Routine prolactin measurement is not necessary in the initial evaluation of male impotence.

The authors determined the prevalence of hyperprolactinemia in impotent men in a community setting and assessed the cost of case detection with routine estimation of serum prolactin. They recruited 299 consecutive patients with impotence and determined the hormonal levels (prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone). Pituitary gland imaging was done when the prolactin level was elevated. Simultaneous prolactin and testosterone levels were available for 212 patients. Three patients (1.4%) had elevated prolactin levels but none had pituitary tumor. Two of these had low testosterone levels. Overall, 51 patients (24.1%) had low testosterone levels. Cost of selective prolactin estimation in patients with low testosterone levels resulted in a net saving of $2,574 per case detected. The authors conclude that the prevalence of hyperprolactinemia in impotence is low. Routine measurement of prolactin levels in impotence is not indicated. Selective determination in patients with low testosterone reduces the cost of diagnostic evaluation.

MRI of suprascapular neuropathy in a weight lifter.

Suprascapular neuropathy results from abnormal compression of the suprascapular nerve, typically at the suprascapular or spinoglenoid notch. This may be produced by either mass effect such as ganglion cyst or by certain repetitive shoulder motions producing wide scapular excursion (e.g., hyperabduction), which causes traction upon the nerve. Certain sports activities such as weight lifting predispose to this type of neuropathy. The clinical presentation is frequently not specific and the patient may be sent for MR evaluation to rule out rotator cuff tear or other more common shoulder abnormalities. This entity should be suspected if MR images demonstrate selective atrophy of the spinatus muscles with a structurally intact rotator cuff.

Post-traumatic synovitis presenting as a mass in the suprapatellar bursa of the knee. MRI appearance.

A lobulated mass in the suprapatellar bursa of the knee is presented with MRI findings simulating the features of focal pigmented villonodular synovitis (PVS). Microscopic examination demonstrated a nonspecific, inflammatory mass of hypertrophied synovium. The MRI features of various forms of synovitis are reviewed from recent literature and differential considerations of a suprapatellar, intrabursal mass are discussed.

The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia.

An abnormal chest roentgenogram is essential for the diagnosis of ventilator-associated pneumonia. The diagnostic accuracy of various roentgenographic signs of pneumonia has not been assessed previously in the portable anteroposterior roentgenograms obtained in ventilated patients. Seven roentgenographic signs (air bronchograms, alveolar infiltrates, silhouette sign, cavities, fissure abutment, atelectasis, and asymmetric infiltrates superimposed on diffuse bilateral infiltrates) were evaluated for their accuracy in predicting pneumonia alone, in combination with other signs, or in combination with clinical parameters. The last roentgenogram prior to autopsy of 69 ventilated patients was interpreted by three reviewers and the above signs were correlated with autopsy evidence of pneumonia. Pneumonia was present in 24 (35 percent) of the 69 autopsies. No roentgenographic sign had a diagnostic efficiency of greater than 68 percent. By stepwise logistic regression, the presence of air bronchograms was the only roentgenographic sign that correlated with pneumonia in the total group, correctly predicting 64 percent of pneumonias. In patients without adult respiratory distress syndrome (ARDS), the presence of air bronchograms or alveolar infiltrates correlated with pneumonia, while in patients with ARDS, no roentgenographic sign and only the clinical parameter of purulent sputum correlated with pneumonia. Only a minority (7/22) of worsening alveolar infiltrates in all groups were due to pneumonia and were often confused with ARDS. Alveolar hemorrhage occurred with a surprising frequency (38 percent of autopsies), including 13/45 (29 percent) patients without pneumonia. Alveolar hemorrhage was associated with 29 percent of multiple air bronchograms and 30 percent of bilateral alveolar infiltrates in patients without pneumonia. We conclude that in intubated patients with diffuse bilateral roentgenographic infiltrates, no roentgenographic sign correlates well with pneumonia. No clinical parameter added to the accuracy of either an alveolar infiltrate or an air bronchogram in patients without diffuse infiltrates. Pulmonary hemorrhage and/or infarction are frequent autopsy findings in intubated patients and may be confused radiologically with pneumonia.

Percutaneous decompression for femoral neuropathy secondary to heparin-induced retroperitoneal hematoma: case report and review of the literature.

Retroperitoneal hematoma resulting in femoral nerve injury is a serious potential complication of systemic heparin anticoagulation. Review of the literature reveals lack of agreement with respect to conservative versus surgical management. The authors report the first case in which return of function was established by percutaneous decompression of a retroperitoneal hematoma in a patient who was not a candidate for immediate surgery. The favorable result suggests that percutaneous drainage may represent a reasonable alternative or first step in surgical treatment of this compression.

Fatty liver change as a result of hepatic artery infusion chemotherapy.

Direct hepatic arterial infusion of floxuridine (FUDR) (Roche Laboratories, Division of Hoffman-LaRoche Inc., Nutley, NJ, U.S.A.) has been used extensively in the treatment of metastases of colorectal tumors to the liver. The effectiveness of infusion and tolerance of the chemotherapy has been improved utilizing a totally implantable infusion pump delivery system. However, unequal distribution of drug infusion may occur to different parts of the liver parenchyma as demonstrated by hepatic arterial infusion scintigraphy (HAPS). We present a case of such unequal perfusion in which fatty metamorphosis of the liver occurred in the overperfused liver segment after FUDR therapy. The liver parenchymal changes were followed by serial computerized tomography scans and proven by biopsy during a minilaparotomy. Serial HAPS examinations show redirection of subsequent infusion to the opposite liver lobe due to parenchymal damage and vascular sclerosis. The importance of uniform liver perfusion and a rare dose-related effect of FUDR on liver parenchyma are thereby demonstrated.

Magnetic resonance imaging of hepatic adenoma.

A case of hepatic adenoma imaged by magnetic resonance imaging (MRI) as well as with angiography, computed tomography, and radionuclide imaging is presented. Pathological correlation is also presented. Review of the literature of MRI of hepatic adenoma and related tumors is discussed.

Magnetic resonance imaging in the diagnosis of anterior tibialis muscle herniation.

Magnetic resonance imaging (MRI) can be employed to successfully image the fascial compartments of the leg. Herniated muscle tissue and fascial discontinuity can each be unequivocally identified. Both the extent of fascial splitting and the size of the muscle herniation can be demarcated and quantified. MRI is favored over computed tomography because of its superior ability to distinguish soft-tissues structures, making it possible to see both muscle and fascia separately.

Massive intraoperative atelectasis secondary to untreated mediastinal Hodgkin's disease: report of the hazard and review of the literature.

Mediastinal adenopathy in Hodgkin's disease has been known to cause relative airway compromise, particularly in the more vulnerable left mainstem bronchus. This has been infrequently reported to occur during general anesthesia and to cause respiratory embarrassment, representing a significant hazard. The possibility of its occurrence should be recognized. Preoperative evaluation of the airway by chest films and tomography, followed by radiation therapy in those patients at risk, is recommended to minimize the chances of respiratory complications during general anesthesia.

Arterial anomaly of crucial importance in resection of head of pancreas.

In a patient with pancreatic cancer, an arterial anomaly was observed that apparently consisted of the congenital absence of the celiac axis and the replacement of the pancreaticoduodenal arcade by an anomalous vessel. The complete or near-complete arterial flow to the liver and spleen depended upon this anomalous prepancreatic vessel that arose from the superior mesenteric artery. The anomaly was demonstrated preoperatively by arteriography. At laparotomy, the anomalous artery was prominent, lying across the surface of the head of the pancreas. Unrecognized, its operative interruption might have threatened the life of the patient. Resection of the head of the pancreas would have required restoration of the arterial flow, preferably by vascular grafting. The anomaly appears to be different from those previously described.

Intraoperative interstitial hyperthermia in conjunction with intraoperative radiation therapy in a radiation-resistant carcinoma of the abdomen: report on the feasibility of a new technique.

The application of a new technique of intraoperative interstitial hyperthermia (IOHT) and intraoperative radiation therapy (IORT) was investigated for unresectable abdominal carcinoma. A 43-year-old white male presented with severe back pain due to metastatic adenocarcinoma in the left paravertebral area, producing erosion of the body of T12. The disease had not responded to external beam radiation therapy. The tumor was approached through a thoraco-abdominal incision and IOHT was delivered via interstitial electrodes. Temperature was monitored at 16 locations within the tumor. An LCF hyperthermia unit was utilized to deliver RF power and produced a treatment temperature of 43 degrees C for 60 minutes uniformly throughout the treatment volume. Immediately following hyperthermia treatment, the lesion was treated with 15 meV electrons via IORT to a tumor dose of 25Gy. The patient recovered without complication and had complete relief from pain. Posttreatment CT scans have demonstrated control of disease over a 5-month follow-up period. A clinical pilot study has been established to further investigate the application of this combination therapy.

Pulmonary vein tumor thrombosis and left atrial extension in lung carcinoma.

A case of lung carcinoma extending into left atrium through a pulmonary vein and mimicking left atrial myxoma is presented. The localized enlargement of a pulmonary vein is seen as a possible CT sign of pulmonary vein tumor thrombosis. Computed tomography (CT) and echocardiography are complementary in the correct diagnosis of this condition.