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643

Letters

Effective

Audiovisual

Presentation:

Proper

Citation

of Sources Suggested

AJR article: and Ramsey.

surprised

to note

Readings

(or

that my name

bibliography)

consists of blatant plagiarisms

so from my article

“One Dozen

Ways

in the recent

“snips”

from

the

two

articles

taken verbatim

to Upgrade

Radiologic Presentation” [2] published in 1988. I enclose a copy of my paper for your reference side-by-side

did not appear

included

“Effective Audiovisual Presentation” [1] by Drs. Sagel The reason for my surprise lies in the fact that no small

part of their manuscript or nearly

which

and will

Your Next

two

serve

pages

of

as exam-

pies of some of the material “lifted” from my paper without permission or citation. I am confident you played no knowing role in the matter. I am also confident you will address this issue with the seriousness it deserves because the radiological community will use your response as a measure of how much tolerance you and AJR have for intellectual dishonesty and common theft. Jerome J. Cunningham The Ohio State University, University Hospitals Columbus,

OH

presentations

AJR 1991;156:181-187 2. Cunningham JJ. One dozen ways to upgrade entation. Clear Images October 1988;2(4):20-24

presentation

(perspective).

your next radiologic

pres-

I am responding to the letter from Dr. J. J. Cunningham that some material in our recently published article [1] was taken directly without proper citation from an article he previously published [2]. Although Ruth G. Ramsey is a coauthor of our publication, I wrote the sections of the manuscript under question, and assume full responsibility for the problem. I acknowledge that in several instances Dr. Cunningsurely

was

the

used to emphasize presentations. He legitimately anecdotes

source

of

potential objects

some

cogent

phrases

and

pitfalls in making audiovisual to borrowing without citation

and I apologize for not appropriately referencing his article and appreciate the opportunity to correct this omission. I would like to assure the reader that this oversight was related to the unique genesis of my message

documenting

the

source of many of my lecture notes, rather than any deliberate to deceive and deprive him of proper credit.

and flawed

behavior

effort

The substance of my contribution than 1 0 years before October 1988.

in not carefully

to our article goes back more Sometime in the late 1 970s, I

into

of North

given

in June

an annual

America

to our residents

to several

1984.

Course

in conjunction

on this subject.

academic

Subsequently,

Refresher

given

other

radiology

this information at the

with

Radiological

Dr. Ramsey

starting in November 1988. Myriad enhancements since about 1978 have occurred to the basic talk. Numerous colleagues and residents, both here and at other institutions, have offered me suggestions, articles, and even books on this topic. AlSo, I have attended many sessions at national radiologic meetings, as well as a symposium

sponsored optimal

by Kodak,

presentation

excerpted informational

which addressed of radiologic

proper

material.

slide technique

Valuable information for my own lecture.

and was Such

and incorporated onto slides slide notes, while not shown in the actual lecture, served

as valuable reminders of specific ideas and anecdotes during the preparation process. Unfortunately, I never systematically recorded the source of these recommendations onto my slides. I am almost certain that Dr. Cunningham’s published article from October 1 988 was originally shown to me by one of our senior residents, who I believe commented at the time on the remarkable similarity of our advice to residents needing to prepare and deliver an presentation.

analogies,

Undoubtedly,

I was

and anecdotes,

impressed

with

and incorporated

his lucid

some com-

ments directly into my own slide material, again without carefully noting its origin. The article then either was discarded or returned. It never occurred to me to include it in my reference file as few would be able to locate the controlled circulation journal Clear Images, and it contained

Reply

were

beginning

developed

Society

phraseology,

1 . Sagel 55, Ramsey RG. Effective audiovisual

article

was

audiovisual

43210-1228

REFERENCES

ham’s

giving an annual presentation

Similar

departments

I was particularly in the

began

no

references;

and

at

the

time,

I had

no

intention

of

publishing an article for which precise attribution would be required. Our paper was written to convey the advice and admonitions Dr. Ramsey and I had been delivering in lectures to residents and staff for many, many years. To assemble my contribution to our solicited article, I initially reviewed all of my slides and transposed their content into my original rough draft. Then I reviewed my reference file, added more information, and finally searched in the Index Medicus for the last 1 0 years to identify original sources analogous to the usual scientific article I would write. I would like to emphasize that when this literature search was conducted, no article from Clear Images ever appeared. With the passage of time and after repeatedly talking about this subject, I was confused about what contentions and phrases had been “borrowed” from others, and which had been my own creation. To my chagrin, even on some controversial points, I was unable to identify references for many of the guidelines. Since the material was intended purely as advice, and no innovative claim for these concepts was intended, the text was not footnoted with specific citations and a short list of “suggested reading” simply was appended to the article. While potentially controversial, I would con-

644

LETTERS

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tend that the rules for effective audiovisual presentation common sense, well accepted, and familiar to many

are largely experienced

lecturers, and almost all have been published previously in some form. My sloppy behavior in not scrupulously labeling the sources of material incorporated into my lectures should not be condoned. I intend to be more meticulous in detailing the origin of information in the future. I sincerely regret having offended Dr. Cunningham. Stuart S. Sagel Washington

University

School

of Medicine

St. Louis,

MO 63110

AJR:157,

September

we perform mediastinal sonography on lymphoma patients even though the technique is more physician intensive and more operator

dependent

than CT, are the following:

(1) Sonography

is less expen-

can detect mediastinal lymphomas with a sufficiently high sensitivity [1 j. (3) Sonography is suited for followup examinations because of the standardized and reproducible secsive

CT. (2) Sonography

than

tion planes (clearly defined by the narrow size of the acoustic and mediastinal

window

vessels)

[2, 3]. (4) The qualitative criterion (echogenicity) of sonography may be a more reliable indicator for vital tumor tissue or clinical outcome than the quantitative criterion (lymph node

size) obtained

with CT [2, 3].

One of the main arguments against using mediastinal sonography in lymphoma patients is that sonography is not particularly useful for

REFERENCES 1 . Sagel 55, Ramsey RG. Effective AJR 1991;156:181-187

2. Cunningham

audiovisual

presentation

October

the assessment

(perspective).

tinum,

JJ. One dozen ways to upgrade your next radiologic

Clear Images

entation.

1988:2(4):

pres-

20-24

of certain

paravertebral

areas

region,

(subcannal

pulmonary

region,

posterior

hila and

medias-

parenchyma,

Sonography

for Mediastinal

of the

Lymphoma

The recent article by Wernecke et al. [1 ] concludes that sonography is “comparable to CT for monitoring patients with mediastinal lymphomas.” These authors found that “in all five cases showing discrepancies between sonographic and CT findings, further followup indicated that the information obtained at sonography correlated more closely with the clinical outcome” and that “the qualitative criterion (echogenicity) it offers may be a more reliable indicator for tumor

tissue

or clinical

outcome

than

the

quantitative

criterion

(lymph node size) obtained with CT.” I was surprised by the conclusions of this article and confused by its message. The research was done in West Germany, where

sonography

is apparently

less expensive.

more readily available

However,

in comparison

than CT. It is also

with CT, mediastinal

sonog-

raphy would seem to be more labor and physician intensive, more operator dependent, more difficult to compare with previous and subsequent examinations, and less useful for assessment of certain areas.

Are Wernecke amination tinal

and colleagues

of the future,

lymphoma

describing

a useful diagnostic

or is the sonographic

pass#{233}on

arrival?

assessment

Is mediastinal

ex-

of medias-

sonography

is readily

available?

the assessment

Does

esophageal

of mediastinal

sonography

have

any

role

in

lymphoma? Ferris M. Hall Beth Israel Hospital Harvard

Medical

Boston,

supraaortic,

School

MA 02215

1 . Wernecke monitoring

comitant

with

chest radiography

P, Hoffmann

G, et al. Value of sonography in of mediastinal lymphoma: comparison and CT. AiR 1991;1 56:265-272 response

paratracheal

node

chains)

involvement

of the superior

mediastinal

lymph

nodes),

which

not

tored with sonography [2, 3]. One advantage of sonography over CT is that sonography may provide information about vital tumor tissue irrespective of the size of the mediastinal lymph nodes. Sonography be used to detect lymphomatous involvement of nonenlarged mediastinal lymph nodes [2, 3]. Furthermore, it seems that sonography can be used to differentiate accurately between scar tissue and residual vital tumor [2, 3]. However, further studies with larger groups of patients are necessary to validate these observations. can

follow-up

sonography

has

substantially

West

Germany

and

but the lack of training

abdominal

training

patients

improved

the

radiologic

Sonography can be performed in addition to chest radiography in routine follow-up every 3-6 months after therapy. With this protocol, we were able to detect mediastinal recurrence in four patients in 1 990 at a very early stage (mediastinal lymphomas 0.8-2.0 cm in diameter). In our opinion, the main limitation of mediastinal sonography in both

of lymphoma

technique

sonography

problems,

United

States

and experience

although

new

the

at our hospital.

performed

is not the

lack

in this examination.

of accuracy

Mediastinal

since 1984 at our institution,

is a

and

at a stage comparable with that of in the late 1 970s. We are aware of these

but we hope that other institutions

will be con-

vinced of the diagnostic efficacy and practicability of this new technique. Mediastinal sonography should not be seen as an exotic tool implemented by some specialized sonographers, but as a widely available and accurate imaging method, when training problems are overcome.

Reply We are grateful for Dr. Hall’s comments, because they are the first published reaction to our efforts to establish mediastinal sonography as a useful and accurate imaging technique. CT is not much less available in West Germany than it is in the United States. The reasons

lymph

be assessed by sonography. In our series, we did not miss any mediastinal manifestation of newly diagnosed Hodgkin disease at sonography, but we did miss some mediastinal lymphomas in those regions that are more difficult to assess with sonography. Nevertheless, all lymph nodes undetected by sonography showed a therapeutic response identical to that of those detected and monicould

relatively K, Vassallo the therapeutic

and

newly diagnosed Hodgkin disease in the series of Castellino et al. [4] had isolated involvement of paravertebral lymph nodes (without con-

sonography, REFERENCE

prevascular,

radiograIn newly (all nodes

are involved in 98% of patients with thoracic disease 14]. The sensitivity of sonography in these mediastinal regions (98%, 92%, and 89%) 5 almost equal to that of CT [1 j. Only one of 203 patients with

Mediastinal

being

performed for the assessment of lymphoma in the United States? If not, is this because of a presumed lack of accuracy or because CT

and

bone structures). In this respect, CT has an undisputed advantage. The role of mediastinal sonography is not to compete with CT but to be an additional diagnostic method (besides conventional phy) and therefore reduce the number of CT examinations. diagnosed Hodgkin disease, the superior mediastinal nodes

vital

1991

Karl Wernecke Pierre

University

Vassallo

Peter E. Peters of Muenster Medical School 4400 Muenster, Germany

AJR:157,

September

REFERENCES

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645

LETTERS

1991

1 . Wemecke K, Vassallo P, POtter R, LUckener HG, Peters PE. Mediastinal sonography: sensitivity of detection with sonography compared with CT and radiography. Radiology 1990;175:137-143 2. Wemecke K, Vassallo P, Hoffmann G, et al. Value of sonography in monitoring the therapeutic response of mediastinal lymphoma: comparison with chest radiography and CT. AJR 1991;1 56:265-272 3. Wemecke K. Mediastinal sonography: examination technique, diagnostic efficiency and value in diagnostic imaging of the mediastinum. New York: Springer-Verlag, 1991

2. Shoemaker DP, Garland CW, Steinfeld Jl, Nibler JW. Treatment of expermental data. In: Experiments in physical chemistry, 4th ed. New York: McGraw-Hill, 1981:253. New PFJ, Rosen BR, Brady TJ, et al. Potential hazards and artifacts of ferromagnetic devices

and

in nuclear

nonferromagnetic magnetic

resonance

surgical

and

imaging.

Radiology

dental

materials

and

1983;147:

139-

149

4. Shellock FG, Crues biomedical implants: 1988;151

JV. High-field-strength

MR imaging

and metallic

an

of deflection

forces.

ex

vivo

evaluation

AJR

:389-392

4. Castellino RA, Blank N, Hoppe RT, Cho C. Hodgkin disease: contributions of chest CT in the initial staging evaluation. Radiology 1986;160:603-605

Localization I would

Inappropriate

Use of Significant

figures is the practice of round-

ing off an experimental result so that it contains only the digits of known certainty plus the first uncertain digit [1 , 2]. When readings

are taken that involve estimation interpolated

digits

are always

Rules for measured in the chapters

Leading

or interpolation,

conceded

and calculated

referenced

the estimated

or

to be uncertain.

numerical

values can be found

[1 , 2] and can be summarized

as follows:

zeros

are not significant. For example, 3.1 415 and 0.0031 41 5 both are significant to five figures. Zeros bounded on the right and left by nonzero digits are significant. For example, The convention

zeros are bounded

61 23 and 6003 are both significant to four figures. of using significant figures is ambiguous when

by digits on the left side only. For example,

200

ml can be significant to one, two, or three figures. One way to avoid this problem is to use scientific notation. For example, 2.00 x 102 ml unambiguously implies three significant figures (trailing zeros are significant), whereas 2 x 1 02 implies only one significant figure. Another way to avoid this problem is to use a different unit of measurement. Instead of 200 ml, use 0.2 I to imply one significant figure.

When a result is derived from a measured value, the result can not be more accurate than the measured value. For example, New et al. [3] measured a deflection angle on a clip of 57#{176} (i.e., two significant figures of accuracy). The calculated force was given as 31 69 dynes (i.e., four significant figures). More appropriate would be 3.2 x 1 0 dynes. For a value of mass of 160 mg, the forces per gram was then

given as 19,863 dynes/g (i.e., five significant figures [31 69 divided by 0.16 is 19,806.3, but that is not the subject of this letter]). This result should be reported as 2.0 x 10 dynes/g. Shellock and Crues [4] report the deflection force on a contraceptive diaphragm as 1 1 195 dynes (i.e., five significant figures). This implied that the deflection angle as measured on a protractor was 31 .695#{176}, when it was admitted that the protractor was accurate to ± 0.50.

The convention of using significant figures should be observed in order to convey the accuracy of a measured or calculated experimental

like to comment

result. Nolan J. Kagetsu New York University Medical Center New York, NY 10016

DA, West DM. The evaluation of analytical data. In: Fundamentals

of analytical

1969:25-58

chemistry,

2nd

ad.

New

York:

Holt,

on the recent transection

Rinehart

& Winston.

letter by Mitnick et al. [1] of a breast localization

wire. They stated that I have “suggested the routine use of a postlocalization stiffening wire to avoid transection.” In fact, I descnbed a postlocalization needle, not a wire, to avoid the pitfall of wire

transection

[2].

The

concept

of a covering

needle

is an essential

element of one of the spring-hook wire devices in which a stiffening cannula is used, and it is an integral part of the curved J-wire localizer system (Mammalok, North American Instrument, Glens Falls, NY) because both the needle and wire are left in place [3]. As Mitnick et al. correctly state, this reduces the complication of wire transection. Marc J. Homer Tufts University New England Medical Center Hospitals Boston, MA 02111 REFERENCES 1 . Mitnick

JS,

Vazquez

MF,

Harris

MN,

Buchbinder

55.

Localization

of

transected wire (letter). AJR 1991;1 56:866 2. Homer MJ, Fisher DM, Sugarman HJ. Post-localization needle for breast biopsy of nonpalpable breast lesions. Radiology 1981;140:241 -242 3. Homer MJ. Localization of nonpalpable breast lesions with the curved-end retractable wire: leaving the needle in vivo. AJA 1988;151 :919-920

Diagnosis Subtraction

of Hemopericardium Angiography

Hemopericardium

complication

is a relatively

of penetrating

During

common

chest trauma.

and

Digital

potentially

lethal

It may be overlooked

on

the chest radiograph because the resultant increase in cardiac diameter may be subtle, particularly if previous radiographs are not available for comparison. The associated distension of the superior

mediastinal as evidence giography.

venous structures of possible We

with tamponade

arterial

describe

a case

injury,

may be misinterpreted

leading

of suspected

to a request arterial

injury

for anin which

digital subtraction angiography (DSA) showed features of pericardial tamponade. A 21 -year-old man was stabbed in the left third intercostal space. On admission, he was hemodynamically stable, but a chest radiograph showed superior mediastinal widening that was interpreted as hematoma, possibly due to an arterial injury. On intraarterial DSA, the aortic arch and major arteries appeared normal, but on closer

inspection, pericardial The distance cardial

fluid,

the cardiac outline could be clearly discerned inside the outline before the injection of contrast medium (Fig. 1). separating most

likely

the two structures blood.

penicardial fluid collection. REFERENCES 1 . Skoog

Wire

about the pitfall of inadvertent

Figures

Many of the numerical values stated at radiology meetings and published in the radiologic literature contain too many significant figures. The use of these “extra digits” implies a level of accuracy of

these results that is unjustified. The convention of using significant

of Transected

Sonography

At penicardiotomy,

strongly confirmed

suggested

a moderate

blood was drained, and a laceration of the pulmonary was sutured. DSA is sensitive to slight differences in radiographic can show subtle differences in density not necessarily

pen-

a 20-mm-wide

volume of

outflow

tract

contrast and seen on plain

LETTERS

646

AJR:157,

September

show a patent biliary tree in three neonates; 1311 rose bengal a patent biliary tree at 48 hr in two and at 168 hr in one.

1991

showed

I. E. T. Stewart

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Huntingdon,

Hinchingbrooke PE18 8NT, United

CAMBS

Hospital Kingdom

REFERENCES 1 . Tomsi the

JM,

2. Spivak

JO, Velcek

HaIler

neonate:

imaging

W, Sarkar

Diagnostic

utility

FT. Choledochal cyst and biliary atresia cases. AJR 1990;1 55:1273-1276

findings

in

in five

5, Winter

D, Glassman

of hepatobiliary

M, Donlan

scintigraphy

with

E, Tucker in

wTcDISlDA

KJ. neo-

natal cholestasis. J Pediatr 1987;1 10:855-861 3. Collier BD, Treves 5, Davis MA, Heyman S. Subramanian G, McAfee JG. Simultaneous and 1311 rose bengal scintigraphy in neonatal jaundice. Fig. 1.-Hemopericardium on digital subtraction angiograms. A, Subtracted cardiac image shows epicardial fat (short arrow) widely separated from pericardial outline (long arrow). B, unsubtracted image shows a faint curvilinear lucency representing epicardlal fat (long straight arrows), distended azygos vein (short straight arrow), and a paravertebral hematoma (curved arrow).

radiographs. We think that the appearance on DSA in this case was due to the misregistration of mask and image, which emphasized the epicardial fat layer outlining the myocardium (Fig. 1A). This is analogous to the penicardial band of density sometimes seen on lateral [1] and frontal

[2] chest

radiographs

in the presence

of penicardial

Radiology

1980;134:719-722

Reply

Dr. Stewart is correct in that cholescintigraphy is not diagnostic but merely suggests the diagnosis of biliary atresia. We did not mean to imply that cholescintigraphy was that specific. The other diseases must be included in the differential diagnosis. Jean Torrisi Jack 0. HaIler SUNY Health Science Center at Brooklyn Brooklyn,

fluid.

NY

11203

We think this is a useful observation to make on all DSA studies which concomitant or unsuspected penicardial fluid on hemopeni-

in

cardium

may

be present.

This

is especially

important

in trauma

patients, in whom the blood may accumulate rapidly after referral for angiography, with cardiac decompensation following. We stress the importance of not disregarding the cardiac DSA merely because of movement artifact; be present.

area during

viewing

useful information

of

may

Schuur

Hospital/University

Cape

of Cape

Town,

Fluoroscopy

In the

November

a portable

C-arm

ing disorders.

South Africa

Lane EJ, Carsky EW. Epicardial fat: lateral plain film analysis in normal and pericardial effusion. Radiology 1968;91 :1-5 2. Carsky EW, Mauceri RA, Azimi F. The pericardial fat pad sign. Radiology 1.

1980;137:303-308

limited

image

Atresia

in the

The paper by Tonnisi et al. [1] misinterprets the accuracy cholescintigraphy in the diagnosis of biliary atresia. The absence biliary

activity

in the small

bowel

atresia but also with intrahepatic

is compatible

cholestasis,

not only

neonatal

of of with

hepati-

tis, bile duct paucity, and total parenteral nutrition cholestasis [2]. Additional cholescintigraphs obtained later often show radionuclide activity in the small bowel, thus excluding biliary atresia [2]. The limitations of mTc cholescintignaphy-the short half-life of the radionuclide and its delayed appearance in the small bowel-are well illustrated by Collier et al. [3], who examined five neonates who had hepatitis. Simultaneous studies were done with 9Tc-p-butyl-iminodiacetic

acid

and

iodine-i

31 rose

bengal.

The

first

technique

failed

to

I wish

for examining

is cumbersome

to

draw

to

the

to use and has attention

of

your

the availability of a commercial C-arm fluoroscopic unit that is attached to a 90/90 tilt table. The unit is produced by Fischer Imaging Corp. (Denver, CO) and is called the Imager. It has a 1000mA 1 50-kVp 1 00-kW generator and is equipped with a 1 2 x 9 x 6 in. (30 x 23 x 1 5 cm) image intensifier. The image intensifier can be moved in a craniocaudal and an in and out motion as with any

conventional rotation

fluonoscopic

unit. In addition,

and a 45#{176} craniocaudal

In addition

Cyst and Biliary

C-arm fluoroscope

resolution.

method

and I have been using it for the with swallowing disorders. How-

readers

disorders,

radionuclide

I agree that this is an excellent

ever, the portable

Town

REFERENCES

Choledochal Neonate

1990 issue of AJR, Davis et al. [1] describe using fluoroscopic unit to examine patients with swallow-

such patients, and my colleagues past 4 years in studies of children

D. J. Solomon S. Beningfield Groote

C-Arm

C-arm

to its value for studies fluoroscopy

it is capable

of a full 90#{176}

tilt. has other

of patients distinct

with swallowing

advantages.

Fit young

patients usually can be easily rolled into position, but in many clinical situations, it is advantageous to obtain the desired imaging position by using a C-arm rather than by moving the patient. This is particularly true in infants and children. Some of these situations are as follows: (1) young infants who are swallowing or voiding (they frequently will stop doing this when rolled into an alternative position); (2) children who are intubated; (3) children who are in pain or discomfort after trauma, such as a pelvic fracture or recent surgery; (4) situations in

which horizontal-beam imaging with the patient in a prone position (e.g., for identification of a tracheoesophageal fistula) is desirable; (5) any oblique views that can be obtained more easily and accurately by using

advantage

the C-arm

than by rolling

the patient

of the unit is that craniocaudal

into position.

(Another

tilt can be used when

structures of interest overlap, for example, the pylonic antrum.) In summary, C-arm fluoroscopy offers many distinct advantages. The Fischer Imager is comparable to any conventional fluoroscopic

AJR:157,

September

LETTERS

1991

room and just as easy to use but has the added advantage a C-arm.

of having

647

REFERENCE 1 . Feinberg

MJ, Ekberg 0. Videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of degluti-

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Mervyn D. Cohen Indiana University Medical Center Indianapolis, IN 46202-5200

tion. AJR 1991;156:293-296

REFERENCE 1 . Davis M, Palmer P. Kelsey C. Use of C-arm fluoroscope with swallowing disorders. AJR 1990;155:986-988

to examine

patients

Reply As Dr. Hall points

been established.

My coauthors

and I are gratified

that

Dr. Cohen

agrees

with

our

opinion that C-arm fluoroscopy has a useful place in the diagnosis of swallowing disorders, and we thank him for pointing out other areas in which the C-arm feature is useful. Although we do not have personal experience with the Fischer Imager, the literature about the unit indicates that it would be a useful addition for a department with adequate space and finances to acquire it. Our point was that most radiology departments now have a portable C-arm unit that can be used advantageously in the diagnosis of swallowing

disorders. Michael

University

Davis

of New Mexico Medical Center Albuquerque, NM 87131

normal

and

effects

pathologic

Videofluoroscopy Aspiration

in Elderly Patients

with

Feinberg and Ekberg [1] recently reviewed 50 barium swallow examinations performed in elderly patients who were known to aspirate. The mean age of the patients was 87 years. Dementia was present in 21 , stroke in 15, and Parkinson disease in five. The authors concluded that “an accurate and valid assessment of oropharyngeal in elderly

patients

with aspiration

is possible,”

and stated

that “critical management decisions regarding dietary alterations, degrees of oral intake, and institution of artificialfeeding often depend on the videofluorographic assessment of aspiration.” I commend Feinberg and Ekberg difficult problem. However, I question

for this lucid discussion of a their contention that videofluo-

rographic assessment of aspiration in this group of patients often affects management decisions, and I doubt it has much meaningful effect on the lives of most of these elderly patients. The question of efficacy was not addressed in this article, and, to my knowledge, it has not been addressed in any previous publication. Certainly it would be difficult to assess in a controlled fashion. My own limited experience has been that once such an examination is offered, it is used increasingly in patients whose mental status is limited.

A patient’s

ability

to tolerate

different

foods,

function

of intervention.

and

studies

has not

clinical trials have been

describe

As radiologists,

the

techniques

we conducted

tigation [1] that we hope will contribute

a clinical

and

inves-

to the scientific basis required

for decisions about treatment. Leading authorities [2, 3] have stressed the need for dynamic imaging in the evaluation of oropharyngeal swallowing disorders. We agree with Dr. Hall’s comments on the importance of the clinical evaluation in such cases. The videofluorographic examination gives only a brief view of function under somewhat artificial conditions and

may not accurately reflect function or capabilities outside the radiology department. Dysfunction is often intermittent or variable and is affected by levels of alertness, conditioning, and cooperation. The results of the radiologic examination always multiple clinical evaluations before an overall

We strongly

severely

of swallowing

done that indicate a significant reduction in morbidity or mortality for any age group or specific condition. However, the discipline is relatively new and is still in the descriptive phase, attempting to outline

Reply

dysfunction

out, the efficacy

No large, well-controlled

support

Logemann’s

must be correlated with assessment is made.

recommendation

[4] that age

should not be a factor in the selection of patients for swallowing therapy. For the frail elderly who have neuropsychiatnc illnesses, physical and mental health are often affected by their ability to eat and drink normally. Working as part of a multidisciplinary team, we have participated in the care of hundreds of such patients. As with all new imaging procedures, we first educated referring clinicians

about

the appropriate

patients

role of videofluoroscopy.

think tients’

quality

mental

We do not study

precludes adequate evaluation or pawhose management will not be affected by our results. We that our clinically correlated radiologic assessment affects pa-

tients

whose

status

of life by directly

influencing

what,

how,

and

if they

are

fed. Admittedly, we sometimes find ourselves struggling with other team members about what ought to be done when multiple options are available, each with its own benefits and burdens. This situation has provided both a challenge and an opportunity for us as radiologists to assert leadership in shaping attitudes and approaches to this difficult

but common

problem. J. Feinberg General Hospital Buffalo, NY 14203 Olle Ekberg Malmo General Hospital Malmo, Sweden Michael

Buffalo

solids

vs liquids, or small vs large boluses often can be assessed better by the astute observer who feeds the patient each day than it can be during the short period of observatioh in the fluoroscopic suite when artificial radiopaque food materials are used. Obviously, in selected patients, videofluoroscopic assessment of swallowing function is useful, and I commend Feinberg and Ekberg on their important and continuing contributions in this field. Ferris M. Hall Beth Israel Hospital Harvard Medical School Boston, MA 02215

REFERENCES 1 . Feinberg tion:

MJ, Ekberg

importance

0. Videofluoroscopy

of evaluating

in elderly

patients

both oral and pharyngeal

with

aspira-

stages of degluti-

tion. AJR 1991;156:293-296 2. Dodds WJ, Logemann JA, Stewart ET. Radiologic assessment of abnormal oral and pharyngeal phases of swallowing. AJR 1990; 1 54 :965-974 3. Jones B, Donner MW. Examination of the patient with dysphagia. Radiology 1988;167:319-326 4.

Logemann

JA.

Effects

Clin

Am

1990;23:1045-1056

North

of aging

on the

swallowing

mechanism.

Otolaryngol

648

LETTERS

Fig. bone

1.-Radiograph

of

archeologic

shows

AJR:157,

dry-

graph

ectrodactyly,

Downloaded from www.ajronline.org by 186.190.31.219 on 11/05/15 from IP address 186.190.31.219. Copyright ARRS. For personal use only; all rights reserved

Form

of Metatarsal

McMaster Hamilton,

Ontario,

University

Canada

Smithsonian Washington,

L8S

J. Congenital

Robert Mann Institution DC 20560

abnormalities malformations:

of the

limbs.

Br

notes and comments.

J

Hosp

Chicago:

Med

Year

3. Resnick D. Additional congenital or heritable anomalies and syndromes. In: D. Resnick, G Niwayama, eds. Diagnosis of bone and joint disorders, 2nd ed. Springfield, IL: Thomas, 1988:3541-3600 4. McCredie J. Congenital fusion of bones: radiology, embryology and pathogenesis.

Clin Radiol

Subluxation Hemarthrosis

1975:26:47-51

of the Humeral Head Associated in a Patient with Hemophilia

Inferior subluxation caused by hemarthrosis

with

of the humeral head, pseudodislocation, is due to a fracture or bleeding disorder. It may

be misdiagnosed as a dislocation.

Appropriate

therapy

such as joint

aspiration may be delayed if this entity is not recognized. A case of a misdiagnosed pseudodislocation is presented. A 1 5-year-old boy was brought to the emergency department for evaluation of a painful right shoulder after a blow to the joint that occurred

while

he

was

wrestling.

radio-

shoulder

shows

cysts along glenoid

cavity, metaphyseal mor, and subluxation head.

pseudotuof humeral

The

initial

physical

radiographs

of the

right

shoulder

showed

inferior

subluxation

of the

humeral head, subchondral cysts along the glenoid cavity, and a hemophilic pseudotumor within the humeral metaphysis (Fig. 1). The subluxed humeral head was initially misinterpreted as an anterior dislocation.

Widening

of the joint

space

due

to hemarthrosis

recognized, and aspiration of the joint was were interpreted the next day by a radiologist. Hemarthrosis is common among persons

occurring

in 75-90%

delayed who

of them. It is more common

was

not

until the films

have

hemophilia,

in active children

than in adults and affects the knee, elbow, hip, and shoulder most often. Joints subjected to repeated stress are involved most frequently, and the initial bout of stress predisposes the joint to subsequent bleeding [1]. Early recognition of pseudodislocation may speed appropriate therapy and prevent painful and improper attempts at reduction. William H. McCuskey Mercy Hospital of Pittsburgh Pittsburgh,

PA

15219

REFERENCE

4L9

REFERENCES 1981;26: 194-203 2. Warkany J. Congenital Book Medical, 1971

right

Synostosis

Congenital anomalies of the feet have been noted in many populations throughout the world [1 -3]. One such anomaly, a unique form of metatarsal synostosis accompanied by ectrodactyly (absence of the phalanges), has only recently been discovered. Because of its rarity in clinical and archeologic samples, this case is presented for comparison of gross and radiologic features. The example is the left foot of a 20- to 25-year-old Eskimo woman from the archeologic site of Tigara at Point Hope, Alaska, dating from approximately AD. 1400 to 1850. The deformity consists of ectrodactyly, hypoplasia and fusion of the distal second tofifth metatarsals, and mild hypoplasia of the calcaneus (Fig. 1). Radiographs show sclerosis along the lateral shafts of the left second and the right fifth metatarsals and osteoporosis and an irregular trabecular pattern in the calcaneus. This deformity is thought to represent a congenital malformation caused by the inappropriate organization of mesenchyme during the fifth week after conception that is due to a primary defect in the embryonic sensory nerves [4]. Anne Keenleyside

1 . Fixsen

of

subchondral

synostosis, and hypoplasia of left foot (left, top and bottom). contralateral bones (right, top andbottom) are shown for comparison. metatarsal

A Rare

1991

Fig. 1.-Anteropostenor

specimens

unilateral

September

examination

revealed an erythematous, swollen shoulder with a severely limited range of motion. It was known that the patient had hemophilia. Plain

1 . Resnick

D, Niwayama

Philadelphia:

0. Diagnosis

Saunders,

of bone

and joint

disorders,

2nd ed.

1988:2497-2520

Paradoxical Signals (Short T2, Long Patient with a Soft-Tissue Tumor

T2) in a

A 48-year-old woman had had a nontender mass in the right thigh for several months. MR imaging of the thigh and pelvis (6.5-mm axial and coronal slices) was performed on a 1 .5-T General Electric Signa magnet with spin-echo pulse sequences with Ti , balanced, and T2 weighting. A 3-cm poorly defined mass with low signal intensity on all sequences was shown in the right thigh, infiltrating the tensor fascia lata (Fig. 1 A). A smaller nodular mass was noted inferiorly, suggesting a satellite lesion. Biopsy of the mass revealed a desmoid. Wide local excision of the lesion with tumor-free margins was done. Approximately 2 years later, follow-up MR showed an aggressive 4.0-cm mass infiltrating the muscles adjacent to the right hip (Fig. 1 B). The mass had low signal intensity on Ti -weighted images and mostly high signal intensity on T2-weighted sequences. Again, biopsy showed a desmoid, and the tumor was removed by wide local excision. Histologic features of the original tumor included a bland proliferation of spindled cells scattered among wavy collagen fibers. The recurrent desmoid had less abundant collagen and greater cellularity.

Most soft-tissue of masses

has been addressed

having

and other masses a short

the subject have been

T2

either

have a long T2. The significance before

biopsy

or after

treatment

of several publications [1 , 2]. The questions the value of this feature in separating benign

AJR:157,

LETTERS

September1991

649

1987;148:

1247-1250

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2. de Lange EE, Fechner RE, Wanebo HJ. Suspected recurrent rectosigmoid carcinoma after abdominoperineal resection: MR imaging and histopathologic findings. Radiology 1989;170:323-328 3. Negendank WG, Al-Katib AM, Karanes C, Smith M. Lymphomas: MR imaging

contrast

diology

1990;177:209-216

characteristics

with

4. Lee JKT, Glazer HS. Controversy Radiology

Lateral

Fig. 1.-Paradoxical signals of a soft-tissue tumor. A, Coronal T2-weighted (2000/80) MR image of pelvis shows a desmoid and satellite lesion (arrow) with low signal intensity (short T2) infiltrating subcutaneous fat and muscles of right thigh. Tumor was resected. B, Follow-up coronal T2-weighted (1900/75) MR image of pelvis obtamed 2 years after resection shows recurrent desmoid at site of original tumor. New tumor has mainly high signal intensity (long T2).

Murali

St. Louis

Sundaram

Christine University Medical

Janney Center

St. Louis, MO 63110-0250

basis

M, McGuire MH, Schajowicz F. Soft-tissue for decreased signal (short T2) on T2-weighted

appearance

of fibrosis.

1990:177:21-22

Meniscus

Pseudotear

or “Line

of Murray”

began

to consider

this

condition

a normal

variant.

Since

then,

we

have seen approximately 30 similar equivocal tears. To our knowledge, surgery has not shown tears in any of these cases. In our experience, all of these pseudotears have identical characteristics.

They

are

almost

always

in the

posterior

horn

of the

lateral

meniscus and on MR have subtle increased signal intensity extending in a thin line down to the inferior articular surface. They are seen on the sagittal proton-density images but not on the T2-weighted images of standard spin-echo sequences (2500/20, 80 [TR/TE]) with normal windowing. With narrow windowing, the line is more easily seen; it abuts but does not clearly break through the inferior articular surface. It is obliquely oriented centrally toward the joint rather than vertically or obliquely and peripherally as in the normal variant caused by the

interface

with the meniscofemoral

ligaments.

of interest to the practicing radiologist is that we have seen these with the Signa 1 .5-T imager but not with the GE Max 0.5T imager (General Electric, Milwaukee, WI). We use dedicated knee coils with both systems. Histologic studies will be of interest. Because of the thin linear characteristic and because we occasionally see pseudotears in young Perhaps

patients,

we hypothesized

In patients

that

this

might

be a developmental

variant.

in whom

the characteristics are similar to the appearance of Figures 1 B and 3, rather than that of Figure 2, in the paper of Kaplan et al., we continue to favor this hypothesis. Figure 2 shows a thicker band of signal easily seen on routine windowing; we would more likely consider this myxoid degeneration, which indeed was found histologically in their study. We would like to know if Kaplan et al. have had any cases with the more subtle linear signal for which histologic correlation is available since the study was submitted for publication. Paul D. Traughber Saint Alphonsus Regional Medical Center Boise, ID 83706 University of Utah Medical Center Salt Lake City, UT 84132 William T. Murray Saint Aiphonsus Regional Medical Center Boise, ID 83706

REFERENCE

REFERENCES 1 . Sundaram

in the MR imaging

Ra-

correlations.

We noted with interest the recent article by Kaplan et al. [1 ] on pseudotears of the menisci. We first observed this finding of an equivocal tear about 3 years ago in the posterior horn of the lateral meniscus. We have named it “the line of Murray” after the musculoskeletal radiologist who first observed it. The firstfew times we noted it, we asked the referring orthopedic surgeon to do an arthroscopic follow-up examination. As none of the entities were tears at surgery, we

from malignant lesions, in separating recurrent tumors from posttreatment fibrosis, and in predicting tumor histology. The conclusion of one study [1] of soft-tissue tumors with short T2 was that this signal pattern could not be used to separate benign from malignant lesions but could be used to generate a differential diagnosis by predicting histologic compositions of relative acellulanty and abundant collagen. De Lange et al. [2] reached a similar conclusion in a study that examined the MR features of suspected recurrent rectosigmoid carcinoma after abdominoperineal resection; rectal masses with short T2 were related to either postoperative or radiation fibrosis or a desmoplastic reaction from recurrent tumor. In contrast, Negendank et al. [3] found that Hodgkin lymphomatous masses that contained dense fibrosis had high signal intensities on T2 sequences as compared with more uniformly cellular and homogeneous non-Hodgkin lymphomas. Some reservations have been expressed about these apparently paradoxical conclusions on fibrosis, including (1 ) sampling error and (2) possible chemical and structural differences in fibrous tissue associated with lymphomas [4]. The nodules of aggressive fibromatosis may have long or short T2 and may be associated with smaller satellite lesions. Our patient provided us a unique opportunity to study a tumor and its recurrence in the same location approximately 2 years later. Paradoxical T2 signals were obtained for the two masses. Histologic examinations confirmed that both tumors were due to aggressive fibromatosis; however, more collagen and less cellularity was seen in the mass with the short T2. This further confirmed, in a patient serving as her own control, that it is the histologic composition and not the tumor type that influences signal intensity. Gregg A. Baran

clinical-pathologic

masses: histologic MR images. AJR

1 . Kaplan PA, Nelson NL, Garvin KL, Brown DE. MR of the knee: the significance of high signal in the meniscus that does not clearly extend to the surface. AJR 1991;156:333-336

650

LETTERS

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Reply

AJR:157, September1991

regardless

On behalf of #{182}flcoauthors and myself, I thank Drs. Traughber and Murray for their interest in our article [1 ] on the appearance of equivocal meniscal tears on MR. The experience of Drs. Traughber and Murray is of interest, and it is comforting to know that our results agree with theirs. Unfortunately, we have no histologic information on the numerous patients who had increased linear signal in the posterior horn of the lateral meniscus. There is simply no reason to remove these menisci at arthroscopy, because no tear is detected. Without histologic information, I cannot be certain what is responsible for this finding on MR; the pseudotear may be a normal variant. I think that what is most important is for radiologists to recognize that

Letters

are published

Letters

to the

of the cause, the finding

and that no tear will be found

prevent unnecessary

surgery.

probably at surgery.

must

not be more

two

This recognition

of Nebraska

Medical

will Kaplan Center

Omaha, NE 68105

REFERENCE i . Kaplan PA, Nelson significance

NL, Garvin KL, Brown DE. MR of the in the meniscus that does not clearly

of high signal

the surface. AJR 1991:156:333-336

of the Editor than

has no clinical signifi-

Phoebe

University

and are subject to editing. typewritten pages. One or two figures may be included. Abbreviations should not be used. See Author Guidelines, page A5. Material being submitted or published elsewhere should not be duplicated in letters, and authors of letters must disclose financial associations or other possible conflicts of interest. Letters concerning a paper published in the AJR will be sent to the authors of the paper for a reply to be published in the same issue. Opinions expressed in the Letters to the Editor do not necessarily reflect the opinions of the Editor. Editor

at the discretion

cance

double-spaced,

knee: extend

the to