Left Oblique View Research Articles

Combination of Superior and Superomedial Pedicle Techniques in Reduction Mammaplasty: A Modified Approach to Increase Upper Pole Fullness.

Creation of the upper pole fullness is one of the basic goals in reduction mammaplasty. The superior pedicle (S-P) technique brings extra tissue to the upper pole, but folding of a long pedicle can compromise circulation of the nipple-areola complex (NAC). Although the pedicle is not folded in superomedial pedicle (SM-P) technique, it has disadvantage of not bringing extra tissue to the upper pole. We designed a new approach by combining the advantages of S-P and SM-P techniques. Thereby, we aimed to increase upper pole fullness in SM-P or superolateral pedicle (SL-P) mammaplasty. We operated 20 female patients (study group) with the modified SM-P/SL-P technique for breast reduction between 2010 and 2022. Preoperatively, mean sternal notch-nipple distance was 32.6 ± 2.5cm. The upper pole fullness was created by using a superiorly based glandular flap, while the SM-P (17 patients) or SL-P (three patients) was used to carry the NAC. We assessed the success rate of the upper pole fullness, compared with two control groups of 40 patients who underwent conventional SM-P mammaplasty (control group I: 20 patients) and who underwent conventional S-P mammaplasty (control group II: 20 patients). Two plastic surgeons, who do not know which technique was used, assessed before and after photographs of 60 patients regarding success rate of upper pole fullness. To evaluate the success rate, the degree of the difference in the upper pole fullness between before and after photographs has been scored 1-10 for each patient. Below 5 was considered as no difference (unsuccessful), 5-7 as moderate difference (average), 8-10 as significant difference (successful). Photographs of the patients had been taken from five different angles: frontal, right and left oblique views, and right and left sides. Out of 10, mean score was 8.2 ± 1.2 in study group, 7.1 ± 1.8 in control group I, 8.2 ± 1.5 in control group II. Postoperatively, no major complications were observed, such as glandular necrosis, total NAC necrosis, partial (> 50%) NAC necrosis, skin necrosis, or poor NAC sensitivity in none of 60 patients. By using this modification, it is possible to increase upper pole fullness in SM-P/SL-P mammaplasty. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Vieussens' Arterial Ring

The Vieussens' artery is an anastomotic communication between the conus branch of the right coronary artery and the left anterior descending (LAD). Vieussens' ring is so named because it circles around the great vessels in the form of a partial ring. The course of the artery can be best understood in 2 orthogonal views. In the left oblique view, the artery appears coursing upward to the left. In the right oblique view, it courses anteriorly across the right ventricular outflow tract. The clinical significance of Vieussens' arterial ring lies in it being a major source of collateral blood flow to an occluded LAD. The presence of this large collateral may explain preserved ventricular function in our patient, despite severe triple-vessel disease.

Tricuspid valve in congenital heart disease: multimodality imaging and electrophysiological considerations.

The tricuspid valve (TV) has been neglected for many years. Only recently, new studies demonstrated the prognostic role of the tricuspid valve lesions. In addition to that, new interventional approaches offer the possibility to noninvasively treat tricuspid valve disease. In this review, our aim was to summarize the role of different imaging techniques in the assessment of tricuspid valve with particular regards to congenital heart diseases. Finally, we analyze the importance of the TV and its adjacent regions from an electrophysiological point of view, both in structurally normal hearts and in congenital heart diseases. The most relevant transthoracic echocardiography (TTE) views to visualize the TV are the "modified" parasternal long axis, the apical views and subcostal projections, such as right oblique or left oblique views. However, simultaneous visualization of the three leaflets is possible only with three-dimensional TTE or, sometimes, in parasternal short axis and subcostal short axis views in children. 3D echocardiography is promising in this field. Indeed, its unique projections, such as en-face views from the right ventricular and atrial perspectives, are able to define the spatial relationship of the tricuspid leaflets with the surrounding structures. Moreover, multimodality imaging assessment has been recently proposed for the diagnostic assessment of the TV, especially before percutaneous intervention. Cardiac computed tomography provides valuable anatomic spatial information of the TV apparatus. Cardiac magnetic resonance is able to provide, noninvasively, detailed morphological and functional information of the valve.

Optimum Radiological Screening Examination for Lumbar Spine

A retrospective study was performed to assess the diagnostic contribution of oblique view films of the lumbar spine, to information obtained from anteroposterior (AP) and lateral films, as an initial screening tool for the detection of pars interarticularis defects. Twenty-two cases of lumbar spondylolysis were selected from 243 lumbar spine reports, randomly combined with 40 plain X-rays of normal lumbar spines, and evaluated by radiology residents. The frequency of correctly detecting a pars defect on lateral vs. right and left oblique views was determined. Of the bilateral spondylolyses, 85% were diagnosed on lateral films compared to 35% on oblique radiographs. Both views gave poor diagnostic yield in detecting unilateral pars defects. In evaluating a total of 186 X-rays, an average of 31 oblique films were incorrectly diagnosed, as compared to an average of 14 misdiagnosed lateral films. Considering the low sensitivity associated with the use of oblique view radiography, in addition to the extra cost and significantly increased radiation exposure seen with this procedure, our findings indicate that oblique views should be used only for selected patients who might require further investigation. We therefore recommend that the initial lumbosacral radiological evaluation be limited to AP and lateral views.

Coronary sinus and great cardiac vein electroanatomic mapping predicts the activation delay of the coronary sinus branches.

Implantation of left ventricular (LV) lead in segments with delayed electrical activation may improve response to cardiac resynchronization therapy (CRT). The search for the latest LV electrical delay (LVED) site can be time-consuming. To assess if electrical mapping of coronary sinus (CS) and magna cardiac vein can help to identify the latest activated CS branch. We retrospectively evaluated 48 consecutive patients who underwent electroanatomic mapping system-guided (EAMS)-CRT device implantation with ≥2 mapped CS branches. The activation mapping of the CS and relative branches were performed using an insulated guide wire. LVEDwas defined as the interval between the beginning of the QRS complex on the surface electrocardiogramand the local electrogram and expressed in milliseconds (ms). Thirty-two(67%) patients showed left bundle branch block (LBBB) and 16 (33%) non-LBBB electrocardiographic patterns. A total of 116 CS branches (mean, 2.4/patient;range, 2-5) were mapped. In the left oblique view, most patients (N = 39, 81%) showed the latest CS-LVED in lateral segments whilenine(19%) showed the latest CS-LVED in anterior or posterior segments. Specifically, 94% of patients with LBBB showed the latest CS-LVED in lateral segments while CS activation among non-LBBB patients was heterogeneous. In all patients, the CS branch that demonstrated the highest LVED originated from the latest activated segment of the CS. Electrical mapping of CS allows identifying the latest activated branches. This finding may contribute to simplify CRT device implantation compared to activation mapping of all the branches.

Left Ventricular Volume and Function Assessment: a Comparison Study between Echocardiography and Ventriculography

Background: The left ventricular ejection fraction (LVEF) measurement is a common tool for evaluating the LV systolic function. The application of the global longitudinal systolic strain (GLS) parameter in the assessment of the myocardial function has also received special attention recently. Objectives: This study was aimed at comparing the LVEF and LV volumes obtained by the two methods of catheterization and twodimensional (2D) echocardiography (available in our institution) and assessing the correlation between the LVEF and the GLS. Patients and Methods: In this cross-sectional study, 45 patients were recruited from coronary angiography candidates. The patients underwent echocardiography immediately before catheterization. The LVEF and LV volumes were measured via echocardiography using the apical four- and two chamber-views. The GLS was calculated through the automated functional imaging algorithm. Left ventriculography was performed by calculating the LVEF in the right and left oblique views. Results: The LVEF values obtained by the two methods of ventriculography and echocardiography were not significantly different. The highest correlation regarding the echocardiographic LVEF was obtained in the angiographic right anterior oblique view (P < 0.001, r = 0.95). There was a good agreement as regards the biplane LVEF between 2D echocardiography and ventriculography (-0.5 ± 13.27; CI of 95%). The GLS showed a significant correlation with the estimated EF in both methods, the highest being with the Biplane Simpson method (r = -0.84; P < 0.001). Linear regression was used to obtain the formula for estimating the 2D LVEF from the GLS [LVEF = 2.53 (GLS) + 10.48]. The GLS values ≥ -21.7% and≤ -11.7% were consistent with normal and severe global LV systolic dysfunction, respectively. The inter- and intraobserver agreement was more evident in the GLS measurement rather than in the LVEF. Conclusions: Despite the widespread use of 2D LVEF and its good agreement with ventriculography, strain analysis seems to be more reliable as a quantitative tool for ventricular assessment.

Hidden Sentinel Node in Cutaneous Melanoma

Sentinel lymph node (SLN) biopsy is a well-established staging method for melanomas. Several techniques have been described to identify the first lymph node receiving lymphatic flow from the primary tumor. Injection of 99mTc-nanocolloid into the tumor bed followed by lymphoscintigraphy provides a road map for the surgeon. However, in a variable percentage of cases, the sentinel node may remain undiscovered during this procedure [1]. This problem is well-known with regard to the identification of lymph nodes in the head and neck, where the complex anatomy as well as the presence of vital structures renders lymphatic mapping a challenging procedure [2]. Hence, we would like to share our experience in this field by describing the case of a 40-year-old woman who was referred to our department for a 1.33-mm-thick melanoma of the upper external quadrant of the left breast (Fig. 1). Previous surgical excision had been followed by histopathologic analysis reporting an infiltrating cutaneous melanoma with vertical growth and a mitotic index=2, and without ulceration. Fig. 1 Melanoma of the upper external quadrant of the left breast. As a consequence, the patient underwent lymphoscintigraphy (Fig. 2). Planar imaging of the thorax was performed 10 minutes, 30 minutes, and 2 hours and 4 hours after the injection of the radiopharmaceutical. No hot spot could be identified as a sentinel lymph node. Hence, lymphoscintigraphy was postponed for two weeks but, again, neither lymphatic drainage nor a sentinel lymph node was shown. One day later, intraoperatively, a γ-ray detection probe (Navigator, USSC, Norwalk, CT, USA) was used through the intact skin to check the axilla. No radioactivity was found and, in consultation with our institution's oncologists, axillary lymphadenectomy was planned. Widening of the margins was performed, and the hand-held gamma probe was subsequently inserted into the resulting defect (Fig. 3). Radioactivity was found on the deep upper portion of the defect. An accurate dissection, guided by a gamma probe, was performed, and one radioactive node was removed. After removal of the sentinel node, the wound showed no further radioactivity. As a consequence, lymphadenectomy was not performed. Histological analysis of the sentinel node showed the presence of metastatic cells. Fig. 2 Lymphoscintigraphy of the patient with an image at 10 minutes after the injection of the radiopharmaceutical. No hot spot could be identified as a sentinel lymph node. Fig. 3 Preoperative image of the patient undergoing widening of the margins of the previous melanoma excision. Left oblique view of the breast with the scar of the previous melanoma excision. Sentinel node biopsy was first introduced in melanoma patients in 1992 [1]. Since this initial experience, several techniques have been described to identify the first node receiving lymphatic flow from the primary tumor. Preoperative mapping by mean of lymphoscintigraphy has become of paramount importance in melanoma patients due to the unpredictability of lymphatic drainage patterns [3]. However, there are some reports in the literature describing its failure in identifying the SLN. Jansen and colleagues showed that the predicted number of sentinel nodes detected with lymphoscintigraphy was accurate in only 81% of lymph node fields and that its limited discriminating power was the most frequent reason for discrepancies with surgical findings [1]. Hidden sentinel nodes have also been reported in breast cancer patients. Several techniques have been suggested to address this problem, such as delayed imaging, re-injection of the radiopharmaceutical, post-injection massage, injection of saline around the tumor, and hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) scan. In our patient, no sentinel node was shown by lymphoscintigraphy. Two reasons were hypothesized to be responsible for this finding: disruption of the lymphatic drainage induced by surgical excision or concealment of the axillary sentinel node behind the injected radioactivity. Intraoperatively, the latter proved to be true, thus overcoming the need for primary lymphadenectomy. Lymphoscintigraphy is an important guide for sentinel node biopsy, but it may sometimes fail to provide an adequate road map for the surgeon, as in our patient. In such cases, multi-directional scintigraphic views must be considered, in order to detect hot nodes concealed by the injection site, as described for axillary nodes in breast cancer of the upper lateral quadrant [4]. The intraoperative use of blue dye and/or a gamma probe is of paramount importance to compensate for the limitations of scintigraphy, thus allowing the surgeon to perform an oncologically adequate procedure and to spare the patient primary or wrong-site lymphadenectomy. However, the use of blue dye may produce adverse effects, such as urticaria, hypotension, and bronchospasm, and may have marginal benefits, as described by Lingam et al. [5]. As a consequence, intraoperative gamma probing remains a mainstay in cases of hidden nodes or false-negative scintigraphic findings.

The Angry Face Syndrome

The Angry Face Syndrome

The ‘starfish’ sign: a novel sonographic finding with B‐flow imaging and spatiotemporal image correlation in a fetus with total anomalous pulmonary venous return

Total anomalous pulmonary venous return (TAPVR) is a serious congenital anomaly that can lead to delivery of a critically ill newborn if not recognized during fetal life.1,2 Volpe et al.3 have described the inclusion of B-flow imaging using spatiotemporal image correlation (STIC) for fetuses with total anomalous pulmonary venous connection. We now wish to report another affected fetus that extends these original observations and further demonstrates the value of this methodology for detailed anatomic evaluation of complex congenital heart disease. A 19-year-old woman, gravida 1 para 0, was referred to our unit at 21 weeks’ gestation for an abnormal cardiac screening examination that included left cardiac axis deviation, ventricular septal defect (VSD), and a single overriding arterial outflow tract. In addition to her clinical examination, she agreed to participate in an imaging research protocol that was approved by the institutional review boards of William Beaumont Hospital and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Volume ultrasonography (Voluson E8, GE Healthcare, Milwaukee, WI, USA) demonstrated the following: (1) right-sided aortic arch; (2) large perimembranous VSD with overriding aorta; (3) pulmonary atresia; (4) large aortopulmonary collateral artery arising anteriorly from the descending aorta; and (5) poorly visualized pulmonary veins into the left atrium. Our differential diagnosis included tetralogy of Fallot with pulmonary atresia and truncus arteriosus. Anomalous pulmonary venous return was also considered because of the poorly visualized pulmonary veins into the left atrium. Four-dimensional ultrasonography with B-flow and STIC imaging were later used to demonstrate a confluence of pulmonary veins that drained into a vertical vein behind the left atrium, resembling a starfish in shape (Figure 1, Videoclip S1). Figure 1 4D ultrasonography, using B-flow imaging and spatiotemporal image correlation, demonstrating tetralogy of Fallot, pulmonary atresia and total anomalous venous return, from a left oblique view of the posterior heart. A confluence of pulmonary veins drains ... Amniocentesis results revealed an apparently unrelated partial duplication of the short arm of chromosome 16 (16p11.2 to 16p12), but not a 22q minus chromosomal anomaly. A male infant was delivered at term gestation. Neonatal echocardiography confirmed tetralogy of Fallot with pulmonary valve atresia, levocardia, and a right aortic arch. Situs solitus was noted without evidence of isomerism. An aortopulmonary collateral vessel ultimately supplied both pulmonary arteries and the ductus arteriosus was absent. Four pulmonary veins drained into a vertical vein that emptied into a left innominate vein. This vessel subsequently coursed beneath the aortic arch into a right superior vena cava. Postnatal surgery on day 3 included placement of a conduit that connected the right ventricle to the pulmonary artery, perimembranous VSD closure, and correction to total anomalous venous return. The infant had failure to thrive with persistent chylous pleural drainage and eventually expired at 5 months of age. B-flow technology digitally enhances signals from weak blood reflectors from vessels and, at the same time, suppresses strong signals from surrounding tissues.4 The method does not rely on Doppler ultrasonography to display blood flow, is angle-independent, and permits relatively high frame rates with excellent spatial resolution. This approach may be advantageous over color or power Doppler imaging when used in conjunction with STIC for the evaluation of fetal vasculature. Our findings extend those in the original case series of Volpe et al. of fetuses with TAPVR using B-flow imaging and STIC.3 This image demonstrates an unusual degree of anatomic detail for this complicated anomaly and now documents a starfish-like appearance of confluent pulmonary veins as a supracardiac form of TAPVR. In our experience, most prenatal cases of congenital heart disease can be adequately visualized using conventional 2D ultrasonography. Some complex heart anomalies, however, can be further characterized from the additional use of volume sonography with B-flow imaging.

Vascular ring and coarctation of the aorta associated with oesophageal atresia

Fig. 1. Upper left oblique view using a volume rendering technique from heart and great vessels. Ascending aorta (AA) is medial and gives rise first to left carotid artery (LCA), then to right carotid artery (RCA) and right subclavian artery (RSCA), left subclavian artery (LSCA) arising from the upper part of the descending aorta. The aortic arch is right sided (RAA) and its distal portion is very hypoplastic (*). Most of the left sided descending aorta’s (DA) blood flow comes through a large persistent ductus arteriosus (PDA). LPA: left pulmonary artery; PAT: pulmonary arterial trunk; RPA: right pulmonary artery.

Lateral spinal artery aneurysm associated with a posterior inferior cerebellar artery main trunk occlusion

347 Manuscript received May 8, 2005; accepted in final form January 18, 2006. Address reprint requests to: Hisashi Kubota, M.D., Department of Neurosurgery, Yamaguchi University School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan. email: hisakubo@yamaguchi-u.ac.jp. FIG. 1. Admission angiographic studies. A: Neither the PICA nor the aneurysm was clearly visible on the right VA angiogram. B: Right VA angiogram (left oblique view) showing a 4 3 4–mm aneurysm with a well-demarcated round shape (arrowhead) 25 days after admission. The PICA main trunk (arrow) is not visible. FIG. 2. A: Intraoperative view of the LSA aneurysm. B: Artist’s drawing in which the suction tip and dissector have been erased. The collateral vascular network on the posterolateral surface of the medulla oblongata supplied the blood flow to the distal PICA territory. a = aneurysm; b = LSA; c = PICA; d = occlusive PICA; e = VA; f = collateral artery. Spinal artery aneurysms are rare in intracranial lesions, and lateral spinal artery (LSA) aneurysms have been reported in only two cases.1 We describe the first case of an LSA aneurysm developing after posterior inferior cerebellar artery (PICA) occlusion. This 59-year-old woman was admitted to our hospital with sudden-onset severe headache and consciousness disturbance. A computerized tomography (CT) study revealed subarachnoid hemorrhage (SAH) in the posterior fossa, mostly around the medulla oblongata. Initial and subsequent angiographic studies demonstrated no vascular malformation (Fig. 1A). Fourteen days after admission, a new angiographic study showed a small aneurysm near the PICA, but its precise origin was not obvious. At 25 days, a fourth angiographic study revealed complete occlusion of the ipsilateral PICA, in which small collateral arteries were seen (Fig. 1B). During surgical exploration we found that the aneurysm was located on the LSA that contributed to the distal revascularization of the PICA (Fig. 2). After isolating the aneurysm, the lesion was excised. A ventriculoperitoneal shunt was placed to treat the hydrocephalus. Posttreatment, the patient’s disturbed consciousness gradually improved. The LSA arises from the PICA or vertebral artery (VA) and descends beside the spinal cord posterolaterally, entering into the posterior spinal artery (PSA).1,2 To our knowledge, there have been only a few reports of aneurysms of the LSA1 or of the PSA.3–5 If the VA or PICA is occluded, resulting in changing hemodynamic forces, the LSA occasionally plays an important role as a collateral artery. Although LSA aneurysms are rare, in cases involving posterior fossa SAH and an initially negative angiogram, one must persist with further angiography with particular attention to distal branches of the posterior circulation, like the LSA, which can harbor an aneurysm.

Accelerated recognition of left oblique views of faces

Because faces in portraits are depicted more frequently in a left rather than a right oblique (half-profile or 3/4) view, we addressed the question of whether people find it easier to recognize the left or right 3/4 view of a familiar person's face. We examined the ability of 13 subjects to match familiar faces that were presented in either the left or right 3/4 view, with names that were presented either before or after the faces (face-name and name-face matching tasks, respectively). In both tasks, the subjects responded more rapidly to a left than to a right 3/4 view of the same face. This suggests that during face recognition the processing of information from faces that are presented in the left 3/4 view is dominant over the processing of right 3/4 views of familiar faces.

Dominance of the left oblique view in activating the cortical network for face recognition

Faces in portraits are often depicted from the left 3/4 view (an oblique view of the face that is intermediate between the frontal view and left profile). Here, we used functional magnetic resonance imaging (fMRI) to show that, compared with photographs of right 3/4 views of familiar faces, photographs of left 3/4 views of the same faces elicited stronger neural responses in the right middle occipital/inferior parietal cortex, and right inferior frontal gyrus; which are known to be involved in face recognition. By contrast, there was no differential activation in the temporal cortex including the superior temporal sulcus and fusiform gyrus, which are thought to process face-related visual stimuli at a stage that precedes recognition. We suggest that the preference for the left 3/4 view of faces was produced at a later stage of facial information processing that involves attention or memory retrieval.

Reliability and Validity of Chest Radiograph Surveillance Programs

Due to the lack of consensus in the literature in the use of posteroanterior (PA) vs PA with right and left oblique views as the optimum radiograph surveillance methodology to investigate pleural changes, a study was undertaken to evaluate the reliability, sensitivity, and specificity of these two approaches. Three experienced radiologist B readers used the 1980 International Labor Office classification system for pneumoconiosis to independently read chest radiographs of workers with individual identifiers masked. All radiographs were read first as a PA view only. Unknown to the B readers, each subject's PA was then matched to his or her corresponding right and left oblique views (film triad) and re-read several weeks later. The respiratory health of 652 workers exposed to refractory ceramic fiber was assessed as part of cross-sectional and longitudinal surveillance programs. kappa Statistics for interreader and intrareader reliability between the PA view and film triad methods were calculated. Sensitivity, specificity, and positive predictive value were assessed by comparing the initial cross-sectional study to the longitudinal study. The film triad method had considerably higher interreader reliability (kappa = 0.59) compared to the PA-only method (kappa = 0.44). Results from the initial cross-sectional study were then compared to findings evaluated longitudinally. The film triad again was superior, demonstrating a positive predictive value of 73.7% compared to only 47.8% for the PA method. It is our recommendation that the film triad method be used in surveillance studies where both parenchymal and pleural changes are anticipated.

Risk factors for cervical atherosclerosis in patients with transient ischemic attack or minor ischemic stroke.

Our purpose was to study potential determinants of the presence and the severity of cervical atherosclerosis in patients with transient ischemic attack or minor ischemic stroke. Two hundred ninety-four patients up to 60 years of age were included in this cross-sectional study. The male to female ratio was 171/123. Atherosclerosis was defined as the presence of any visible atherosclerotic lesion in anteroposterior or left oblique views of cervical arteries in aortic arch angiograms. The severity of atherosclerosis was assessed using three scores, which were computed separately for the total thickness and length of all plaques as well as for the percent stenosis of the vessels. Atherosclerosis was present in 180 patients (61.2%). In a multiple stepwise logistic regression analysis, age, serum triglycerides, smoking history for more than 20 years, arterial hypertension (defined as systolic or diastolic blood pressure values at least 150 or 100 mm Hg, respectively, or the use of antihypertensive medication), regular light alcohol consumption (inversely), and body mass index (marginal inverse association) were independent determinants of the presence of atherosclerosis; the respective odds ratios were 1.1/1 y, 1.8/1 mmol/L, 3.3, 2.4, 0.3, and 0.9/1 kg/m2. In multiple linear regression models, age was associated positively and the ratio of high density lipoprotein to total cholesterol was associated negatively with the severity of atherosclerosis regardless of the scoring method, whereas current smoking and female sex were predictors only of the percent stenosis and the length of the lesions. Arterial hypertension showed a significant association only with the length of the lesions. Age, cigarette smoking, and arterial hypertension contribute substantially to atherosclerosis in cervical arteries, but this study also confirms the independent associations of lipid or lipoprotein variables with atherosclerotic disease. An independent inverse association of regular light consumption of alcohol with cervical atherosclerosis was also observed.

Breast thermography.

This discussion of breast thermography reviews the following: techniques; the "normal" thermogram found in approximately 65% of gynecologic patients; analysis and classification of a thermogram; factors influencing thermograms (breast symmetry, breast size, age, parity, history of breast feeding, menstrual cycle, pregnancy and lactation, exogenous steroid therapy, menopause and danazol, family history of breast carcinoma, benign breast disease, and time; thermograms and breast carcinoma; and clinical considerations. The temperature and the vascularization of the breast, which are modified by endocrine, inflammatory, and tumoral influences, can be studied through pictures formed by multiple simultaneous temperature in measurements called thermograms. Thermographic examinations must be performed in a draft-free, temperature, and humidity controlled room, where a constant temperature 20 degrees C is maintained. Using telethermography, a front and right and left oblique views must be taken. For contact thermographic studies, the cholesterol plate or sheet on which color distribution corresponds the best to the patient's mean temperature should be selected and a front and an oblique view should be taken of each breast. Thermograms must be analyzed by noting anatomic and vascular symmetry, by measuring temperature differences between comparable areas of the 2 breasts, and by observing the normal round contour of the breast. In addition, repeat thermograms must be compared to previous studies and any observed change must be noted. Increased heat can be vascular, focal, or diffuse. Recent reports and opinions on relationships between abnormal thermograms and cancer are controversial. The most favorable reports on the value of thermograms in the identification and management of breast cancers originate from the University of Strasbourg and the Cancer Institute of Marseille. It is the belief of this physician that thermography is not a specific test for carcinoma detection, for the diagnosis of any other breast disease. It is, however, a sensitive marker of local thermal and vascular abnormalities, which can be helpful in focusing attention on specific patients and for research. The greatest interest of clinical thermography lies in its use in the detection of carcinoma. Patients who have an abnormal thermogram need thorough clinical evaluation. It is possible that the greatest potential application of thermography is in its use in comparison studies.

Evaluation of the cervical spine in whiplash injuries.

In contradistinction to the crippling and fatal injuries associated with speeding vehicles on our Nation's highways, there is being seen with increasing frequency a more subtle though at times distressing injury in accidents involving vehicles traveling at slower speeds on our urban and suburban roads. These “whiplash injuries” have received considerable attention in the literature, with discussions of their mechanisms (4, 6, 7), physiology (9), treatment (8, 9), follow-up, and medicolegal implications (2, 3). One hundred and seven cases have been reviewed. In our experience, the patient, in most instances the driver of an automobile, reports that he was slowing down or waiting for a traffic light to change when another vehicle struck his car from the rear. He will usually state that his head snapped backward forcibly and was then jerked forward with equal violence. Seletz (9) has described the injury as due to an acute flexion or a severe hyperextension of the cervical spine. Nagle (7) believes that it can occur as a result of striking any object “head on” as well as of being struck from behind. Personal communication with several radiologists indicates a great divergence of views concerning the number of roentgenograms and the projections to be used, as well as roentgen criteria employed, in arriving at a diagnosis of whiplash injury. The attempt made at Meadowbrook Hospital (Hempstead, New York) to standardize roentgen exposures in such cases, and to assess the findings which will contribute to a diagnosis of whiplash injury, forms the basis of this paper. Method Patients considered as having been subjected to the type of trauma described above were examined radiographically by a “whiplash series,” which included the following projections: 1. An anteroposterior view of the cervical spine (supine, Bucky technic at 40 in.) (Fig. 6, A) 2. An open-mouth view of the odontoid (as above) (Fig. 7) 3. A lateral view of the cervical spine, with chin relaxed (at 72 in., standing) (Fig. 2, B) 4. A lateral view in maximum flexion (72 in., standing) (Fig. 2, A) 5. A lateral view in maximum extension (72 in., standing) (Fig. 2, C) 6. A 45° right oblique view (72 in., standing) (Fig. 5, A) 7. A 45° left oblique view (as above) Fifty adult patients, 25 men and 25 women, all of whom had previously sustained a whiplash injury, were compared to 35 normal adults (25 men and 10 women). The paucity of volunteers in this latter group is a reflection of current fear of ionizing radiations. In the normal group, no history of trauma or symptomatology referable to the cervical spine could be elicited. In all instances a low-dose roentgen technic was employed; fast screens, high-speed films, use of cones, filters, and gonadal shielding kept the total roentgen exposure low.

The roentgen diagnosis of mitral stenosis.

The roentgen diagnosis of mitral stenosis and its differentiation from mitral insufficiency are more important than ever now that mitral commissurotomy is available. The ideal patient for mitral commissurotomy is one who has pure mitral stenosis, or at least no predominating insufficiency, with no involvement of any of the other heart valves, and who has pulmonary congestion but no right heart failure. Auscultation may be misleading because there may be a loud systolic murmur when the mitral valve is predominantly stenotic; surgery will benefit the patient. Roentgen examination is often of help. Radiographs furnish more exact information than fluoroscopy and provide a permanent record besides. We have found films in the anteroposterior and lateral positions most helpful, together with the right oblique. (The left oblique view is of little value for determining left ventricular enlargement.) Fluoroscopic examination is useful in detection of calcification of the valves. We have also been

Double outlet right ventricle: A partial transposition complex

Three anatomic variations of a partial transposition complex characterized by pulmonary and systemic arterial circuits arising entirely from the right ventricle are described. Clinical data is presented in the first, the “Eisenmenger type,” in which the heart revealed coarctation and complete transposition of the aorta, large pulmonary artery in normal position, ventricular septal defect, and patent ductus arteriosus. The clinical picture of this syndrome is characterized by slowly developing cyanosis, a parasternal systolic murmur, occasionally a diastolic murmur and signs of aortic coarctation. Survival may reach the second decade. Fluoroscopy reveals plethoric lung fields, combined ventricular enlargement, and a wide supracardiac shadow in the anteroposterior and left oblique views. Another example of this category was complicated by absence of the aortic arch. It was associated with a small separate ascending aorta, absence of the aortic arch, and descending aorta supplied by a patent ductus. All vessels arose from the right ventricle. Survival past the age of 6 years has not been recorded in this type. The second principal variation of the “double outlet” right ventricle is the Fallot type. It resembles the tetralogy of Fallot because of various degrees of pulmonary hypoplasia. Biventricular enlargement, however, suggests that one is not dealing with a true tetralogy, and angiocardiography may demonstrate the exact relationship of the septal defect to aortic and pulmonary orifices.

ROENTGEN VISUALIZATION OF THE SPLEEN A METHOD USEFUL TO CLINICAL DIAGNOSIS

A routinely applicable method of roentgen visualization of the spleen is described, which is useful to diagnose the enlarged but not parpable spleen. Technique: The patient is given one-half to one effervescent powdor before meal. Then the P. A. and left oblique views are taken in prone position, using a Potter-Bucky diaphragm. The films are exposed at 40 inch distance, one to one-half second, 100-120ma., 65-75kv. The measurements of the spleen shadow are illustrated in Fig. 4. The criteria for determining splenic enlargement are as follows. 1) The spleen is not enlarged if the “T” is less than 5cm and the “W” is less than l0cm. 2) The spleen is doubtfully enlarged if the “T” is from 5 to 6cm or the “W” is from 10 to 12cm. 3) The spleen is probably enlarged if the “T” is more than 6cm or the “W” is more than 12cm or the “D” is more than 1.5cm. 4) The spleen is definitly enlarged if the “T” and the “W” are more than 6cm and 12cm respectively, while the “D” is more than 1.5cm. The other signs of enlarged spleen which can decide the diagnosis in questionable cases are: The upper pole of the spleen reaches to the top of the diaphragm, and the shape of stomach-bubble is cylindrical or oblonged. The following should be added: 1) In the cases of greatly enlarged spleen, its size and shape are recorded by the roentgenogram in spine position with no contrast technique. 2) Tomographic studies of 15 normal subjects show that the angle of normal splenic axis (A. A. in Table 3.) to the transverse plane in prone position is 8 degrees upward to 26 degrees downward, and far less than that of the direction of the 10th. rib (A. R.).