Advanced multiple beam equalization radiography: receiver operating characteristic comparison with screen-film chest radiography.

OBJECTIVE: To test the hypothesis that the advanced multiple beam equalization radiography (AMBER) imaging system is superior to conventional chest radiography in the demonstration of diffuse infiltrative lung disease, emphysema, pulmonary nodules, calcification within nodules, and mediastinal or hilar masses and lymphadenopathy. MATERIAL AND METHODS: The study involved 115 patients, each of whom underwent chest computed tomography (CT), AMBER, posteroanterior chest radiography, and conventional posteroanterior stereoscopic chest radiography (two films). All radiographs were obtained with the InSight Thoracic Imaging System. Four chest radiologists independently analyzed the 115 AMBER studies, 115 unpaired single conventional radiographs (a single film from a stereoscopic pair), and 115 stereoscopic conventional radiographs (2 films) for the presence of diffuse infiltrative lung disease, emphysema, pulmonary nodules, calcification within nodules, and mediastinal or hilar masses and lymphadenopathy. For each abnormality detected, the radiologists described their level of confidence based on a scale of 1 to 5. The 115 CT examinations were interpreted by consensus among 3 of the chest radiologists. The CT results were considered the standard. Receiver operating characteristic (ROC) techniques were used for statistical analysis. RESULTS: No statistically significant differences were found with ROC techniques between the AMBER system and single or stereoscopic conventional screen-film radiography for the abnormalities studied. CONCLUSION: We noted no clinically significant difference between AMBER and either single or stereoscopic conventional screen-film radiography in this prospective study of 115 patients in which CT (performed within 1 week of both radiographic examinations) was the standard.

Spontaneous intrauterine linear skull fracture: a rare complication of spontaneous vaginal delivery.

BACKGROUND: Fetal skull fracture has been reported in conjunction with difficult delivery or extrinsic trauma. CASE: We report a case of linear, undisplaced, nondepressed skull fracture occurring in a 3540-g male infant born at 37 weeks and 4 days' gestation. Linear skull fracture occurred despite an uncomplicated spontaneous vaginal delivery in the absence of extrinsic trauma or cephalopelvic disproportion. Subsequent clinical follow-up 6 years later revealed normal neurological development without evidence of epileptiform activity or focal neurologic deficit. CONCLUSION: Linear skull fracture in association with uncomplicated, spontaneous vaginal delivery is distinctly rare, in contrast to focal, congenital molding depressions of the skull. This case demonstrates that normal spontaneous vaginal delivery without instrumentation or obvious complication can involve sufficient trauma to result in a linear skull fracture. The precise etiology of these fractures requires further study.

Implementing an EMR: paper's last hurrah.

The implementation of an electronic medical record system in any large organization is as complex a task as the design of the system. During implementation, it is necessary that health care providers using the electronic system are able to communicate with colleagues who are continuing to work with the paper record. The Mayo Clinic in Rochester, Minnesota, is well along the path to implementing an electronic medical record system. One of the key issues addressed has been the need for the electronic system to integrate with the paper record. This need to function in the dual electronic/paper environment has placed new demands on printers, required revision of some paper forms, and required the electronic system to create facsimilies of paper record forms. In addition, new security issues have been raised. Dual paper/electronic environment issues are an important challenge in the implementation of an electronic medical record.

Breast biopsy: a comparative study of stereotaxically guided core and excisional techniques.

OBJECTIVE: The major objectives of this prospective study were to compare pathologic findings from stereotaxic core and excisional biopsies performed on patients with impalpable breast lesions and to compare the initial mammographic impression with the final histologic diagnosis. SUBJECTS AND METHODS: All patients referred for preoperative localization of impalpable breast lesions between October 29, 1991, and January 15, 1993, were eligible for the study. If the patient and the lesion, on the basis of mammography, were considered suitable for core biopsy, the patient was asked to participate. Four hundred forty-five excisional biopsies were performed. One hundred sixty lesions were evaluated by core biopsy; for 104 of these lesions, five or more core samples were removed. Core biopsies were done with 14-gauge biopsy needles and were followed by a localization procedure. The pathologic features of core and excisional specimens were compared. RESULTS: Biopsy results were compared for 93 (58%) benign and 67 (42%) malignant lesions. Of 104 lesions evaluated with at least five core specimens, 56 (54%) were benign and 48 (46%) were malignant. Results of core biopsy corresponded to those of excisional biopsy for 96% of benign lesions, 83% of malignant lesions, and 90% overall; sensitivity of core biopsy for malignant lesions was 85%. Of 56 lesions for which fewer than five core specimens were obtained, 37 (66%) were benign and 19 (34%) were malignant. Results of core biopsy corresponded to those of excisional biopsy for 81% of benign lesions, 79% of malignant lesions, and 80% overall; sensitivity of core biopsy for malignant lesions was 84%. Specificity of core biopsy for the entire series of benign lesions was 100%. CONCLUSION: For mammographic lesions that are believed to be not malignant or not very likely malignant, stereotaxic core biopsy decreases the need for excisional biopsy.

Diagnostic tests for lung cancer.

The goals of diagnostic testing in patients with suspected lung cancer are to establish the diagnosis and to determine the stage of the disease so that appropriate therapy can be initiated. Unless a patient has hemoptysis, fever, or a change in cough as an initial manifestation, resectable lung cancer will seldom be diagnosed on the basis of the history. Screening tests--particularly chest roentgenography--have usually identified the abnormality. The managing physician should then select diagnostic procedures that are associated with low risk and that will provide further diagnostic and staging information. A biopsy will almost always be necessary before definitive therapy can be planned. In many cases, a single procedure--for example, a needle biopsy of a hepatic lesion or biopsy of a supraclavicular lymph node--will provide a definitive diagnosis and establish the stage of the disease. The roles of cytology, histopathologic examination, radiologic studies, and various types of biopsy in the diagnosis of lung cancer are reviewed in this report.

Postoperative parathyroid high-frequency sonography: evaluation of persistent or recurrent hyperparathyroidism.

Sixty consecutive postoperative patients with recurrent or persistent hyperparathyroidism were scanned before reoperation using high-frequency (10 MHz) real-time sonography. The sonograms were interpreted prospectively, and the results correlated with subsequent surgical findings to determine the diagnostic accuracy of this technique in the localization of enlarged parathyroid glands. A total of 59 abnormal glands were found in 51 patients at operation: 45 in the neck and 14 in the mediastinum. Sonography identified 37 of the 45 cervical glands for a sensitivity of 82% in the neck. The mediastinum cannot be evaluated by sonography due to the bony thoracic cage, although if the mediastinal glands are included, the overall sensitivity was 63%. In the 14 patients with negative neck explorations but positive mediastinal explorations, sonography was negative in 12 patients, but false-positives were suspected in two patients, yielding a specificity of 86% in the neck. High-frequency sonography is a sensitive, rapid, and noninvasive technique for localizing enlarged cervical parathyroid glands in patients with recurrent or persistent hyperparathyroidism.

High-resolution parathyroid sonography.

A total of 165 consecutive patients with suspected primary hyperparthyroidism was scanned preoperatively using high-resolution real-time sonography. The sensitivity of the procedure was 69% and the specificity 94% in the localization of individually enlarged parathyroid glands. In the subgroup of 21 patients undergoing reoperation in the neck, the sensitivity and specificity were 80% and 92%, respectively. In patients with a single parathyroid adenoma, there was a close but not linear correlation between sonographic diagnostic accuracy and the size of the adenoma, which in turn was directly related to the serum calcium and immunoreactive parathyroid hormone levels. High-resolution sonography has become the procedure of choice in our institution for the preoperative localization of enlarged parathyroid glands in the neck.

Small-part ultrasonography in primary hyperparathyroidism: initial experience.

Small-part, real-time ultrasonography using a high-resolution real-time ultrasound scanner was evaluated in 100 consecutive patients undergoing cervical exploration for primary hyperparathyroidism. The radiologic accuracy was 76%. This accuracy was related directly to the weight of the resected gland(s). The surgical success rate with ultrasonography was 96%, whereas the rate without ultrasonography was 97%. Operating time was not appreciably decreased. The exact role of this new modality in the management of primary hyperparathyroidism is as yet unclear.

Computed tomographic mammography (CTM).

Breasts of 724 patients were studied by physical examination, mammography, and computed tomographic mammography (CTM) using a scanner designed for evaluation of the breast. Among cases in which CTM was not accompanied by use of contrast material, there were 60 malignant lesions, of which 10% were missed by mammography, 32% by CTM, and 8% by both. Among cases where CTM was supplemented by a 50 ml injection of 75% contrast material, there were 63 malignant lesions, of which 14% were missed by mammography, 16% by CTM, and 3% by both. Among cases where CTM was supplemented by a 300 ml infusion of 30% contrast material, there were 41 malignant lesions, of which 7% were missed by mammography and 5% by CTM, but none by both. Clinically, 22% of the malignant lesions in the infusion series were occult. There were 44 benign lesions in patients studied with the infusion technique. With mammography 68% were suspicious for malignancy, and with CTM, 56%.

Clinical evaluation of computerized tomographic mammography.

This is an initial report of the first clinical study using computerized tomographic mammography (CTM). A study is being conducted comparing CTM and conventional mammographic techniques in patients who subsequently undergo breast biopsy. This report analyzes the experience with 160 breast lesions found in patients who were examined using CTM without contrast material. One hundred lesions were benign and 60 were malignant. Mammography correctly identified 54 of the malignant lesions while CTM identified 41. Five lesions were missed by both modalities. The report also analyzes results experienced with 79 lesions found in patients who were examined with CTM both before and after the intravenous injection of contrast material. Forty-six of these lesions were benign and 33 were malignant. Mammography correctly identified 28 of the malignant lesions while CTM identified 27. Only one lesion was missed by both modalities. It is planned to continue this study, especially to enlarge our experience with the use of contrast material in breast scanning.

Computerized reconstructive tomography applied to breast pathology.

Breast tumors can be clearly defined from the surrounding breast parenchyma by the use of computerized reconstructive tomography. Certain types of fibrocystic mastitis also can be distinguished from tumors, but other types of fibrous mastitis and probably fibroadenomas may not be distinguishable from tumors unless contrast material is used.

Breast cancer detection today: an opinion.

The family physician, more than most other physicians, is faced with rapidly increasing demands for breast cancer screening. The old standby, physical examination, is now accompanied by mammography, xeromammography, and, more recently, thermography. In this paper, we present our opinion, based on the collective experience at the Mayo Clinic, regarding the use and effectiveness of the several modalities, including mammography, xeromammography, and thermography, available for detection of breast cancer today.