Assessment of the clinical utility of the rim and comet-tail signs in differentiating ureteral stones from phleboliths.

OBJECTIVE: This study was designed to assess interobserver variability in identifying the rim and comet-tail signs and to determine the clinical utility of these signs in determining whether or not the calcifications with which they are associated represent ureteral calculi. MATERIALS AND METHODS: Two radiologists and a radiology resident, unaware of the final diagnosis, reviewed preselected helical CT images from renal stone examinations in patients with 65 indeterminate pelvic calcifications. Assessment of calcifications for rim or comet-tail signs was performed independently of an assessment for the following five secondary signs of urinary tract obstruction: caliectasis, pelviectasis, ureterectasis, perinephric stranding, and renal enlargement. Agreement in identifying rim and comet-tail signs was assessed by obtaining kappa statistics. The utility the of rim or comet-tail signs in determining whether ureterolithiasis was present in patients in whom perinephric stranding and ureterectasis were present or absent was determined. The frequency with which one or more of each of the five assessed secondary signs was identified ipsilateral to a calcification having rim or comet-tail signs was also tabulated. RESULTS: Kappa values for interobserver agreement ranged from 0.49 to 0.73. In only one patient was a rim sign detected in the absence of ureterectasis and perinephric stranding. Reviewers identified at least three of the five assessed secondary signs ipsilateral to calcifications showing a rim sign in all but one patient (by each radiologist) and four patients (by the resident). When three or more secondary signs of obstruction were seen ipsilateral to a calcification having a comet-tail sign, in all but one instance, this was because the calcification was a ureteral calculus or because there was a separate ipsilateral ureteral calculus. CONCLUSION: In many instances, observers did not agree about whether the rim and comet-tail signs were present. The rim sign was observed in the absence of any secondary signs of urinary tract obstruction in only one (1.5%) of the 65 patients in our series (95% confidence interval, 0-5.3%). The comet-tail sign, when accompanied by secondary signs of obstruction, should indicate that an ipsilateral ureteral stone is present and not the reverse.

Adverse effects of increased body weight on quantitative measures of mammographic image quality.

OBJECTIVE: The purpose of our study was to show that compressed breast thickness on mammograms in overweight and obese women exceeds the thickness in normal-weight women and that increased thickness results in image degradation. SUBJECTS AND METHODS: Three hundred consecutive routine mammograms were reviewed. Patients were categorized according to body mass index. Compression thickness, compressive force, kilovoltage, and milliampere-seconds were recorded. Geometric unsharpness and contrast degradation were calculated for each body mass index category. RESULTS: Body mass index categories were lean (3%), normal (36%), overweight (36%), and obese (25%). Body mass index was directly correlated with compressed thickness. In the mediolateral oblique view, the mean thickness of the obese category exceeded normal thickness by 18 mm (p < 0.01), corresponding to a 32% increase in geometric unsharpness. Mean obese thickness exceeded lean thickness by 33 mm (p < 0.01), corresponding to a 79% increase in unsharpness. Similar trends were observed for the craniocaudal view. In the mediolateral oblique projection, there was an increase of 1.0 kVp (p < 0.01) for obese compared with normal and 1.7 kVp (p < 0.01) between lean and obese, corresponding, respectively, to a 16% and a 25% decrease in image contrast because of scatter and kilovoltage changes. Milliampere-seconds increased by 47% on the mediolateral oblique images in the obese category compared with normal body mass index. CONCLUSION: An increased body mass index was associated with greater compressed breast thickness, resulting in increased geometric unsharpness, decreased image contrast, and greater potential for motion unsharpness.

Progressive esophageal leiomyomatosis with respiratory compromise.

Leiomyomatosis is a rare neoplastic condition of the pediatric esophagus. Presenting symptoms usually overlap with more common esophageal disorders, namely, gastroesophageal reflux. A patient is presented in whom leiomyomatosis progressed to the point of causing cachexia and respiratory compromise.

Use of a phycoerythrin-conjugated anti-glycophorin A monoclonal antibody as a double label to improve the accuracy of FMH quantification by flow cytometry.

The use of flow cytometry for quantifying fetomaternal haemorrhage is increasing, and has been shown to be more accurate than the Kleihauer-Betke test for evaluating larger bleeds of over 4 mL in volume. Red cells are stained with fluorescently labelled monoclonal anti-D. Cells for analysis are normally gated manually on the basis of forward and side scatter. We investigated whether the use of an antiglycophorin A monoclonal antibody conjugate (red cell specific) in a dual labelling technique would improve the gating of RBC and FMH quantification. Mixes of adult rr and cord R1r RBC were prepared to simulate 1, 0.5, 0.25, 0.12 and 0.06% fetal bleeds. Phycoerythrin-conjugated BRIC 256 (mouse monoclonal antiglycophorin A) was used to label all RBC, and FITC-BRAD-3 monoclonal anti-D was used to determine the proportion of D-positive cells. Results from the dual labelling experiments were compared to those from single labelling of the same mixtures with FITC-BRAD-3 alone, using gated and ungated data. The results showed that single labelling with manual gating gave falsely low FMH estimates. We conclude that use of a fluorescently labelled antiglycophorin A antibody improves the accuracy of the FMH measurement by flow cytometry, as manual subjective gating of RBC excludes a higher proportion of fetal than of adult RBC.

Detection of weak D and D(VI) red cells in D-negative mixtures by flow cytometry: implications for feto-maternal haemorrhage quantification and D typing policies for newborns.

Quantitation of feto-maternal haemorrhage (FMH) by flow cytometry (FC) has been shown to be more accurate than the Kleihauer-Bekte test. Fetal cells will be predominately of R1r or R2r phenotype, with antigen site numbers per cell (SPC) of between 9900 and 16000. If the fetus is of weak D or partial D(VI) phenotype, fewer SPC will be present. Red cells from 20 adult weak D samples were mixed with rr red cells to give 1% mixes. Mixtures were stained and analysed by FC, using two different monoclonal reagents. The SPC of each sample was measured using SOL-ELSA with Scatchard plot analysis. 18 samples could not be distinguished and had <1000 SPC. Two samples that could be distinguished had 1350 and 3000 SPC. Red cells from seven samples of D(VI) were also analysed. None of these samples could be distinguished: SPC were all <1000. Although one of the reagents used reacts with D(VI) cells, quantitation of a D(VI) FMH would not be possible due to low SPC. The ability of fetal red cells with low Rh D SPC to cause immunization is questionable; failure to measure FMH in these cases is unlikely to cause clinical problems, as long as suitably sensitive serological reagents and techniques are used to type all weak D and D variant babies as Rh D positive, and thus ensure that the mother is given the appropriate dose of anti-D.

Limitations of student evaluations of curriculum.

RATIONALE AND OBJECTIVES: Medical student surveys are used extensively in the development and modification of curriculum. The purpose of this study was to look at medical student surveys of a radiology lecture series, evaluating the accuracy of student perceptions of learning and factors affecting them. MATERIALS AND METHODS: After a "Case of the Week" lecture series, 156 3rd-year medical students returned a survey evaluating the experience with 10 questions on a four-point scale (1 = disagree, 4 = agree very much) and took a clinical competency assessment (CCA) examination with a radiology substation. Survey responses were compared with actual examination performance, analyzed for how overall learning was characterized in specific educational objectives, and evaluated for factors affecting perceived learning. RESULTS: The mean response for perceived CCA examination preparedness was 1.83. The mean radiology station test score was 90.43%. Correlations between student perception of learning and the scoring of focused learning objectives ranged from 0.33 to 0.48 (P < .01). Students responding 1 to items assessing perceived lecture organization, stimulation to read, and interest in the field of radiology had mean scores for perception of overall learning of 2.09-2.44 and mean scores for recommendation of course continuation of 1.68-2.46. Students responding 4 had means of 3.25-3.81 and 3.06-4.0, respectively. CONCLUSION: Student perceptions of the value of curriculum were inaccurate compared with external measures of performance, and students poorly related their general impressions to specific learning objectives. Perceived lecture organization, stimulation to read, and interest in radiology as a specialty affected perceived overall learning and perceived value of the lecture series.

Quantitation of monoclonal antibodies by ELISA. The use of purified mouse IgG and mouse IgM monoclonal antibodies as standards in a quantitative ELISA measuring monoclonal antibodies produced by cell culture.

Murine monoclonal antibodies (MAbs) of IgG1, IgG2a and IgG2b subclasses and IgM class in hybridoma culture supernatants were quantified using a sensitive, reliable, optimized indirect double antibody sandwich ELISA. In the ELISA, the MAb in the culture supernatants was sandwiched between affinity isolated heavy chain specific polyclonal antibodies used for capture and detection. Quantitation was achieved by comparison with a standard curve produced by a purified MAb of the same class, subclass or ideally the same clone as the MAb to be quantified. These quantitative results were compared with those obtained using purified IgG and IgM polyclonal serum samples as standards and those obtained by total protein estimation using measurement at OD280nm. The IgG subclass MAbs used as standards were purified using protein G and the IgM class MAb was purified by ion exchange followed by gel filtration chromatography. Bovine IgG contamination of the MAb supernatants and the purified MAbs was also measured by a double antibody sandwich ELISA.

Analysis of the structure and activity of A and A,B immunoglobulin A monoclonal antibodies.

A study of the serologic activity and molecular structures of three spleen-derived mouse IgA monoclonal human blood group-specific supernatants was undertaken; this was part of an evaluation of these monoclonals as blood typing reagents. The monoclonal antibodies were eluted through a precalibrated size-exclusion column, and fractions were analyzed by immunoblotting, heavy and light chain-specific enzyme-linked immunosorbent assay, and liquid- and solid-phase serologic tests. Results indicated that one of the supernatants (anti-A specificity) contained tetrameric and monomeric forms of IgA, while the other two (anti-A,B specificity) contained three higher polymeric forms (1000-4000 kDa) and one dimeric form. The tetrameric and polymeric forms showed red cell agglutinating activity, whereas the dimeric and monomeric forms did not. All forms contained heavy and light chains. The monomeric anti-A showed specific binding to appropriate red cells in a solid-phase assay, but the dimeric anti-A,B fractions did not. Purified fractions stored at 4 degrees C did not show any equilibration toward other forms, which indicated that the molecules are stable once secreted. The use of such antibodies as blood grouping reagents requires careful monitoring to ensure that high proportions of nonagglutinating molecular weight forms are not produced, as they could compromise the performance of the reagent by binding to red cell antigen in competition with the agglutinating forms.

Chemical crosslinking of proteins of the influenza virion. 1. Interrelationships.

Purified influenza virus (A/FPV/Rostock/34; H7N1) was reacted with one of three chemical crosslinking reagents [dimethylsuberimidate (DMS), tartryl diazide (TDA) and formaldehyde] under conditions designed to give a ladder of crosslinked polypeptides (putative homo- and heteropolymers) when analysed by SDS-polyacrylamide gel electrophoresis under reducing conditions. The different virion polypeptides were identified by Western blotting with monospecific antisera against HA1, HA2, NP, and M1. When reacted with any crosslinker NP preferentially formed 2mer and 4mer homopolymers while M1 formed 2mers, 4mers, 6mers, and 8mers. 2mers and 3mers of HA1 were detected after crosslinking with TDA and DMS but homopolymers of HA2 could not be identified with certainty due to comigrating M1. One heteropolymer was clearly identified as 1NP:1M1 (with DMS and TDA) and others, as expected, as components of the haemagglutinin spike 1HA1:1HA2, 2HA1:2HA2, and 3HA1:3HA2. Formaldehyde gave rise only to HA1:HA2 polymers. The presence of other heteropolymers containing NP in conjunction with HA2 and HA1 seemed likely. Whenever HA2 ran with an Mr of about 50k it comigrated with M1 suggesting it may have formed (with DMS or TDA) a 1HA2:1M1 heterodimer. However it is possible that this band consisted of HA2 homodimers comigrating with M1 homodimers. Patterns of crosslinking with DMS and TDA were similar although not identical, but those obtained with formaldehyde were markedly different. All patterns were highly reproducible.

Chemical cross-linking of proteins of the influenza virion. 2. Acid-induced irreversible conformational changes in HA1 and HA2.

Purified influenza virus (A/FPV/Rostock/34;H7N1) was exposed briefly to pH 5 before returning to an alkaline pH. Virus was then reacted with one of three chemical cross-linking reagents [dimethyl suberimidate (DMS), tartryl diazide (TDA), or formaldehyde which span 11, 6, and 2A, respectively]. Cross-linked polypeptides were analysed by SDS-polyacrylamide gel electrophoresis under reducing conditions and identified with monospecific antisera against HA1, HA2, NP and M1. Acidification resulted in changes in the cross-linking patterns for both HA1 and HA2 which could be detected with all three reagents. Most notable were the data with formaldehyde: under alkaline conditions cross-linking gave only HA1:HA2 heteropolymers but after brief acidification none of these were formed and in their place was a novel HA1 homodimer, an HA2 homotrimer and an HA2 of Mr 50k cross-linked to form a homodimer with another HA2 or to a heterodimer with M1. Although cross-linking by formaldehyde was much more affected by acidification of the virus than cross-linking by DMS or TDA, over half the polymers cross-linked by DMS were no longer formed after acidification. The patterns of cross-linking of NP and M1 were unchanged by low pH treatment.

Subclinical infections in mice resulting from the modulation of a lethal dose of Semliki Forest virus with defective interfering viruses: neurochemical abnormalities in the central nervous system.

The lethal encephalitis caused in mice by Semliki Forest virus (SFV) is modulated to a subclinical infection by administration of defective interfering SFV, although virus still multiplies both in the central nervous system (CNS) and systemically. Here we report that such infections result in unique and selective changes in the normal levels of CNS neurotransmitters some of which persist after infectious virus can no longer be detected. This represents a previously undocumented category of infection which may have a bearing on the aetiology of those human neurological and neuropsychiatric diseases to which viruses are believed to contribute.

Protection of mice infected with a lethal dose of Semliki Forest virus by defective interfering virus: modulation of virus multiplication.

Certain defective interfering (DI) Semliki Forest virus (SFV) preparations completely protected the majority of mice inoculated with a normally lethal dose of SFV, and the surviving mice showed no signs of disease during the period of observation. Depending upon which DI SFV preparation was used, the survivors were resistant to challenge with 100 LD50 SFV (DI SFV p13a), or were completely sensitive (DI SFV p4), the latter having evidently failed to establish a protective immunity. In this report we compared the ability of these two DI SFV preparations to inhibit multiplication of infectious virus in mice inoculated with 10 LD50 SFV. The following conclusions emerged: virus multiplication was profoundly inhibited in the majority of mice treated with either of the DI virus preparations although there was significant multiplication in most tissues, including brain. The number of mice showing evidence of reduced infectivity titres (58%) correlated well with the 60% which survived without disease in lethality experiments. Despite the presence of infectivity, no SFV antigen or histopathological lesions were detected in brain or spinal cord. The DI virus preparations p4 and p13a altered the distribution of infectivity in the mouse in different ways: during the first 2 days of the infection modulated by DI virus p4, the infectivity titres (in brain, olfactory lobes and spleen) were comparatively high, being greater than 1% of those in mice inoculated with standard virus alone. However, from day 3, titres declined precipitously and there was little infectivity in any of the tissues investigated. On the other hand, mice treated with DI SFV p13a had, over the entire duration of infection, greatly reduced though significant infectivity in brain, olfactory lobes and spleen and very little infectivity in serum. In a minority of mice (14.5%), DI virus p13a altered the distribution of infectivity between different tissues so that there was significantly decreased virus in just one or two of the four tissues investigated, suggesting that the infection was being subtly modulated by the DI virus. Interference assays failed to detect DI SFV in any tissue samples although the effects of DI virus on infection in the mouse were obvious.