Glenoid labral tears: prospective evaluation with MRI imaging, MR arthrography, and CT arthrography.

OBJECTIVE: We prospectively compared MR imaging, MR arthrography, and CT arthrography to determine the sensitivity of each technique in detecting glenoid labral tears and in determining whether the labrum is detached or degenerated. SUBJECTS AND METHODS: Thirty patients 19-39 years old (mean, 27 years old) who had either signs and symptoms of shoulder instability or shoulder pain of unexplained origin were referred for diagnostic imaging. Each patient underwent MR imaging, followed by MR arthrography after intraarticular injection of 25 ml of a dilute solution of gadopentetate dimeglumine. Twenty-eight of thirty patients underwent CT arthrography after intraarticular injection of air and radiographic contrast material. Each patient also underwent arthroscopy or open surgery. RESULTS: At surgery, labral tears were found in 28 patients; a detached fragment was found in 26 patients. The labrum was found to be degenerated in 18. A labral tear was detected on MR images in 26 (93%) of 28, on MR arthrograms in 27 (96%) of 28, and on CT arthrograms in 19 (73%) of 26. A detached labral fragment was detected on MR images in 12 (46%) of 26, on MR arthrograms in 25 (96%) of 26, and on CT arthrograms in 13 (52%) of 25. Labral degeneration was detected on MR images in two (11%) of 18, on MR arthrograms in 10 (56%) of 18, and on CT arthrograms in four (24%) of 17. MR arthrography was the best of the three imaging techniques for showing the inferior part of the glenoid labrum and inferior glenohumeral ligament. CONCLUSION: MR arthrography and MR imaging both showed labral tears with greater sensitivity than CT arthrography did. MR arthrography was the most sensitive of the three techniques for detecting a detached labral fragment and labral degeneration. Furthermore, MR arthrography afforded the best visualization of the inferior part of the labrum and the inferior glenohumeral ligament. MR imaging and MR arthrography also enabled direct visualization of rotator cuff disease and other unsuspected associated abnormalities.

Testicular microlithiasis: ultra sound appearance.

Testicular microlithiasis is a diffuse, benign condition involving both testicles without architectural distortion. Multiple, bright echoes are present on ultrasound examination which rarely cause shadowing. Many associated conditions have been reported in patients with this entity. As this is a benign entity, knowledge of its appearance and associated conditions to prevent unnecessary surgery is important.