The radiographic prevalence of hilar and mediastinal adenopathy in adult cystic fibrosis.

BACKGROUND: It has been stated that the hilar and mediastinal lymph nodes in adults with cystic fibrosis are invariably enlarged from chronic inflammation. However, until correlation with computed tomography and magnetic resonance imaging became possible, the visualization of this feature on plain chest radiographs received very little attention, and even the advent of these modalities, little has been written on the subject. OBJECTIVE AND METHODS: To determine the frequency of positive radiographic evidence of hilar and mediastinal adenopathy, the chest radiographs of 48 adult patients with cystic fibrosis were reviewed. RESULTS: Adenopathy was found in a total of 25 (52%) of the patients hilar in 22 (46%) and mediastinal in 21 (44%). The adenopathy was chronic and slowly progressive in all of the patients, and in no case did it resolve. The distribution of the adenopathy resembled sarcoidosis in 19 of the 25 patients and lymphoma in another patient. CONCLUSIONS: The diagnosis of adenopathy was thought to be acceptably accurate: among patients for whom CT scans were also available, CT confirmed the radiographic diagnosis of abnormality in 22 of 24 sets of hilar lymph nodes and all 14 sets of mediastinal lymph nodes. When observed on chest radiography, mediastinal adenopathy was invariably widespread throughout the mediastinum. The presence of adenopathy was correlated with more severe pulmonary involvement, as assessed by the Brasfield scoring system. However, the importance of observing adenopathy radiographically lies in allaying concerns about the development of sarcoidosis or systemic lymphatic disease in these patients and preventing unnecessary concern and investigation.

Elevated serum lipoprotein(a) is a risk factor for clinical recurrence after coronary balloon angioplasty.

BACKGROUND: Elevated lipoprotein (Lp) (a) concentrations are associated with coronary artery disease and myocardial infarction. Lp(a) is structurally related to proteins involved in lipid transport, fibrinolysis, coagulation, and cellular mitogenesis and is known to have important physiological interactions with the coagulation and fibrinolytic systems. Because these processes may be important to arterial healing after balloon injury, we hypothesized that elevated Lp(a) concentrations may be associated with recurrence of symptoms and restenosis after balloon angioplasty. METHODS AND RESULTS: We assessed 240 consecutive patients undergoing coronary balloon angioplasty with measurements of Lp(a), total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, apolipoprotein A-I, and apolipoprotein B-100 concentrations from fresh specimens. Patients were evaluated 4 to 6 months after angioplasty for clinical recurrence by repeat angiography if angina had returned or by maximal exercise treadmill testing with thallium imaging if patients remained asymptomatic. Ninety-seven patients (40%) had clinical recurrence; 143 (60%) did not. Patients with recurrence had significantly greater Lp(a) concentrations compared with those without (median, 29 versus 14; P < .0001). Each patient quintile stratified by increasing Lp(a) concentrations had incrementally greater recurrence rates ranging from 27% (lowest quintile) to 60% (highest quintile). By multivariate logistic regression analysis, Lp(a) concentration was the only predictor of recurrence (P < .0001). A subset of frozen, stored serum samples showed a significant decrease in measured Lp(a) concentration over time (mean, 605 days; P < .01). CONCLUSIONS: An elevated Lp(a) concentration was a risk factor for clinical recurrence after percutaneous transluminal balloon coronary angioplasty. Other lipid levels or clinical characteristics were not significantly associated with recurrence. When serum was frozen and stored for a prolonged period, Lp(a) concentration decreased over time.

Do false positive thallium-201 scans lead to unnecessary catheterization? Outcome of patients with perfusion defects on quantitative planar thallium-201 scintigraphy.

OBJECTIVES: We postulated that artifactually abnormal thallium-201 scans are well identified at the time of initial clinical interpretation by experienced readers and do not lead to unnecessary coronary angiography. BACKGROUND: Exercise thallium-201 scintigraphy employing quantitative imaging techniques has yielded sensitivity and specificity values of 80% to 90%. There are image artifacts, such as breast shadows, and variants of normal that, if not correctly identified, can lead to a high false positive rate for detection of coronary artery disease. METHODS: Data from 338 consecutive patients with one or more focal thallium-201 defects on quantitative planar images were reviewed. All patients had undergone symptom-limited exercise scintigraphy and were classified as having either artifactual or nonartifactual thallium-201 defects after review of clinical reports. RESULTS: Of the 265 patients with defects judged to be nonartifactual on clinical readings, 167 underwent coronary angiography, which demonstrated significant coronary artery disease (> or = 50% stenosis) in 161 (96%) and normal findings in 6. Four of the latter six had documented prior myocardial infarction. The remaining 73 patients (85% female) had thallium-201 defects deemed to be artifactual on clinical readings, chiefly as a result of breast (66%) and diaphragmatic (8%) attenuation or variants of normal (26%). Only 4 (5%) of the 73 patients underwent subsequent coronary angiography; none had coronary artery disease. One had aortic stenosis and two had variant angina. Follow-up (mean 20 +/- 2 months) of the 69 patients in this group who did not undergo coronary angiography revealed no deaths and one nonfatal non-Q wave myocardial infarction. CONCLUSIONS: Artifactual defects on quantitative planar thallium-201 scintigraphy are well recognized by experienced interpreters and do not result in a high false positive rate leading to unnecessary cardiac catheterization. The incidence of coronary artery disease is high in patients with thallium-201 defects judged to be nonartifactual, and many patients with perfusion defects and angiographically normal coronary arteries have organic heart disease.

Reversible cerebral, hepatic and renal lesions in severe pre-eclampsia.

Several authors have reported the appearance of reversible hypoattenuated cerebral lesions, representing ischemia, in computed tomography scans of patients with severe pre-eclampsia. Hepatic hemorrhage and sometimes rupture have also been reported in this setting, but these problems have apparently never occurred in a patient with reversible ischemia. The authors describe a 34-year-old patient with severe pre-eclampsia in whom reversible cerebral ischemia developed in combination with hepatic and renal hematomas, which subsequently partially resolved.

Gastroduodenal artery aneurysm: treatment by transcatheter embolization.

Aneurysm of the gastroduodenal artery is a rare but well recognized complication of acute and chronic pancreatitis. It appears to be secondary to the proteolytic action of activated pancreatic enzymes on the arterial wall. A case is reported of massive, life-threatening hemorrhage in a patient with a gastroduodenal artery aneurysm. The aneurysm was diagnosed by angiography and treated by embolization with Gianturco coils, the first successful use of this technique. A review of the literature revealed that bleeding in the upper gastrointestinal tract is a very common clinical presentation and is frequently fatal. Arteriography followed by computerized tomography are the most specific modalities of diagnosis.