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Feuerstein IM, Brazaitis MP, Zoltick JM, Barko WF, Vaitkus MA, Combs JJ, Burger LM, Blanck RR. Electron beam computed tomography screening of the coronary arteries: experience with 3,263 patients at Walter Reed Army Medical Center. Mil Med 2001; 166:432-42. [PMID: 11370209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023] Open
Abstract
The U.S. Department of Defense desires to reduce the impact of coronary atherosclerosis on its active duty, retired, and dependent populations. Electron beam computed tomography (EBCT) is currently the best way to noninvasively image the coronary arteries directly. Between August 1997 and February 1999, a total of 3,263 patients were scanned by EBCT in the Radiology Department at Walter Reed Army Medical Center. Scans were performed on 2,415 men (74%) and 848 women (26%). The most common age group was 50 to 54 years (25%). Coronary calcification was found in approximately half of the patients (46%), and the magnitude of the score was strongly associated with age and male gender. Average scores increased exponentially with age, doubling every 7 years. In men, average scores ranged from 17 units in those aged 35 to 39 years to 842 in those older than 70 years old. In women, average scores ranged from 1 in those 35 to 39 years to 162 in those older than 70 years. Significant numbers of patients fell into the high-risk categories, with 8% of men in their 40s, 20% of men in their 50s, 33% of men in their 60s, and 49% of men in their 70s with high scores. Scores of more than 400 units were seen in 368 patients (8%) overall. There is a large amount of coronary calcium present in military personnel and their dependents, in patterns that are consistent with previous studies. Many patients had very high scores that are consistent with advanced coronary artery disease. EBCT should play a central role in the identification of occult calcific atherosclerosis of the coronary arteries in military, retired, and dependent patients.
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Affiliation(s)
- I M Feuerstein
- Department of Radiology, Room 1X05B, Building 2 (Heaton Pavilion), Walter Reed Army Medical Center, 3900 Georgia Avenue NW, Washington, DC 20307, USA.
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OʼMalley PG, Jones DL, Feuerstein IM, Taylor AJ. Lack of Correlation between Psychological Factors and Subclinical Coronary Artery Disease. Cardiopulm Phys Ther J 2001. [DOI: 10.1097/01823246-200112010-00015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hunt ME, O'Malley PG, Vernalis MN, Feuerstein IM, Taylor AJ. C-reactive protein is not associated with the presence or extent of calcified subclinical atherosclerosis. Am Heart J 2001; 141:206-10. [PMID: 11174333 DOI: 10.1067/mhj.2001.112488] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Both high-sensitivity C-reactive protein (hsCRP) and electron beam computed tomography (EBCT) coronary artery calcification (CAC) are valid markers of cardiovascular risk. It is unknown whether hsCRP is a marker of atherosclerotic burden or whether it reflects a process (eg, inflammatory fibrous cap degradation) leading to acute coronary events. METHODS A nested case-control study was performed of 188 men enrolled in the Prospective Army Coronary Calcium study. The serum hsCRP levels (latex agglutination assay) were evaluated in subjects with CAC (CAC score >0, n = 94) and compared with age- and smoking status-matched control subjects (CAC score 0, n = 94). RESULTS Levels of hsCRP in the highest quartile were related to the following coronary risk factors: smoking status, low-density lipoprotein cholesterol, body mass index, glycosylated hemoglobin, fibrinogen, and homocysteine. The mean hsCRP level was similar in cases (+CAC, 0.20 +/- 0.22 mg/dL) and controls (-CAC, 0.19 +/- 0.21 mg/dL; P =.81) and was unrelated to the log-transformed CAC score (r < 0.01, P =.91). Multivariable analysis controlling for standard risk factors, aspirin, and statin therapy found only that low-density lipoprotein cholesterol was related to CAC. CONCLUSIONS Despite associations with standard and emerging cardiovascular risk factors, hsCRP is unrelated to the presence and extent of calcified subclinical atherosclerosis. This implies that CAC (a disease marker) and hsCRP (a process marker) may be complementary for the prediction of cardiovascular risk.
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Affiliation(s)
- M E Hunt
- Department of Medicine and Cardiology Service, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA
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4
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Abstract
BACKGROUND The relation between psychological variables and clinically evident coronary artery disease has been studied extensively, although the potential mechanisms of such a relation remain speculative. We studied the relation between multiple psychological variables and subclinical coronary artery disease to assess the possible role of such variables in atherogenesis. METHODS We conducted a prospective study of 630 consecutive consenting, active-duty U.S. Army personnel, 39 to 45 years of age, without known coronary artery disease. Each participant was assessed for depression, anxiety, somatization, hostility, and stress. Subclinical coronary artery disease was identified by electron-beam computed tomography. RESULTS The mean (+/-SD) age of the subjects was 42+/-2 years; 82 percent were male, and 72 percent were white. The prevalence of coronary-artery calcification was 17.6 percent (mean calcification score, 10+/-49). The prevalence of prior or current psychiatric disorders was 12.7 percent. There was no correlation between the coronary-calcification score and the scores measuring depression (r= -0.07, P=0.08), anxiety (r=-0.07, P=0.10), hostility (r=-0.07, P=0.10), or stress (r=-0.002, P=0.96). Somatization (the number and severity of durable physical symptoms) was inversely correlated with calcification scores (r=-0.12, P=0.003), even after we controlled for age and sex. In multivariate logistic-regression models, a somatization score greater than 4 (out of a possible 26) was independently associated with the absence of any coronary-artery calcification (odds ratio, 0.49; 95 percent confidence interval, 0.25 to 0.96). CONCLUSIONS Our data suggest that depression, anxiety, hostility, and stress are not related to coronary-artery calcification and that somatization is associated with the absence of calcification.
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Affiliation(s)
- P G O'Malley
- Department of Medicine, Walter Reed Army Medical Center, Washington, DC, USA.
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Jones LM, Mair EA, Fitzpatrick TM, Lyon RD, Feuerstein IM. Multidisciplinary airway stent team: a comprehensive approach and protocol for tracheobronchial stent treatment. Ann Otol Rhinol Laryngol 2000; 109:889-98. [PMID: 11051428 DOI: 10.1177/000348940010901001] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tracheobronchial stents are being used with increasing frequency to treat major airway obstruction from both malignant and benign processes. Traditionally, stents have been placed via rigid bronchoscopy, flexible bronchoscopy, or fluoroscopy by members of various individual disciplines. We describe a novel multidisciplinary airway stent team (MAST) protocol for tracheobronchial stent placement and endoscopic management of major airway obstruction. A patient with symptoms of airway obstruction is generally first evaluated with a computed tomography scan and a videotaped flexible bronchoscopy. These studies are reviewed by the team otolaryngologist, pulmonologist, and interventional radiologist. A treatment plan, including the type and location of stents and the need for adjuvant therapies, is formulated. Stent placement is performed in the operating room under general anesthesia. Rigid bronchoscopy, with flexible bronchoscopy and fluoroscopy as needed, allows precise stent placement and the best use of various therapeutic methods. The MAST protocol combines the skills, knowledge, and unique therapeutic options of specialists from otolaryngology, pulmonology, and interventional radiology. This approach allows optimal stent placement and the use of other endobronchial therapies, including laser ablation, balloon dilation, photodynamic therapy, cryotherapy, and brachytherapy. A protocol with representative case reports is presented, along with a review and comparison of several of our most commonly used stents. Otolaryngologists who practice bronchoesophagoscopy, by virtue of their operative skill and knowledge of airway management, are well equipped to become leaders of MASTs and are encouraged to initiate MASTs at their institutions.
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Affiliation(s)
- L M Jones
- Otolaryngology-Head and Neck Surgery Service, Walter Reed Army Medical Center, Washington, DC, USA
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6
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O'Malley PG, Taylor AJ, Gibbons RV, Feuerstein IM, Jones DL, Vernalis M, Brazaitis M. Rationale and design of the Prospective Army Coronary Calcium (PACC) Study: utility of electron beam computed tomography as a screening test for coronary artery disease and as an intervention for risk factor modification among young, asymptomatic, active-duty United States Army Personnel. Am Heart J 1999; 137:932-41. [PMID: 10220644 DOI: 10.1016/s0002-8703(99)70419-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Screening for coronary artery calcium with electron beam computed tomography (EBCT) has potential diagnostic and prognostic implications. Most prior research on this technology has been done on selected, high-risk populations. The goal of the Prospective Army Coronary Calcium (PACC) study is to determine the utility of EBCT for the detection of coronary calcium as a screening test for coronary artery disease and as an intervention for risk factor modification among young, asymptomatic, active-duty personnel undergoing the United States Army's Cardiovascular Screening Program. METHODS AND RESULTS Three study designs will be used to address the objectives of this investigation: (1) a cross-sectional study of 2000 unselected, consecutive participants to determine the prevalence and extent of coronary calcification in the 40- to 45-year-old Army population, (2) a randomized, controlled trial with a 2 x 2 factorial design involving 1000 participants to assess the impact of EBCT information on several dimensions of patient behavior, with and without intensive risk factor case management, and (3) a prospective cohort study of 2000 participants followed for at least 5 years to establish the relation between coronary calcification and cardiovascular events in an unselected, "low-risk" (by conventional standards) Army population. CONCLUSIONS We present a review of the literature on the clinical utility of EBCT, with a focus on the limited research in young, asymptomatic populations. The details of the PACC study (begun in October1998) are presented. The results of the PACC study will determine the clinical utility of EBCT in young, asymptomatic patients.
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Affiliation(s)
- P G O'Malley
- Department of Medicine, the Cardiology Service, Walter Reed Army Institute of Research, Washington, DC, USA
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7
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Summers RM, Andrasko-Bourgeois J, Feuerstein IM, Hill SC, Jones EC, Busse MK, Wise B, Bove KE, Rishforth BA, Tucker E, Spray TL, Hoeg JM. Evaluation of the aortic root by MRI: insights from patients with homozygous familial hypercholesterolemia. Circulation 1998; 98:509-18. [PMID: 9714107 DOI: 10.1161/01.cir.98.6.509] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In homozygous familial hypercholesterolemia (HFH), the aortic root is prone to develop atherosclerotic plaque at an early age. However, the aortic wall and plaque have not yet been assessed in this condition by MRI. We evaluated the aortic root by use of MRI in 17 HFH patients and 12 normal control subjects in a prospective, blinded, controlled study. METHODS AND RESULTS Morphological assessment of the aortic root was done with spin-echo and gradient-echo MRI scanning. Comparisons were made with a number of measures of disease severity, including cholesterol-year score, calcium score on electron-beam CT (EBCT), and size of Achilles tendon xanthomas. Atherosclerotic plaque, visible on fat-suppressed images but never on water-suppressed images, was present in 9 HFH patients (53%). Supravalvular aortic stenosis was present in 7 patients with HFH (41%). Maximum supravalvular aortic wall thickness was significantly greater and OD and lumen cross-sectional area (CSA) were smaller in patients than in control subjects (P=0.006, 0.0005, and 0.06, respectively). Maximum wall thickness was associated with a greater calcium score on electron-beam CT (P=0.02). Although the cumulative exposure of the aortic root to cholesterol (the cholesterol-year score) was significantly correlated with the Achilles tendon CSA and vascular calcification, this score did not correlate with the wall thickness or aortic CSA. CONCLUSIONS This study not only demonstrates the utility of MRI for detecting and characterizing aortic root atherosclerotic plaque and supravalvular aortic stenosis in HFH patients but also suggests that the LDL receptor plays a direct or indirect role in aortic mural development and vascular growth.
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Affiliation(s)
- R M Summers
- Diagnostic Radiology Department, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA.
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Abstract
Diagnosis of hypoplastic aortic root with ultrafast computed tomography provides important clinical information in homozygous familial hypercholesterolemic patients with supravalvular aortic stenosis.
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Affiliation(s)
- E Jones
- Department of Radiology of the Clinical Center of the National Institutes of Health, Cardiology Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
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Premkumar A, Walworth CM, Vogel S, Daryanani KD, Venzon DJ, Kovacs JA, Feuerstein IM. Prospective sonographic evaluation of interleukin-2-induced changes in the gallbladder. Radiology 1998; 206:393-6. [PMID: 9457191 DOI: 10.1148/radiology.206.2.9457191] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To describe the changes in the gallbladder induced by interleukin-2 (IL-2) therapy and to correlate the findings with the clinical course. MATERIALS AND METHODS Twenty-five men with human immunodeficiency virus (HIV) infection were examined prospectively with right upper quadrant ultrasonography (US) before and after receiving IL-2 therapy. Four patients also underwent US after a second course of IL-2. The gallbladder was evaluated for wall thickening, echotexture, and intramural and pericholecystic fluid. Correlation was made between the clinical signs and symptoms, IL-2 dose, CD4 cell count, and the US appearance of the gallbladder. RESULTS There was significant correlation between symptoms of right upper quadrant pain during IL-2 therapy and US abnormalities of the gallbladder, including an increase in wall thickening (P = .012) and the development of intramural (P = .015) and pericholecystic (P = .006) fluid. More severe abnormalities were seen with higher IL-2 doses. All symptoms resolved with cessation of IL-2 therapy. In patients who underwent repeat US, the gallbladder reverted to a normal appearance. No correlation was found between the CD4 cell count and the development of symptoms or the US appearance of the gallbladder. CONCLUSION IL-2-induced changes resolve rapidly with cessation of therapy, and no surgical intervention is needed. These changes can be avoided or reduced by decreasing the IL-2 dose during subsequent cycles.
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Affiliation(s)
- A Premkumar
- Department of Diagnostic Radiology, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892-1182, USA
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10
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Abstract
We studied the effects of a 12-week progressive resistance strength training program in weakened muscles of 5 patients with sporadic inclusion body myositis (IBM). Strength was evaluated with Medical Research Council (MRC) scale ratings and quantitative isometric and dynamic tests. Changes in serum creatine kinase (CK), lymphocyte subpopulations, muscle size (determined by magnetic resonance imaging), and histology in repeated muscle biopsies were examined before and after training. After 12 weeks, the values of repetition maximum improved in the least weakened muscles, 25-120% from baseline. This dynamic effect was not captured by MRC or isometric muscle strength measurements. Serum CK, B cells, T-cell subsets, and NK cells remained unchanged. Repeat muscle biopsies did not reveal changes in the number and degree of degenerating fibers or inflammation. The size of the trained muscles did not change. We conclude that a supervised progressive resistance training program in IBM patients can lead to gains in dynamic strength of the least weak muscles without causing muscle fatigue and muscle injury or serological, histological, and immunological abnormalities. Even though the functional significance of these gains is unclear, this treatment modality is a safe and perhaps overlooked means of rehabilitation of IBM patients.
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Affiliation(s)
- S A Spector
- Neuromuscular Diseases Section, NINDS, National Institutes of Health, Bethesda, MD 20892, USA
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11
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Abstract
BACKGROUND Indinavir, a protease inhibitor widely used to treat patients with HIV infection, has been associated with nephrolithiasis. Distinctive urinary crystals and a spectrum of urologic disorders were noted in patients receiving indinavir. OBJECTIVE To determine the composition of urinary crystals and the frequency of asymptomatic crystalluria and urinary tract symptoms in patients receiving indinavir. PATIENTS Patients with HIV infection who were enrolled in studies conducted at the National Institutes of Health. MEASUREMENTS Microscopic urinalysis, high-performance liquid chromatography (HPLC) and mass spectrometry of urinary crystals and stones, and clinical evaluation of patients with urologic symptoms. RESULTS Of 240 patients receiving indinavir, 142 provided urine specimens for analysis. Twenty-nine (20%) had crystals consisting of plate-like rectangles and fan-shaped or starburst forms. Mass spectrometry and HPLC confirmed that these crystals were composed of indinavir. Of 40 patients who were not receiving indinavir, none had similar crystals (P < 0.001). Nineteen of the 240 patients receiving indinavir (8%) developed urologic symptoms. Of these, 7 (3%) had nephrolithiasis and the other 12 (5%) had previously undescribed syndromes: crystalluria associated with dysuria and crystalluria associated with back or flank pain. Four of the patients with the latter syndrome had radiographic evidence of intrarenal sludging. CONCLUSIONS Indinavir forms characteristic crystals in the urine. This crystalluria may be associated with dysuria and urinary frequency, with flank or back pain associated with intrarenal sludging, and with the classic syndrome of renal colic.
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Affiliation(s)
- J B Kopp
- National Institute of Diabetes and Digestive and Kidney Diseases, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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12
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Mackall CL, Fleisher TA, Brown MR, Andrich MP, Chen CC, Feuerstein IM, Magrath IT, Wexler LH, Dimitrov DS, Gress RE. Distinctions between CD8+ and CD4+ T-cell regenerative pathways result in prolonged T-cell subset imbalance after intensive chemotherapy. Blood 1997; 89:3700-7. [PMID: 9160675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Rapid recovery of CD4+ T cells after intensive chemotherapy is limited by an age-dependent decline in thymopoiesis. Here we sought to determine whether similar limitations exist for CD8+ T-cell regeneration. After intensive chemotherapy, CD8+ T cells had a faster effective doubling time than CD4+ T cells (median, 12.6 v 28.2 days, P < .05). Accordingly, at 3 months posttherapy, mean CD8+ T-cell number had returned to baseline, whereas mean CD4+ T-cell number was only 35% of pretherapy values (P < .05). These differences were primarily due to very rapid expansion of CD8+CD57+ and CD8+CD28- subsets. At 3 months posttherapy, there was no relationship between age and CD8+ T-cell number (R = -.02), whereas CD4+ T-cell number was inversely related to age (R = -.66) and there were no discernible differences in CD8+ recovery among patients with or without thymic enlargement, whereas CD4+ recovery was enhanced in patients with thymic enlargement after chemotherapy (P < .01). Therefore thymic-independent pathways of T-cell regeneration appear to rapidly regenerate substantial numbers of CD8+, but not CD4+ T cells, resulting in prolonged T-cell subset imbalance after T-cell depletion. These inherent distinctions between CD4+ v CD8+ T-cell regeneration may have significant implications for immunotherapeutic strategies undertaken to eradicate minimal residual neoplastic disease after cytoreductive chemotherapy.
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Affiliation(s)
- C L Mackall
- Laboratory of Mathematical Biology, National Cancer Institute, and the Clinical Pathology Department, National Institutes of Health, Bethesda, MD 20892-1928, USA
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Dugi KA, Feuerstein IM, Hill S, Shih J, Santamarina-Fojo S, Brewer HB, Hoeg JM. Lipoprotein lipase correlates positively and hepatic lipase inversely with calcific atherosclerosis in homozygous familial hypercholesterolemia. Arterioscler Thromb Vasc Biol 1997; 17:354-64. [PMID: 9081692 DOI: 10.1161/01.atv.17.2.354] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Homozygous familial hypercholesterolemia (FH) is a rare genetic disorder that leads to premature atherosclerosis due to a defective LDL receptor. There is, however, a large degree of phenotypic heterogeneity at the level of atherosclerosis even in patients with identical mutations of the LDL receptor protein. Lipoprotein lipase (LPL) and hepatic lipase (HL) are crucial enzymes in lipoprotein metabolism, and both have been proposed as having proatherogenic as well as antiatherogenic effects. To evaluate a potential role for these enzymes in the severity of atherosclerosis, we correlated postheparin LPL mass and activity as well as HL activity with the volume of total calcific atherosclerosis (heart and thoracic aorta), coronary artery calcific atherosclerosis, and Achilles tendon width as measured by computed tomography in 15 FH homozygotes. LPL dimer and total mass were positively correlated with all three parameters (r = .65 to .87, P < .01) as was LPL activity (r = .52 to .63, P < .05). HL activity was negatively correlated with total and coronary artery calcified lesion volume (r = -.55 to .57, P < .05). In a multiple regression model of the coronary artery lesion volume, LPL dimer mass and HL activity together accounted for 84% of the variability (r = .92, P < .0001). In a multiple regression model of the total calcified lesion volume, HL activity, total cholesterol, age, and LPL dimer mass together accounted for 85% of the variability (r = .92, P = .0005). These data demonstrate a significant correlation of LPL mass and activity with the extent of calcific atherosclerosis in homozygous FH. It is not clear whether LPL is the cause or consequence of the observed correlation, but if the association between LPL and coronary artery lesions is also present in patients with other genetic dyslipoproteinemias, LPL could constitute a new risk factor for cardiovascular disease.
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Affiliation(s)
- K A Dugi
- Department of Radiology, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892-1666, USA
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Abstract
We evaluated changes in the dynamic and isometric strength in the newly weakened quadriceps muscles and asymptomatic triceps muscles of 6 patients with postpolio muscular atrophy (PPMA) after 10 weeks of progressive resistance strength training. Alterations in muscle size were determined with magnetic resonance imaging. Serum creatine kinase levels were measured throughout training, and histological signs of muscle injury and changes in muscle fiber size and types were assessed with muscle biopsies before and after training. Exercise training led to an increase in dynamic strength of 41% and 61% for the two knee extensor tests, and 54% and 71% for the two elbow extensor tests. Up to 20% of the improvement was maintained 5 months after cessation of training. Isometric strength, whole muscle cross-sectional areas of quadriceps and triceps muscles, and serum muscle enzymes did not change. No destructive histopathological changes were noted in the repeat muscle biopsies, and no consistent changes in muscle fiber size or fiber type percentages were observed. These results demonstrate that a supervised resistance training program can lead to significant gains in dynamic strength of both symptomatic and asymptomatic muscles of PPMA patients without serological or histological evidence of muscular damage.
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Affiliation(s)
- S A Spector
- Neuromuscular Disease Section, NINDS, National Institutes of Health, Bethesda, Maryland 20892, USA
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15
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Schmidt HH, Hill S, Makariou EV, Feuerstein IM, Dugi KA, Hoeg JM. Relation of cholesterol-year score to severity of calcific atherosclerosis and tissue deposition in homozygous familial hypercholesterolemia. Am J Cardiol 1996; 77:575-80. [PMID: 8610605 DOI: 10.1016/s0002-9149(97)89309-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The high concentrations of low-density lipoprotein cholesterol in plasma lead to accelerated atherosclerosis in patients homozygous for familial hypercholesterolemia (FH). We addressed the hypothesis that lipid deposition in the arterial vasculature and in nonvascular tissues in these patients correlates with both the duration and severity of their hypercholesterolemia. The severity of calcific atherosclerosis was defined by calcification scores and a calcified volume determined by electron beam tomography. The extent of tendinous xanthomatosis was quantitated by computed tomography. A cholesterol-year score was calculated based on the age and the yearly mean serum cholesterol concentration of each patient. Seventeen patients homozygous for FH were followed up. The average total cholesterol concentration in the study group was 780 +/- 231 mg/dl (20.2 mmol/L), and the cholesterol-year scores ranged from 2,172 mg-year/dl (56 mmol-year/L) to 32,260 mg-year/dl (834 mmol-year/L). Achilles tendon width (r=0.86) and cross-sectional area (r=0.81; both p <0.001) were best correlated with the cholesterol-year score. In addition, the coronary (r=0.61; p<0.05), ostial (r=0.45; p<0.05), and total (r= 0.77; p<0.001) calcification atherosclerosis scores all were best correlated with the cholesterol-year score. Calcific atherosclerosis was not observed in these patients until the cholesterol-year score exceeded 10,000 mg-year/dl (260 mmol-year/L). These findings establish a direct association of cholesterol-year with extravascular lipid deposition in tissues of patients with FH. The cholesterol-year score may be useful in defining the risk of atherosclerosis in patients with more common forms of hypercholesterolemia.
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Affiliation(s)
- H H Schmidt
- Molecular Disease Branch of the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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Abstract
OBJECTIVE Morphing is an image processing technology that transforms one image into another by generating a series of intermediate synthetic images. The ability to perform morphing, once restricted to high-end graphics workstations, is now widely available for desktop computers. We investigated the potential use of morphing for displaying radiographic images. MATERIALS AND METHODS Morphing was performed with commercially available software (Morph 2.5; Gryphon Software, San Diego, CA) on a Macintosh (Apple Computer, Cupertino, CA) computer. Images from 26 patients with serial radiologic studies were selected, digitized, and morphed. Key points and key surfaces were identified on the images to improve the quality of the morph movie, a process that took approximately 15 min. The images were then morphed into a continuous Quick Time (Apple) movie lasting 5-7 sec. When a sequence contained more than two images, a single movie incorporating all the images was created. The intervals between segments of the movie were made proportional to the actual time elapsed between the images. Images obtained with different techniques (positron emission tomography and MR imaging) were also morphed. Three observers judged the quality of the morph movies as satisfactory, good, or excellent. RESULTS Twenty of the 26 movies were judged to be of good or excellent quality. The movie format allowed the rapid display of multiple images in a concise 5- 7-sec time frame. Moreover, the movie allowed the recognition of several simultaneous processes more easily than was possible with static images. Morphing two images of the same anatomic site using different techniques (MR imaging and positron emission tomography) proved to be a simple method of superimposing images. CONCLUSION Morphing is a readily available and easily learned technique for displaying serial studies. The movie format is a more interesting, intuitive, and concise summary of events than can be provided by serial static images. Morphing may be useful for displaying large numbers of serial images in a short time for occasions such as clinical conferences or teaching purposes.
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Affiliation(s)
- P L Choyke
- Department of Radiology, National Institutes of Health, Warren G. Magnuson Clinical Center, Bethesda, MD 20892-1182, USA
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Mackall CL, Fleisher TA, Brown MR, Andrich MP, Chen CC, Feuerstein IM, Horowitz ME, Magrath IT, Shad AT, Steinberg SM. Age, thymopoiesis, and CD4+ T-lymphocyte regeneration after intensive chemotherapy. N Engl J Med 1995; 332:143-9. [PMID: 7800006 DOI: 10.1056/nejm199501193320303] [Citation(s) in RCA: 782] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Inadequate reconstitution of CD4+ T lymphocytes is an important clinical problem complicating chemotherapy, human immunodeficiency virus infection, and bone marrow transplantation, but relatively little is known about how CD4+ T lymphocytes regenerate. There are two main possibilities: bone marrow-derived progenitors could reconstitute the lymphocyte population using a thymus-dependent pathway, or thymus-independent pathways could predominate. Previous studies have suggested that the CD45RA glycoprotein on CD4+ T lymphocytes is a marker for progeny generated by a thymus-dependent pathway. METHODS We studied 15 patients 1 to 24 years of age who had undergone intensive chemotherapy for cancer. The absolute numbers of CD4+ T lymphocytes in peripheral blood and the expression of CD45 isoforms (CD45RA and CD45RO) on these lymphocytes were studied serially during lymphocyte regeneration after the completion of therapy. Radiographic imaging of the thymus was performed concomitantly. RESULTS There was an inverse relation between the patients' ages and the CD4+ T-lymphocyte counts six months after therapy was completed (r = -0.92). The CD4+ recovery correlated quantitatively with the appearance of CD45RA+CD4+ T lymphocytes in the blood (r = 0.64). There was a higher proportion of CD45RA+CD4+ T lymphocytes in patients with thymic enlargement after chemotherapy than in patients without such enlargement (two-sided P = 0.015). CONCLUSIONS Thymus-dependent regeneration of CD4+ T lymphocytes occurs primarily in children, whereas even young adults have deficiencies in this pathway. Our results suggest that rapid T-cell regeneration requires residual thymic function in patients receiving high-dose chemotherapy.
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Affiliation(s)
- C L Mackall
- Experimental Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892
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18
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Mautner GC, Mautner SL, Froehlich J, Feuerstein IM, Proschan MA, Roberts WC, Doppman JL. Coronary artery calcification: assessment with electron beam CT and histomorphometric correlation. Radiology 1994; 192:619-23. [PMID: 8058924 DOI: 10.1148/radiology.192.3.8058924] [Citation(s) in RCA: 255] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To assess the reliability of electron beam computed tomography (CT) in the detection of calcific deposits in coronary arteries. MATERIALS AND METHODS The authors quantitatively evaluated a total of 4,298 segments of coronary arteries with electron beam CT and histomorphometry. RESULTS Regression analysis of the electron beam CT calcium score versus histomorphometric calcium area produced an r2 value of .92 (r = .96; P < .0001). Ninety-three percent (78 of 84) of all coronary arteries with stenosis of 76%-100% contained calcific deposits, and 20% (17 of 83) of all coronary arteries with stenosis of 0%-50% contained calcific deposits. CONCLUSION The amount of calcific deposits detected with electron beam CT correlates highly with histomorphometric measurements. Also, the amount of calcific deposits correlates well with the degree of coronary artery stenosis. Electron beam CT, therefore, is a promising noninvasive technique that can help depict the presence and extent of atherosclerotic plaques.
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Affiliation(s)
- G C Mautner
- Department of Diagnostic Radiology, Clinical Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892
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19
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Mautner SL, Mautner GC, Froehlich J, Feuerstein IM, Proschan MA, Roberts WC, Doppman JL. Coronary artery disease: prediction with in vitro electron beam CT. Radiology 1994; 192:625-30. [PMID: 8058925 DOI: 10.1148/radiology.192.3.8058925] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE To investigate the potential to predict coronary artery disease with electron beam computed tomography (CT). MATERIALS AND METHODS Fifty heart specimens were examined with electron beam CT and histomorphometric techniques to measure calcific deposits as a percentage of blockage. RESULTS In group A specimens (from cadavers of patients with symptomatic coronary artery disease), calcific deposits were identified at electron beam CT in 41% (584 of 1,426) of all segments of coronary arteries; in group B specimens (with asymptomatic coronary artery disease), in 24% (369 of 1,535) of all segments; and in the normal control specimens, in 4% (47 of 1,337) of all segments; segments (group A vs control specimens, P < .0001; group B vs control specimens, P = .02). On the basis of logistic regression analysis, coronary artery disease would be predicted if the average electron beam CT calcium score exceeds 0.32. The sensitivity and specificity of electron beam CT in the detection of calcific deposits per coronary artery was 94% and 76%, respectively. CONCLUSION The electron beam CT calcium score appears to be an effective predictor of coronary artery disease.
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Affiliation(s)
- S L Mautner
- Department of Diagnostic Radiology, Clinical Center, National Institutes of Health, Bethesda, MD 20892
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20
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Hoeg JM, Feuerstein IM, Tucker EE. Detection and quantitation of calcific atherosclerosis by ultrafast computed tomography in children and young adults with homozygous familial hypercholesterolemia. Arterioscler Thromb 1994; 14:1066-74. [PMID: 8018661 DOI: 10.1161/01.atv.14.7.1066] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Ultrafast computed tomography (CT) is a new method for detecting calcific lesions in the coronary arteries. The ability of CT to detect and quantify coronary artery atherosclerosis in children and young adults at risk for malignant atherogenesis was evaluated. A total of 11 consecutive familial hypercholesterolemic (FH) homozygotes (3 to 37 years old) participated. Untreated total cholesterol concentrations were 488 to 1277 mg/dL (12.7 to 33.2 mmol/L). Angiography detected significant lesions in 7 of 11 patients. CT detected calcific atherosclerosis in all 9 of the patients older than 12 years of age, including all those with angina. CT was more sensitive in detecting aortic root and coronary ostial lesions, where atherosclerosis first appears in homozygous FH. The volume of calcification (in cubic millimeters) correlated with the severity and duration of the hypercholesterolemia (r = .62, P < .05) as well as with the presence of angina (P < .05). All patients with angina (7 of 7) had > 150 mm3 of calcified volume, whereas only 1 of 4 asymptomatic patients had a volume score > 150 mm3. We conclude that (1) coronary and aortic calcium phosphate deposits are common in young FH homozygotes; (2) these deposits are associated with the presence of angiographic stenoses, as has been seen in adults with coronary atherosclerosis; and (3) aortic calcific deposits are more common than calcific coronary lesions.
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Affiliation(s)
- J M Hoeg
- Molecular Disease Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892
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21
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Powell FC, Spooner KM, Shawker TH, Premkumar A, Thakore KN, Vogel SE, Kovacs JA, Masur H, Feuerstein IM. Symptomatic interleukin-2-induced cholecystopathy in patients with HIV infection. AJR Am J Roentgenol 1994; 163:117-21. [PMID: 8010196 DOI: 10.2214/ajr.163.1.8010196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This study reports the clinical and radiologic findings in seven patients infected with HIV who had 10 consecutive episodes of symptomatic cholecystopathy induced by infusion of interleukin-2. SUBJECTS AND METHODS Ten episodes of right upper quadrant pain associated with gallbladder wall thickening were seen in seven of 29 HIV-infected patients who received IV interleukin-2. Patients received 6-18 million IU/day of continuous interleukin-2 infusion for 5 days. Patients with right upper quadrant pain underwent sonographic examinations, which were interpreted prospectively. Medical records and previous sonographic studies were reviewed retrospectively. Follow-up was obtained through outpatient visits and sonography. RESULTS Right upper quadrant pain during these 10 episodes of cholecystopathy usually developed 4-5 days after starting infusion of interleukin-2. Sonography during that time showed gallbladder wall thickening (mean thickness, 12.4 mm; range, 5-18 mm) and a wide variety of sonographic appearances. Tenderness during sonography was focal in six episodes, diffuse in one, and absent in three. Sludge was identified in one episode; calculi were not seen. Findings on radionuclide biliary scans were normal in three cases. Symptoms abated rapidly in every case after infusion of interleukin-2 was reduced or stopped. No surgery was necessary. When treatment was repeated, three patients had recurrent episodes, with clinical courses and sonographic aberrations showing little variance from the initial episodes. Follow-up sonography in three episodes showed a maximal thickness of the gallbladder wall of 4 mm. No patient had a history or laboratory evidence of intrinsic biliary disease. CONCLUSION Symptomatic thickening of the gallbladder wall during infusion of interleukin-2 can exactly mimic other forms of acalculous cholecystitis, except that when associated with interleukin-2 the thickening is rapidly reversible and surgery is not required. Radionuclide scans can be useful in clinical decision making. The process appears to be benign, and cessation of interleukin-2 therapy, along with close clinical observation, appears to be the appropriate treatment.
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Affiliation(s)
- F C Powell
- University of Illinois College of Medicine, Peoria, IL 61656
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22
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Weinberger M, Hollingsworth H, Feuerstein IM, Young NS, Pizzo PA. Successful surgical management of neutropenic enterocolitis in two patients with severe aplastic anemia. Case reports and review of the literature. ACTA ACUST UNITED AC 1993. [PMID: 8422192 DOI: 10.1001/archinte.1993.00410010127013] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We describe two patients with severe aplastic anemia in whom neutropenic enterocolitis developed while they were undergoing treatment at the National Institutes of Health. Both patients had progressive symptoms while receiving optimal medical management and both underwent and survived surgical intervention despite continued prolonged neutropenia in the perioperative period. This experience contrasts with six cases reported in the literature and suggests that surgery can be employed even in patients with profound neutropenia. Thus, in patients who remain persistently septic or who develop clinical deterioration despite medical management or who have other indications for surgical intervention, neutropenia should not be a contraindication to the appropriate or necessary procedure.
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Affiliation(s)
- M Weinberger
- Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, Md
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23
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Mixson AJ, Friedman TC, Katz DA, Feuerstein IM, Taubenberger JK, Colandrea JM, Doppman JL, Oldfield EH, Weintraub BD. Thyrotropin-secreting pituitary carcinoma. J Clin Endocrinol Metab 1993; 76:529-33. [PMID: 8432799 DOI: 10.1210/jcem.76.2.8432799] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pituitary tumors rarely metastasize outside the central nervous system. Of the more than 100 reported TSH-secreting adenomas, we now describe the first carcinoma. A 40-yr-old woman had transsphenoidal surgery for a large TSH-secreting pituitary adenoma in 1984. She had increased thyroid hormone levels with a TSH that varied from 16-31 microU/mL, and an unusually high alpha-subunit that ranged from 125-150 ng/mL. Because of residual tumor, she had a left craniotomy in 1985 followed by radiation. Despite these therapies, she had a residual tumor that remained stable until January 1989 when her tumor nearly doubled in size. She received radiation therapy and octreotide with marked diminution of the tumor and clinical improvement. In August 1989, she presented with leg weakness, and magnetic resonance imaging revealed a large sacral mass. A biopsy confirmed that the sacral mass was a metastasis from the pituitary tumor. Due to additional metastases in the lung, she received 5-fluorouracil, cytoxan, and adriamycin, with marked decrease in her lesions. Further substantiation of the metastatic pituitary tumor was made when the patient returned in December 1989 with a pleural effusion containing pituitary tumor cells. Of all the reported cases of TSH-secreting adenomas, this case had the highest alpha-subunit portending future metastases. Furthermore, the apparent response to octreotide and response to chemotherapy are encouraging and suggest that new therapies should be explored. Finally, since TSH-secreting adenomas tend to be more invasive than other pituitary tumors, this case underscores the need for early diagnosis and aggressive treatment of these tumors.
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Affiliation(s)
- A J Mixson
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892
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24
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Levine SJ, Kennedy D, Shelhamer JH, Kovacs A, Feuerstein IM, Gill VJ, Stock F, Solomon D, Boylen CT, Masur H. Diagnosis of Pneumocystis carinii pneumonia by multiple lobe, site-directed bronchoalveolar lavage with immunofluorescent monoclonal antibody staining in human immunodeficiency virus-infected patients receiving aerosolized pentamidine chemoprophylaxis. Am Rev Respir Dis 1992; 146:838-43. [PMID: 1416407 DOI: 10.1164/ajrccm/146.4.838] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The yields of both induced sputum examination and bronchoalveolar lavage (BAL) have been reported to be decreased for breakthrough episodes of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients receiving aerosolized pentamidine chemoprophylaxis. This study assessed whether the yield of a single middle or lower lobe BAL could be increased by the utilization of two techniques: (1) indirect immunofluorescent staining with a combination of two murine monoclonal anti-Pneumocystis antibodies in addition to routine toluidine blue O and cytopathologic staining, and (2) the performance of multiple lobe, site-directed BAL (i.e., both upper lobe and middle or lower lobe lavage, including the lobe with the greatest radiographic abnormality). Results of 252 fiberoptic bronchoscopies performed at the National Institutes of Health and the Los Angeles County-University of Southern California Medical Center were analyzed. P. carinii pneumonia was documented in 21 episodes in patients who did not receive prior anti-Pneumocystis chemoprophylaxis and in 41 episodes in patients who received aerosolized pentamidine. Monoclonal antibody staining and multiple lobe, site-directed BAL resulted in similar diagnostic yields for P. carinii in the nonprophylaxis (100%) and aerosolized pentamidine (98%) groups. If BAL had been performed without monoclonal antibody staining and multiple lobe, site-directed lavage, then the yield would have decreased to 95% in the nonprophylaxis group and to 80% in the aerosolized pentamidine group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S J Levine
- Critical Care Medicine Departments, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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25
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Doppman JL, Gill JR, Miller DL, Chang R, Gupta R, Friedman TC, Choyke PL, Feuerstein IM, Dwyer AJ, Jicha DL. Distinction between hyperaldosteronism due to bilateral hyperplasia and unilateral aldosteronoma: reliability of CT. Radiology 1992; 184:677-82. [PMID: 1509049 DOI: 10.1148/radiology.184.3.1509049] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hyperaldosteronism due to a unilateral adenoma must be distinguished from hyperaldosteronism due to bilateral hyperplasia to enable the proper choice between surgical treatment (for adenoma) or medical treatment (for hyperplasia). To compare the efficacy of computed tomography (CT) and adrenal venous sampling, both examinations were performed in 24 patients with primary aldosteronism. All patients with a diagnosis of adenoma based on findings at venous sampling underwent adrenalectomy. The CT-based diagnosis was unilateral aldosteronoma in 17 patients and hyperplasia in seven patients. On the basis of venous sampling, unilateral adenoma was diagnosed in 22 patients; this diagnosis was confirmed by means of unilateral adrenalectomy in 21 patients. The most common error was diagnosis of hyperplasia based on the presence of bilateral nodules on CT scans: In six of seven patients with such a diagnosis, venous sampling and subsequent surgery revealed a unilateral adenoma. In hyperaldosteronism with multiple bilateral nodules, CT cannot reliably permit distinction between hyperplasia and adenoma.
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Affiliation(s)
- J L Doppman
- Department of Diagnostic Radiology, Warren G. Magnuson Clinical Center, Bethesda, Md. 20892
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26
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Mueller BU, Butler KM, Higham MC, Husson RN, Montrella KA, Pizzo PA, Feuerstein IM, Manjunath K. Smooth muscle tumors in children with human immunodeficiency virus infection. Pediatrics 1992; 90:460-3. [PMID: 1518708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- B U Mueller
- Pediatric Branch of the National Cancer Institute, National Institutes of Health, Bethesda, MD
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27
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Abstract
PURPOSE To determine the clinical and radiographic characteristics of sinusitis in patients with human immunodeficiency virus type 1 (HIV-1) infection. PATIENTS AND METHODS A retrospective study was performed that identified all HIV-1-infected patients with sinus radiographs, sinus computed tomograms, or magnetic resonance imaging of the head between 1982 and 1989 (n = 145). Medical record review detailed the clinical course and laboratory parameters in all patients. RESULTS Eighty-nine patients had radiographic evidence of sinusitis; 75 patients had adequate clinical data and comprise the study group. Acute sinusitis was seen in 10 patients (13%), while all 75 patients had mucosal thickening indicative of chronic sinusitis. Fifty patients (67%) were symptomatic with fever, nasal congestion or discharge, and headache being the most common symptoms; nineteen patients (25%) were asymptomatic when their radiographs showed active disease. The mean CD4 count for the group was 276 cells/mm3; 32 (43%) had CD4 counts less than or equal to 100 cells/mm3. Twenty-three patients (31%) received antibiotics orally, parenterally, or both. CONCLUSIONS Sinusitis appears to occur frequently in HIV-infected patients, is often asymptomatic, may be recurrent or refractory, and may be associated with declining immunocompetence in HIV-infected patients.
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Affiliation(s)
- J J Zurlo
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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28
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29
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Weinberger M, Berg SL, Feuerstein IM, Pizzo PA, Witebsky FG. Disseminated infection with Mycobacterium gordonae: report of a case and critical review of the literature. Clin Infect Dis 1992; 14:1229-39. [PMID: 1623079 DOI: 10.1093/clinids/14.6.1229] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Mycobacterium gordonae is only rarely a cause of infection despite its ubiquity in the environment. We describe an 11-year-old girl with disseminated infection due to M. gordonae whose course was complicated by renal failure requiring hemodialysis but who recovered after 15 months of chemotherapy. In a literature search we identified 23 additional cases of infection attributed to M. gordonae, with involvement of the lungs (eight), soft tissue (seven), the peritoneal cavity (three), the cornea (one), and with disseminated disease (five patients, including ours). Two patients were infected with human immunodeficiency virus. We assessed the patterns of infection characteristic of each site and the antibiotic sensitivities of the isolates. Adequate documentation of M. gordonae infection (e.g., amount of growth per culture, detection of specific biochemical characteristics, and confirmation of the organism's identity by a reference center) was lacking in many reports. M. gordonae should not automatically be dismissed as a contaminant when isolated from clinical material. Additional studies are required to establish the extent of this organism's pathogenic role.
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Affiliation(s)
- M Weinberger
- Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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30
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Feuerstein IM, Jicha DL, Pass HI, Chow CK, Chang R, Ling A, Hill SC, Dwyer AJ, Travis WD, Horowitz ME. Pulmonary metastases: MR imaging with surgical correlation--a prospective study. Radiology 1992; 182:123-9. [PMID: 1727274 DOI: 10.1148/radiology.182.1.1727274] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The sensitivity of magnetic resonance (MR) imaging for detection of pulmonary metastases in 11 patients scheduled for thoracotomy and curative resection of metastases was evaluated with a prospective, controlled study. MR imaging performed at 0.5 T was compared with chest radiography, computed tomography (CT), and thoracotomy in 12 cases. (One patient had two separate occurrences of pulmonary metastases.) All images were interpreted in blinded fashion. When all MR sequences were interpreted together, MR imaging enabled correct identification of all patients with pulmonary nodules (100%). CT enabled detection of at least one nodule in all 12 cases (100%) by design; the sensitivity of chest radiography was only 64%. For individual nodules, MR imaging was at least as sensitive as CT (P2 less than .25 [two-sided value]) and significantly more sensitive than chest radiography (P2 less than .01). Among all MR sequences, short inversion time inversion-recovery sequences had the highest sensitivity for detection of individual nodules (82%).
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Affiliation(s)
- I M Feuerstein
- Department of Diagnostic Radiology, National Institutes of Health, Bethesda, MD 20892
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31
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Elwood LJ, Dobrzanski D, Feuerstein IM, Solomon D. Pneumocystis carinii in pleural fluid. The cytologic appearance. Acta Cytol 1991; 35:761-4. [PMID: 1950331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We describe the cytologic appearance of Pneumocystis carinii in pleural fluid of a patient with acquired immunodeficiency syndrome and a rapidly accumulating pleural effusion. The diagnosis of P carinii infection was made by examination of air-dried, Diff-Quik-stained Cytospin preparations of the pleural fluid. The diagnostic appearances of P carinii organisms stained by this method and by the Papanicolaou stain are reviewed. The unusual predominance of the trophozoite forms of the organism in this case made Diff-Quik an ideal special stain for identifying the organisms. Furthermore, this case illustrates a novel presentation of P carinii infection and suggests that P carinii should be considered an etiologic agent in the differential diagnosis of pleural effusion in an immunocompromised host.
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Affiliation(s)
- L J Elwood
- Cytopathology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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32
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Abstract
A patient with type PiZZ alpha-1-antitrypsin deficiency was found to have severe hypoxia despite normal pulmonary function testing and a normal chest radiograph. A nuclear medicine ventilation-perfusion study revealed a right-to-left shunt. Computed tomography showed minimal bleb formation, no diffuse changes, and hepatic changes of cirrhosis with portal hypertension. No nodular pulmonary masses or enlarged peripheral pulmonary vessels were found. The diagnosis of diffuse intrapulmonic arteriovenous shunts ("pulmonary spiders of cirrhosis") was suggested and then confirmed with a dynamic radionuclide flow study.
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Affiliation(s)
- I M Feuerstein
- Diagnostic Radiology Department, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Md 20892
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33
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McKenzie R, Travis WD, Dolan SA, Pittaluga S, Feuerstein IM, Shelhamer J, Yarchoan R, Masur H. The causes of death in patients with human immunodeficiency virus infection: a clinical and pathologic study with emphasis on the role of pulmonary diseases. Medicine (Baltimore) 1991; 70:326-43. [PMID: 1656164 DOI: 10.1097/00005792-199109000-00004] [Citation(s) in RCA: 115] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The clinical records and autopsy data of 75 patients dying with AIDS were reviewed to determine the frequency of individual diseases diagnosed premortem and postmortem, the significance of pulmonary processes found in the lungs at autopsy, and the clinical and pathologic causes of death. Cytomegalovirus (CMV) infection was identified histologically either premortem or postmortem in 81% of patients. The lungs and adrenal glands were infected most commonly. Only one-half of CMV infections were recognized premortem. Pneumocystis pneumonia and Kaposi sarcoma occurred in 68% and 59% of patients, respectively, but were not unsuspected premortem in any patient. Visceral involvement with Kaposi sarcoma, however, was frequently recognized only at autopsy. While disseminated M. avium-intracellulare infection was common (31% of patients), histologically documented pulmonary disease was uncommon (3% of patients). Cryptococcal infection, diagnosed in 10 patients, was confined to the central nervous system in only 1 patient. Toxoplasma, in contrast, infected the brain of only 6 patients. All 75 patients had one or more disease processes identified in their lungs or pleurae at autopsy. These processes included opportunistic infections in 76% of patients, neoplasms in 37% (Kaposi sarcoma in 36% and lymphoma in 3%), and other processes in 60%. The most prevalent pathogen, CMV was found in pulmonary tissue from 44 patients and caused significant disease in 21 patients. Five patients died due to CMV pneumonia. Pneumocystis carinii was found at autopsy in 24 patients. In spite of treatment, pneumocystis pneumonia was fatal in 11 patients. One patient died with concomitant CMV and pneumocystis pneumonia. Kaposi sarcoma, identified in the lungs of 23 patients, led to death in 5 patients via upper airway obstruction, hemorrhage, or parenchymal destruction. Other fatal pulmonary processes included bacterial pneumonia in 9 patients, idiopathic diffuse alveolar damage in 5, cryptococcosis in 2, and pulmonary hemorrhage in 1. Specific clinical criteria were used to determine the cause of death due to organ system failure. Fifty-one percent of patients died due to respiratory failure; 16% from neurologic disease; 17% from hypotension that was not caused by respiratory, neurologic, or cardiac disease; and 3% from cardiac dysfunction. Thirteen percent of deaths did not meet the clinical criteria defining these 4 categories. This clinical assessment was combined with autopsy data to identify specific diseases as causes of death.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- R McKenzie
- National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD 20892
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34
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Silverman PM, Feuerstein IM, Garra BS, Zeman RK. Evaluation of STIR imaging as a complement to spin-echo MR and CT of the porta hepatis/hepatoduodenal ligament. Magn Reson Imaging 1991; 9:73-7. [PMID: 2056854 DOI: 10.1016/0730-725x(91)90099-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Short TI inversion-recovery (STIR) imaging provides specific advantages over standard spin-echo (SE) MR sequences by producing additive effects of T1 and T2 brightening of pathology and suppression of the signal from surrounding fat. We retrospectively evaluated 12 patients with abnormalities, primarily neoplastic, of the porta hepatis/hepatoduodenal ligament (PH/HdL) with CT and MR imaging, including SE and STIR imaging. Masses on CT were of slightly decreased density compared to liver and seen in contrast to surrounding fat in the PH/HdL region. On MR, T1-weighted images provided comparable anatomic detail to CT, with masses clearly distinguished from surrounding fat due to the low signal intensity of masses as compared to fat. T2-weighted images clearly depicted intrahepatic lesions because of their high signal intensity relative to liver. Increased signal in extrahepatic lesions made them less distinctly seen from surrounding fat. STIR images best demonstrated tumor relative to fat. In six cases, CT was equivalent in demonstrating pathology to the best MR sequence. At least one MR sequence demonstrated pathology better than CT in 6 of 12 cases. In five of these six cases, the STIR sequence was better than CT. Thus, MR, particularly STIR imaging, provides a useful technique in imaging of PH/HdL pathology.
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Affiliation(s)
- P M Silverman
- Department of Radiology, Georgetown University Hospital, Washington, D.C. 20007
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Doppman JL, Pass HI, Nieman LK, Findling JW, Dwyer AJ, Feuerstein IM, Ling A, Travis WD, Cutler GB, Chrousos GP. Detection of ACTH-producing bronchial carcinoid tumors: MR imaging vs CT. AJR Am J Roentgenol 1991; 156:39-43. [PMID: 1845787 DOI: 10.2214/ajr.156.1.1845787] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Adrenocorticotrophic hormone (ACTH)-producing bronchial carcinoid tumors tend to occur in the middle third of the lung adjacent to pulmonary vessels. Because they cause signs and symptoms when quite small (by virtue of their ACTH production), they may not be detected by CT. MR imaging was performed in 10 consecutive patients with surgically proved ACTH-producing bronchial carcinoid tumors in order to test the ability of MR to clarify equivocal or indeterminate findings on CT examinations. All bronchial carcinoid tumors had high signal intensity on T2-weighted and short-inversion-time inversion-recovery images, facilitating their distinction from pulmonary vasculature. In eight patients, the CT and MR images were equivalent in the detection of bronchial carcinoid tumors. In two patients, MR showed tumors in the middle third of the lung that were equivocal on CT. MR imaging may distinguish small bronchial carcinoid tumors from adjacent pulmonary vessels in the central third of the lung at a time when the CT study is nondiagnostic or equivocal.
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Affiliation(s)
- J L Doppman
- Department of Diagnostic Radiology, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892
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Pluda JM, Yarchoan R, Jaffe ES, Feuerstein IM, Solomon D, Steinberg SM, Wyvill KM, Raubitschek A, Katz D, Broder S. Development of non-Hodgkin lymphoma in a cohort of patients with severe human immunodeficiency virus (HIV) infection on long-term antiretroviral therapy. Ann Intern Med 1990; 113:276-82. [PMID: 1973886 DOI: 10.7326/0003-4819-113-4-276] [Citation(s) in RCA: 204] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To describe the incidence of non-Hodgkin lymphoma in a group of patients with symptomatic human immunodeficiency virus (HIV) infection receiving long-term dideoxynucleoside antiretroviral therapy. DESIGN We examined the records of all patients with the acquired immunodeficiency syndrome (AIDS) or severe AIDS-related complex who were entered into three long-term phase I trials of zidovudine (azidothymidine, AZT) or zidovudine-containing regimens at the National Cancer Institute between 1985 and 1987. SETTING The Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland. PARTICIPANTS Fifty-five HIV-infected patients with AIDS or severe AIDS-related complex. MEASUREMENTS AND MAIN RESULTS Eight of fifty-five patients (14.5%; 95% CI, 6.5% to 26.7%) developed a high-grade non-Hodgkin lymphoma of B-cell type, a median of 23.8 months (range, 13 to 35 months) after starting antiretroviral treatment. Using the method of Kaplan and Meier, the estimated probability of developing lymphoma by 30 months of therapy was 28.6% (CI, 13.7% to 50.3%) and by 36 months, 46.4% (CI, 19.6% to 75.5%). The patients who developed lymphoma had less than 100 T4 cells/mm3 for a median of 17.8 months (range, 7 to 35 months) and less than 50 T4 cells/mm3 for a median of 15.3 months (range, 5.5 to 35 months) before the diagnosis. All patients presented with non-Hodgkin lymphoma in extranodal sites, and two developed primary brain involvement in the setting of Toxoplasma infection. CONCLUSION Patients with symptomatic HIV infection who survive for up to 3 years on antiretroviral therapy may have a relatively high probability of developing non-Hodgkin lymphoma. Prolonged survival in the setting of profound immunosuppression with substantial T4-cell depletion is probably an important factor in the development of these lymphomas. However, a direct role of therapy itself cannot be totally discounted. As improved therapies for the treatment of HIV infection and its complications result in prolonged survival, non-Hodgkin lymphoma may become an increasingly significant problem.
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Affiliation(s)
- J M Pluda
- National Cancer Institute, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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Affiliation(s)
- I M Feuerstein
- Diagnostic Radiology Department, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892
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Feuerstein IM, Francis P, Raffeld M, Pluda J. Widespread visceral calcifications in disseminated Pneumocystis carinii infection: CT characteristics. J Comput Assist Tomogr 1990; 14:149-51. [PMID: 2298984 DOI: 10.1097/00004728-199001000-00032] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A case of disseminated Pneumocystis carinii infection is presented. Calcifications of similar character were found by CT in the lymph nodes, spleen, liver, and kidneys. Biopsy of a calcified axillary lymph node demonstrated necrotizing granulomatous lymphadenitis, with Pneumocystis organisms and dystrophic calcifications clustered centrally within the granulomas.
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Affiliation(s)
- I M Feuerstein
- Diagnostic Radiology Department, Warren G. Magnuson Clinical Center, National Cancer Institute, National Institute of Health, Bethesda, MD 20892
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Feuerstein IM, Girton ME. Choice of contrast material for four-hour delayed contrast-enhanced computed tomography of the liver. Invest Radiol 1989; 24:776-80. [PMID: 2793390 DOI: 10.1097/00004424-198910000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Four-hour delayed contrast-enhanced computed tomography (DCECT) shows promise for improved detection of focal liver lesions. No previous studies have examined the use of nonionic contrast materials for DCECT. The authors undertook a case-controlled study in monkeys to define the relative efficacies of iopamidol and diatrizoate for DCECT. In this model, diatrizoate made the liver significantly more opaque at four hours than did iopamidol (mean 126.5 vs 87.6 HU, P less than or equal to 0.05). Opacification of the gallbladder and biliary tract occurred more often and was denser with diatrizoate. The relative efficacies of biliary excretion correlate with similarities in molecular structure. While it has been shown that the increased density from DCECT with diatrizoate may allow detection of more metastatic lesions, the clinical utility of the inferior parenchymal density obtained with iopamidol, extrapolated to be approximately 11 to 14 HU in humans, remains to be-established.
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Affiliation(s)
- I M Feuerstein
- Department of Radiology, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland 20892
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Abstract
Various measures of image quality were compared from adult abdomen scans obtained with a subsecond computed tomographic (CT) scanner (Imatron Ultrafast C-100) and a conventional third-generation whole-body scanner (GE9800). Forty images from 13 patients scanned within 2 hours of each other on both scanners were evaluated with techniques standardized as much as possible for CT exposure factors and contrast enhancement. Two observers in consensus evaluated matched anatomic levels using standard window width and level settings. Each image was graded on a scale of 1 (worst) to 5 (best) for spatial resolution, image noise, and presence and type of artifacts. Overall image quality also was graded. Averaged scores were compared between the two scanners. In all categories, scores were slightly higher for the GE9800. However, the differences in spatial resolution, presence of artifacts, overall image quality were not significant using the sign test. There was a significant difference, in favor of the GE9800, in image noise. The types of artifacts differed; the GE9800 produced more motion artifacts from bowel and surgical clips and the Imatron C-100 produced more rib shadow artifacts projecting on the liver and spleen. While the GE9800 produced abdominal images of slightly superior quality in adults, the Imatron Ultrafast C-100 was shown to produce images suitable for routine abdominal imaging in adults.
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Affiliation(s)
- H I Goldberg
- Department of Radiology, University of California, San Francisco 94143-0628
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Feuerstein IM. Semiautomated slide identification by using a personal computer and printer. AJR Am J Roentgenol 1989; 152:861-3. [PMID: 2466398 DOI: 10.2214/ajr.152.4.861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- I M Feuerstein
- Diagnostic Radiology Department, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892
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Abstract
Twenty-nine subjects with occupational asbestos exposure and clinical asbestosis were examined with high-resolution computed tomography (HRCT) to determine its sensitivity, relative to that of conventional computed tomography (CT), for detection of benign asbestos-related disease. Thin-section HRCT scans were obtained at five discrete levels through the mid and lower thorax in both prone and supine positions. The same technique was used in 34 age-similar control patients. Parenchymal abnormalities were seen most frequently in the posterior portion of the lung bases in the asbestos-exposed subjects. HRCT prone scans enabled basal structural abnormalities to be reliably distinguished from gravity-related physiologic phenomena in 25 asbestos-exposed subjects. HRCT was more sensitive than CT in detection of both pleural and parenchymal fibrosis. In subjects with clinical asbestosis, HRCT demonstrated parenchymal abnormality in 96%, compared with 83% for CT. Similarly, pleural thickening was shown in 100% of subjects at HRCT, compared with 93% at CT. HRCT could be an important adjunct in the evaluation of asbestos-related pleuroparenchymal fibrosis. An HRCT study including prone scans is a sensitive, reliable means of detecting thoracic abnormalities in asbestos-exposed individuals.
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Affiliation(s)
- D R Aberle
- Department of Radiology, University of California, San Francisco
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Feuerstein IM, Margulis AR. Semierect computed tomography of the abdomen using the Imatron ultrafast CT scanner. J Comput Assist Tomogr 1987; 11:1107-8. [PMID: 2960705 DOI: 10.1097/00004728-198711000-00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Computed tomography of the abdomen was successfully performed in the semierect position on an Imatron C-100 ultrafast CT scanner. Investigations of gravitational effects on masses or air and/or fluid collections are other potential uses for semierect scanning.
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Affiliation(s)
- I M Feuerstein
- Department of Radiology, University of California at San Francisco
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Feuerstein IM, Margulis AR. Barium filling for glucagon-resistant spasm. Radiology 1987; 164:876-7. [PMID: 3615893 DOI: 10.1148/radiology.164.3.3615893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
The clinical diagnosis of cervical aortic arch rests on the detection of a pulsatile mass in the supraclavicular fossa. Unfortunately, clinical differentiation of a cervical arch from an aneurysm of the great vessels can be difficult. Dynamic computed tomography (CT) can aid in this differentiation and avert the need for angiography.
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Abstract
A 37-year-old woman was evaluated for a neck mass. This was located in the midline below the hyoid bone. Thirty-three years had elapsed since she had undergone subtotal thyroidectomy for hyperthyroidism. Eight years prior to examination, the patient had discontinued her thyroid maintenance medications. She had discovered the mass eight months prior to examination. Thyroid scan (Fig. 1) showed intense uptake in the mass. At operation the mass was attached to the midportion of the hyoid bone by a small fibrous band, as is usual in a thyroglossal duct remnant. Biopsy results showed diffuse thyroid hyperplasia. Thyroglossal duct remnants are known to harbor cysts or thyroid carcinoma, but growths of compensatory hyperplastic tissue are unusual.
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Feuerstein IM, Tiamson EM. Focal cytomegaly of the adult adrenal cortex. A rare variant of black adenoma. Arch Pathol Lab Med 1985; 109:198-200. [PMID: 3838445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A pigmented adrenocortical nodule was found incidentally in an adrenal gland resected for endocrine manipulation of breast carcinoma. The sharply circumscribed, nonencapsulated nodule was composed of cells with diameters as large as 95 micron. The cells had ample eosinophilic cytoplasm and contained much lipofuscin pigment. Electron microscopy disclosed tubulovesicular mitochondria, lipofuscin pigment, cytoplasmic vacuolization, and lipid without degenerative changes or intranuclear inclusions. This unusual lesion of adult adrenal glands is best considered as a rare variant of adrenocortical black adenoma.
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Feuerstein IM, Zeman RK, Jaffe MH, Clark LR, David CL. Perirenal cobwebs: the expanding CT differential diagnosis. J Comput Assist Tomogr 1984; 8:1128-30. [PMID: 6501621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Although initially described as representing collateral venous structures, perirenal cobwebs may be due to a variety of benign and malignant conditions. Six representative cases illustrating the broad differential diagnosis are presented.
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Jumbelic M, Feuerstein IM, Dorfman HD. Solitary intraosseous lymphangioma. A case report. J Bone Joint Surg Am 1984; 66:1479-81. [PMID: 6501348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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