Susan L. Voci

Calf sonography for detecting deep venous thrombosis in symptomatic patients: Experience and review of the literature

We determined the accuracy of sonography in the detection of isolated calf deep venous thrombosis (DVT) and the rate of indeterminate ultrasound examinations in patients with physical signs or symptoms suggestive of DVT.

Bortezomib and gemcitabine in relapsed or refractory Hodgkin's lymphoma

BACKGROUND Given the significant activity and tolerability of gemcitabine in patients with relapsed Hodgkins lymphoma (HL), the critical role that nuclear factor kappa B (NF-kappaB) appears to play in the pathogenesis of this tumor, the ability of bortezomib to inhibit NF-kappaB activity, and laboratory studies suggesting synergistic antitumor effects of gemcitabine and bortezomib, we hypothesized that this combination would be efficacious in patients with relapsed or refractory HL. PATIENTS AND METHODS A total of 18 patients participated. Patients received 3-week cycles of bortezomib 1 mg/m(2) on days 1, 4, 8, and 11 plus gemcitabine 800 mg/m(2) on days 1 and 8. RESULTS The overall response rate for all patients was 22% (95% confidence interval 3% to 42%). Three patients developed grade III transaminase elevation: one was removed from the study and two had doses of gemcitabine held. Almost all patients exhibited inhibition of proteasome activity with treatment. CONCLUSIONS The combination of gemcitabine and bortezomib is a less active and more toxic regimen in relapsed HL than other currently available treatments. It poses a risk of severe liver toxicity and should be pursued with caution in other types of cancer.

Treated Needles Do They Facilitate Sonographically Guided Biopsies

Objective. We sought to compare needle visualization and diagnostic yield rates resulting from the use of several commercially available treated needles in sonographically guided biopsies. Methods. We conducted a randomized prospective study in which 61 patients (42 women and 19 men; mean age, 57 years; range, 19–84 years) were assigned to undergo biopsies (37 thyroid and 24 liver, 2 passes per patient) with 1 of 4 different 22‐gauge needles: Teflon coated, etched tip, echogenic polymer coated, and untreated. Two blinded radiologists independently scored needle shaft and tip visualization from 0 (no visualization) to 4 (excellent visualization). After blinded cytologic evaluation, the individual passes were rated as adequate or inadequate for establishing a tissue diagnosis. Results. The echogenic polymer‐coated needle had the highest mean score ± SD for visualization of both the shaft (3.4 ± 0.90) and tip (3.5 ± 0.87) compared with the untreated (shaft, 2.2 ± 0.77; P = 0.003; tip, 2.8 ± 0.92; P = 0.01), Teflon‐coated (shaft, 2.7 ± 0.94; tip, 3.1 ± 0.75), and etched tip (shaft, 3.0 ± 0.82; tip, 3.0 ± 0.56) needles. Diagnostic yield rates for the 4 different needle types were 75.0% for the echogenic polymer‐coated, 64.7% for the Teflon‐coated, 56.3% for the etched tip, and 75.0% for the untreated needles (no significant difference). Conclusions. The echogenic polymer‐coated needle was the best visualized of all needles evaluated, both treated and untreated. No significant difference was found in diagnostic yield rates, but that may be reflective of the relatively small sample size.

On Teaching Radiology to Medical Students: A Commentary

The article by Scheiner and colleagues of Brown Medical School (Providence, RI) (1) and the correspondence from Afaq of the Imperial College School of Medicine (London, England) (2) in this issue of Academic Radiology reiterate an old problem. In fact, Afaq cites 30 years of references on the difficulty of gaining access to medical students to teach them radiology. The senior author’s experience at four medical schools confirms this impression. Although we found radiology course electives to be popular, they were never required until we reached the University of Rochester. However, development of our “double helix” curriculum with emphasis on problem-based learning and small-group discussions led to the demise of this short radiology lecture series for preclinical medical students. Scheiner et al (1) most ably present the problem that currently exists. Medical students now receive most of their initial exposure to radiographic images through daily patient rounds on their clinical services. Although the clinicians who lead these rounds are most knowledgeable about basic radiographic findings within their specialty, there is a tendency for the clinicians to overread the images when influenced by physical findings and clinical history. In addition, these rounds are held in large groups, and the medical student rarely obtains an optimal position for viewing the images and hearing the discussion. This is now further compromised by workstation reviews in the filmless environment. When viewed from an off-center location, many monitor screens lack full fidelity and in fact obscure detail for everyone except those few within direct vision. Let us reemphasize that our clinical colleagues are not always uncomfortable reviewing radiologic images of disorders in their specialty or subspecialty. When our ultrasound (US) section converted to a filmless system, we did not anticipate the objection and inconvenience expressed by some of our colleagues, most notably pediatric urologists and pediatric orthopedists. Although US images in many cases are static representations of dynamic evaluations (similar to fluoroscopy), these clinicians used the film images (and now paper copies that we presently supply) to discuss patient care issues with the children’s families. However, even though clinicians may be knowledgeable and comfortable viewing images, they usually teach imaging as a correlative adjunct to physical diagnosis and clinical history rather than as a scientific depiction of the pathophysiology of disease. The emphasis of the new curriculum on problem-based learning and small-group discussions is an opportunity for radiologists to be more effective as consultants. However, participation in this new curriculum is extremely labor intensive. Since only a few medical students can be taught at a time, multiple groups of students must be taught; thus it is difficult to find enough radiologists to teach all of these groups because it impinges on their limited clinical and academic time. Medical student teaching is too often considered a distraction from the perceived primary goal of resident education. Radiology clinical clerkships are still a ready opportunity for teaching and medical student contact. They are also more effective when available in the 3rd or 4th year of medical school. If special attention is to be paid to medical student education, it may become difficult to find enough space to accommodate all students that are interested. However, observation of image interpretation sesAcad Radiol 2002; 9:224–225

Sonography: A useful tool to detect the mechanical causes of renal transplant dysfunction

The purpose of this study was to evaluate the utility of sonography in distinguishing between mechanical and nonmechanical causes for renal transplant dysfunction.

Urine leaks in renal transplant patients:Diagnostic usefulness of sonography and renography

We evaluated the utility of sonography and nuclear medicine renography in the detection of urine leaks in 57 renal transplant patients. Sonography and renography were equally sensitive in detecting leaks. But renography was more specific and therefore accurate (p < 0.0001) in detecting leaks. Urine leaks should be considered on sonography, which is often the first imaging study ordered in evaluating renal transplants, with new or increasing peritransplant fluid collections. Leaks should be confirmed by renography before performing additional invasive radiologic or surgical procedures.

Delayed computed tomographic characterization of renal masses: preliminary experience.

AbstractBackground: To evaluate the performance of delayed contrast enhanced computed tomography (DCT) in characterizing renal masses. Methods: Twenty-four patients with suspected renal masses or indeterminate renal masses on previous imaging studies were prospectively evaluated with preintravenous contrast imaging, conventional contrast-enhanced computed tomography (imaging initiated 2 min after intravenous contrast injection), and DCT (imaging initiated 13 min after injection of intravenous contrast). Only lesions larger than 1.0 cm were evaluated, with scanning parameters kept constant across the three scans. Results: All pathologically confirmed renal cell carcinomas (n= 6) were detected on DCT using a threshold attenuation decrease of 10 Hounsfield units (HU). A significant decrease (p= 0.031) in attenuation occurred in renal cell carcinomas (mean = 29.6 ± 23.6 HU) compared with the attenuation change (mean decrease = 1.1 ± 7.1 HU), which occurred in non-neoplastic renal cysts (n= 34). Non-neoplastic renal cysts were correctly classified by DCT 32 of 34 times (94%). Conclusions: In this study, DCT distinguished renal cell carcinomas from non-neoplastic cysts in a vast majority of cases and may aid in characterizing incidentally discovered renal lesions on postcontrast CT.

Risk of significant coronary artery disease as determined by CT measurement of the distribution of abdominal adipose tissue

Purpose The purpose of this work was to determine if CT measurement of the distribution of abdominal adipose tissue is reproducible between observers and is associated with patient risk of significant coronary artery disease. Method We compared 11 male patients having abdominal CT who had a history of significant coronary artery disease and 9 male patients having abdominal CT without a history of coronary artery disease. Two observers, at the level of the umbilicus, independently measured the ratio of visceral adipose tissue (VAT) to total abdominal adipose tissue (TAT). VAT is equal to the sum total of intraperitoneal and retroperitoneal adipose tissue. TAT equals the sum total of visceral and subcutaneous adipose tissue. Measurements were made using a standard software package. Results The mean ratio of VAT to TAT was significantly different (p < 0.05) between patients with a history of coronary artery disease (mean = 0.51, SD = 0.10, range = 0.38–0.69) and without a history of coronary artery disease (mean = 0.40, SD = 0.12, range = 0.23–0.51). Agreement in measurements between observers was excellent (mean difference = 0.01, range = 0.00–0.03, intraclass correlation = 0.99). Conclusion The measurement of the VAT/TAT ratio is highly reproducible between observers, and a high ratio is associated with patient risk of significant coronary artery disease.

Pleural effusions in patients with Hodgkin lymphoma: clinical predictors and associations with outcome.

Abstract Pleural effusions are common in Hodgkin lymphoma (HL). However, little is known about their prognostic significance. One hundred and ten patients with HL who presented to the University of Rochester from 1 January 2003 to 12 December 2010 were reviewed. Pleural effusions were evaluated on review of diagnostic-quality computed tomography (CT) scans. Pleural effusions were present in 26/110 patients: 1/7 (14%) stage I, 11/61 (18%) stage II, 3/18 (17%) stage III and 11/24 (46%) stage IV, and 25/91 (27%) patients had mediastinal involvement, 16/38 (42%) patients had extranodal involvement (any) and 5/14 (35%) patients had E lesions (direct extension to extranodal tissue). Unilateral and bilateral pleural effusions were equally prevalent. Survival analysis demonstrated decreased overall survival for patients with pleural effusions of borderline significance for stage I–IV (p = 0.055) but failed to show significance for patients with stage I–III (p = 0.115). Increasing stage, any extranodal involvement and bulky mediastinal disease were each predictive of pleural effusions. The presence of pleural effusion at presentation may be predictive of inferior survival for patients with Hodgkin lymphoma.

Effect of angiotensin converting enzyme inhibition on the Doppler waveform in dogs with renal artery stenosis.

Our objective was to investigate whether the angiotensin converting enzyme inhibitor enalaprilat improves detection of hemodynamically significant renal artery stenoses in dogs. Renal artery stenoses of 50 to 99% were surgically created unilaterally in five dogs. Doppler ultrasonographic evaluation was performed at baseline (no stenosis), after creation of the stenosis, and after the administration of enalaprilat. The resistive index increased in the nonstenotic kidney (P < 0.01) but not in the stenotic kidney after administration of enalaprilat. The difference in resistive indices between nonstenotic and stenotic kidneys increased significantly (P < 0.05) after administration of enalaprilat. Measurement of the resistive index after administration of an angiotensin converting enzyme inhibitor in humans may improve the performance of Doppler ultrasonography in detecting hemodynamically significant renal artery stenoses.