Thomas C. Lee

Impact of inter-physician communication on the effectiveness of medical consultations

To evaluate the impact of the inter-physician communication on the effectiveness of consultations, consultations performed by general and subspecialty medical consultation services for one week both early and late in the academic year were prospectively evaluated. Physicians commonly requested consultations to get advice on diagnosis (56 percent), advice on management (37 percent), or assistance in arranging or performing a procedure or test (20 percent). Despite our very liberal definitions, the requesting physician and the consultant completely disagreed on both the reason for the consultation and the principal clinical issue in 22 (14 percent) of 156 consultations. Consultants were twice as likely as the requesting physicians to rate consultations as crucial for management (35 percent versus 18 percent, p = 0.001) because they gave significantly higher ratings when they and the requesting physicians did not agree on the reasons for consultation. Consultations ordered for very specific purposes, such as assistance in arranging or performing a test, were rated significantly higher by the requesting physicians. It was found that breakdowns in communication are not uncommon in the consultation process and may adversely affect patient care, cost effectiveness, and education.

Real-Time Localization of Parathyroid Adenoma during Parathyroidectomy

Parathyroidectomy is often challenging. This letter reports the use of intraoperative MRI integrated with real-time navigation to guide parathyroidectomy.

CT Grading of Otosclerosis

BACKGROUND AND PURPOSE: The CT grading system for otosclerosis was proposed by Symons and Fanning in 2005. The purpose of this study was to determine if this CT grading system has high interobserver and intraobserver agreement. MATERIALS AND METHODS: All 997 petrous bone CTs performed between December 2000 and September 2007 were reviewed. A total of 81 subjects had CT evidence of otosclerosis on at least 1 side; 68 (84%) had bilateral disease. Because otosclerosis was clinically suspected in both ears of all 81 subjects even if CT evidence was only unilateral, both petrous bones (162 in total) were included. Two blinded neuroradiologists independently graded disease severity using the Symons/Fanning grading system: grade 1, solely fenestral; grade 2, patchy localized cochlear disease (with or without fenestral involvement) to either the basal cochlear turn (grade 2A), or the middle/apical turns (grade 2B), or both the basal turn and the middle/apical turns (grade 2C); and grade 3, diffuse confluent cochlear involvement (with or without fenestral involvement). One reviewer repeat-graded the petrous bone CTs to determine intraobserver agreement with a 7-month intervening delay to mitigate recall bias. RESULTS: There were 154 agreements (95%) comparing the first grading of reviewer 1 with that of reviewer 2 (κ = 0.93). When the repeat 7-month delayed grading of reviewer 1 was compared with that of reviewer 2, there were 151 (93%) agreements (κ = 0.90). Therefore, mean interobserver agreement was excellent (mean κ = 0.92). There were 155 agreements (96%) comparing the original grading of reviewer 1 with the delayed grading (κ = 0.94), demonstrating excellent intraobserver agreement. CONCLUSIONS: A recently published CT grading for otosclerosis on the basis of location of involvement yielded excellent interobserver and intraobserver agreement.

ACTH and the Regulation of Adrenocortical Secretion

THE secretion of the adrenal cortex is in large part regulated by ACTH from the pituitary gland. However, the cortex is really a two-part gland, and the effect of ACTH on one part is different from...

Propranolol Therapy in Thyrotoxicosis A Review of 84 Patients Undergoing Surgery

The effect of propranolol on the surgical course of 84 thyrotoxic patients undergoing partial thyroidectomy or extrathyroidal surgery was evaluated. Seventy-two patients (group 1) underwent surgery with propranolol as their sole preparatory medication, whereas in 12 (group 2) surgery was carried out after a rather prolonged period of thionamide preparation with the addition of propranolol preoperatively as an adjunctive therapeutic agent. Preoperative pulse rate and systolic blood pressure levels fell in both groups, and the clinical features of thyrotoxicosis were rapidly ameliorated with an average dose of propranolol of 330 mg (range 40 to 1,280 mg) daily. Maximal clinical response occurred within 48 to 72 hours of starting propranolol therapy. In 14 patients in group 1, paired serum calcium levels were reduced by the administration of propranolol preoperatively; serum thyroxine levels were unchanged. Serum thyroxine decay, evaluated postoperatively in the patients in group 1, was decreased. The half life of thyroxine was inversely related to the initial thyroxine levels. Analysis of these data indicates that the administration of propranolol alone provides rapid, safe and effective preparation of thyrotoxic patients for emergency or for elective thyroidal or extrathyroidal surgical procedures.

Propranolol and thyroidectomy in the treatment of thyrotoxicosis.

For decades, the preparation of a hyperthyroid patient for surgery took several weeks or months utilizing thyroid blocking agents and iodine. In 1973, a preliminary report of 20 patients with hyperthyroidism treated with propranolol and thyroidectomy was presented. It was found that a thyrotoxic patient could be prepared for surgery, in an emergency, by intravenous propranolol in less than an hour, or electively by oral propranolol within 24 hours. Since then, 140 additional patients have been similarly treated. It continues to be true at this institution that propranolol, a beta-adrenergic blocking agent, effectively neutralizes the symptoms of autonomic hyperactivity, including sweating, tremor, fever, dilation of blood vessels, and increased pulse rate without significantly affecting thyroid function. An average dose of 160 mg/day was used, with a range of 40 to 320 mg/day. In none of these patients was iodine used; in fact, its use with propranolol is considered unnecessary. A subtotal, near total, or total thyroidectomy was done in all patients, resulting in a 55% incidence of hypothyroidism. There was no postoperative thyroid storm, nerve injury, or permanent hypoparathyroidism. It is believed that the administration of propranolol alone provides a rapid, safe, and effective preparation of the thyrotoxic patient for thyroidal or extrathyroidal surgical procedures during the perioperative period.

Three-dimensional printing of MRI-visible phantoms and MR image-guided therapy simulation

To demonstrate the use of anatomic MRI‐visible three‐dimensional (3D)‐printed phantoms and to assess process accuracy and material MR signal properties.

The Value of Pre- and Intraoperative Adjuncts on the Extent of Resection of Hemispheric Low-Grade Gliomas: A Retrospective Analysis

BACKGROUNDnTo achieve maximal resection with minimal risk of postoperative neurologic morbidity, different neurosurgical adjuncts are being used during low-grade glioma (LGG) surgery.nnnOBJECTIVESnTo investigate the effect of pre- and intraoperative adjuncts on the extent of resection (EOR) of hemispheric LGGs.nnnMETHODSnMedical records were reviewed to identify patients of any sex, ≥ 18 years of age, who underwent LGG surgery at X Hospital between January 2005 and July 2013. Patients were divided into eight subgroups based on the use of various combinations of a neuronavigation system alone (NN), functional MRI-diffusion tensor imaging (fMRI-DTI) guided neuronavigation (FD), intraoperative MRI (MR), and direct electrical stimulation (DES). Initial and residual tumors were measured, and mean EOR was compared between groups.nnnRESULTSnOf all 128 patients, gross total resection was achieved in 23.4%. Overall mean EOR was 81.3%u2009±u200920.5%. Using DES in combination with fMRI-DTI (mean EOR: 86.7%u2009±u200912.4%) on eloquent tumors improved mean EOR significantly after adjustment for potential confounders when compared with NN alone (mean EOR: 76.4%u2009±u200925.5%; pu2009=u20090.001).nnnCONCLUSIONSnUsing DES in combination with fMRI and DTI significantly improves EOR when LGGs are located in eloquent areas compared with craniotomies in which only NN was used.

Spontaneous intracranial hypotension from calcified thoracic disc protrusions causing CSF leak successfully treated with targeted epidural blood patch.

Spontaneous spinal cerebrospinal fluid (CSF) leaks are increasingly recognized in patients presenting with orthostatic headache and ultimately diagnosed with intracranial hypotension. While the precise cause of these spontaneous leaks is unknown, it is thought to result from underlying weakness in the spinal meninges and may be associated with meningeal diverticula or Tarlov cysts. Rarely, calcified intervertebral discs or bony osteophytes can result in CSF leakage, which has been described in the surgery literature but not well recognized in the radiology literature. The authors present three cases of patients presenting with CSF leaks from calcified thoracic disc protrusions that were successfully treated with epidural blood patches.

Zuckerkandl Tubercle of the Thyroid: A Common Imaging Finding That May Mimic Pathology

BACKGROUND AND PURPOSE: The posterior thyroid tubercle, also known as ZT, is an important surgical landmark due to its close proximity to the recurrent laryngeal nerve. A recent case of ZT with a nodular configuration caused clinical concern but was shown on biopsy to be normal thyroid tissue. The purpose of this study was to review a series of CT neck studies to identify how often ZT—specifically, a nodular subtype—was present. MATERIALS AND METHODS: A total of 96 neck CTs from sequential patients were retrospectively identified from January 2010 to July 2010. ZT was defined on imaging as a thyroid lobe extending posterior to the tracheoesophageal groove. A nodular subtype was defined as having a narrowed neck at the level of the tracheoesophageal groove. RESULTS: There were 31 women and 45 men (mean age of 56.1 years, range 22–100 years) who met inclusion criteria. Sixty-seven patients had thyroid glands that extended posterior to the tracheoesophageal groove at CT imaging; this finding was bilateral in 43 patients, more commonly on the right (60 versus 49). Thirty-two of these patients (42.1%; 16 male, 16 female) had a nodular subtype. CONCLUSIONS: ZT is an important surgical landmark of the thyroid that has important radiologic variations. It has a nodular shape in over a third of CT neck studies in our series. Recognition of this feature of the thyroid gland at CT imaging can obviate the need for biopsy and avoid potential recurrent laryngeal nerve injury.