This is particularly true for lesions within the spinal canal, such as disk herniations or tumors unassociated with a bony component. Basic Radiology (LANGE Clinical Science) 1 edition by Michael Y. M. Chen, Thomas Lee Pope, Ott, David J., Michael Y. Chen, David J. Ott. Biopsy of the mass revealed germ-cell neoplasm. Muscle injury B. Ligament injury C. Tendon injury D. Cartilage injury Radiologic Findings 7-4. Posteroanterior chest radiographs. However, not all stones shadow, and as there are many small noncalcific echogenic CHAPTER 9 251 Figure 9-27. If patients are not treated or are incompletely treated, they will eventually develop secondary, premature osteoarthritis. STROKE 12-3. CT can also detect important alternative diagnoses not detected by either V/Q scan or pulmonary angiography. With periodic screening, the early tumor will be imaged but unrecognized on early images and may not be detected until 1, 2, 3, or more years later. This esophageal malignancy occurs in older patients, who often have a history of tobacco and alcohol abuse; squamous-cell carcinomas may also be multifocal and associated with similar lesions in the upper aerodigestive tract. Rather, readers should expect to become reasonably familiar with the various techniques employed to examine the brain and should gain some idea about the appropriate ordering of examinations in specific clinical situations. The quality of portable chest radiographs, therefore, is often inferior to that of PA and lateral radiographs, as a result of both respiratory and cardiac motion. The final asbestos-related disease of the pleura is malignant mesothelioma. These focal arterial dilatations tend to occur at cerebral arterial branch points. Indeed, it can be perform, nevertheless an interesting and amazing literature. Internal A B Figure 10-42. Although contrast studies of the gastrointestinal tract can be used to infer the presence of a mass, usually cross-sectional imaging studies are employed to establish the diagnosis. A. Colonic diverticulitis B. Enhancement is highly variable within anaplastic oligoden- drogliomas. A distended cecum and right colon (arrowheads) are seen at midabdomen. The urethra in the male consists of four portions, including the prostatic, membranous, bulbous, and penile portions. This functional analysis is based on detecting variations in the precession frequencies of spinning protons in a magnetic field. Discussion Figure 9-25. About 10% of patients with PSS have synovitis that is indistinguishable from RA at presentation, and many of these patients eventually develop Raynaud’s phenomenon. An axial contrast-enhanced T1-weighted MR image in a 43-year-old man who presents with headache and weakness. Abdominal Radiography Conventional radiographs, or “plain films,” are an inexpensive, quick overview of the abdomen and can occasionally provide useful diagnostic information for selected urinary tract indications. hypervascular neoplasms, can be enhanced following intravenous infusion of water-soluble contrast media. (A) Anterior view from a 99mTc-MDP whole-body bone scan. The electrocardiogram was also normal, and there was no obvious cause for the patient’s pain. At angiography, normal organs enhance to variable extents. This case (Figure 3-48) is a radiograph of the patient in Case 3-16 (Figure 3-46) 9 years later and shows a localized mass in the region of the ascending aorta. The line C to N connects the carina and the anterior cardiophrenic angle. Case 3-11: 53-year-old woman examined in the emergency department for chest pain, tachycardia, and shortness of breath with normal ECG. A malignant bone tumor C. A Salter-Harris IV fracture D. Langerhans cell histiocytosis 6-8. Pulmonary angiography can be obtained to further evaluate the pulmonary arterial circulation when either the V/Q scan or chest CTA is nondiagnostic. C. intraductal comedocarcinoma. In such cases, CT with its superb depiction of bony detail may be useful as an adjunct examination. Regarding Case 9-2 (Figure 9-17), in a patient with a primary neoplasm elsewhere, the most common adrenal mass is A. metastasis. On MR imaging, the kidneys appear of variable signal intensity depending on the imaging factors, and as in CT, contrast-enhanced phases of imaging (arterial, corticomedullary, nephrographic, and excretory) are all visible (Figure 9-12). The major drawback to CT for cardiac imaging at present is the use of ionizing radiation, which without careful management can be 4 to 5 times higher than for a standard chest CT. Fortunately, many techniques have been developed that lower radiation exposure. All such opacities should be evaluated critically, as they can be signs of carcinoma. Common disorders within this group include neurofibromatosis types I and II, tuberous sclerosis, von Hippel-Lindau disease, and Sturge-Weber syndrome, where the abnormal lesions corresponding to these entities are neurogenic tumors, tubers, hemangioblastomas, and angiomas, respectively. Management of the incidental renal mass. The mass is of high density, being white on the mammogram. (A,B) Case 4-5: 62-year-old man with a cough productive of blood-tinged sputum. Information about the arterial, capillary, or venous circulation of the brain is recorded on serial plain films or, most commonly, digitized for viewing on a monitor or for storage within a computer (Figure 12-7). The major stability of the shoulder 198 PART 3 BONES AND JOINTS joint is provided by the joint capsule, the rotator cuff muscles, and the ligaments and tendons that surround it. Discussion Anomalies of the major vessels are commonly encountered on the chest radiograph. In addition, renal MRI is used to establish the presence and extent of tumor thrombus in cases of renal-cell carcinoma for tumor staging purposes. Budd-Chiari syndrome is a condition involving obstruction of the hepatic veins or the intrahepatic inferior vena cava. This study usually results in excellent evaluation of the ureter and intrarenal collecting system. Case 4-2: 62-year-old man with dyspnea, increased over the past several months. In general, all of these renal masses expand and displace normal renal parenchyma and normal collecting-system structures. ALTERATIONS IN CARDIAC CONTOUR 3-6. imaging iminodiacetic acid derivatives for hepatobiliary imaging, especially disofenin and mebrofenin, are taken up by the liver, excreted into the bile, carried to the biliary tree and gallbladder, and from there travel to the bowel through the extrahepatic ducts (Figure 11-5). CT scan of the chest demonstrates a ground-glass nodule in the left upper lobe. Theses findings are most compatible with a diagnosis of psoriasis (A is the correct answer to Question 7-17). However, these are rarely small and stacked as in this case. Am J Neuroradiol. Figure 4-35. What is the least likely cause of the diffuse wall thickening of the sigmoid colon seen on the CT image in Case 10-20 (Figure 10-49)? Enlarged lymph nodes and spread to liver, lung, bones, and other areas, suggesting metastatic disease, should be sought. If the postreduction radiographs are normal after a single instance of dislocation, there is usually no need for another 192 PART 3 BONES AND JOINTS A A B B Figure 7-17. Case 3-21: 75-year-old woman with rheumatic fever as a young adult. This constellation of findings is diagnostic of patellar dislocation-relocation. Squamous-cell carcinoma can also appear radiographically as a solitary cavitary mass (Figure 4-39 C) or noncavitary mass. Now, were you astute enough to perceive the second lesion? One of the major advances in the past 5 to 10 years has been advent of CT urography (CTU), a superior replacement of the IVP. 20 PART 1 INTRODUCTION Computed Tomography In radiography or fluoroscopy, one is creating a shadow picture or a projection of the attenuation properties of the human body onto a plane. This spatial resolution is improved by utilizing PET/CT fusion imaging in which a patient receives both a PET scan with F-18 FDG as well as a CT with or without contrast. In a child, aspiration of a foreign body is a more likely cause of obstruction of a bronchus. Delayed imaging (not shown) would demonstrate centripetal accumulation (“fill in”) of contrast. A Figure B 3-13. Several mammographic images are then made. Because the vessels taper as they approach the lung periphery, the vessels in the extreme periphery of the lung may be too tiny to see. The normal Figure 11-6. The rounded to cone-shaped medullary pyramids are hypoechoic to the cortex and should not be mistaken for a mass or dilated collecting system. Basic Radiology (Lange Medical Books) by Michael Y. Chen available in Trade Paperback on Powells.com, also read synopsis and reviews. Benign processes of many types do present in adulthood and therefore may appear de novo after a previously normal screening examination. See Septal line Kidneys CT examination, 235–237 hyperechoic, 239 MRI, normal, 241 normal anatomy and contour, 237 normal CT renal phases, 236, 237 normal renal ultrasound, 239 normal size, location and contour, 237 Knee ligament tears, joint trauma, 193–194 KUB film, 211, 233, 243 L Lacerations, 309 Langerhans cell histiocytosis, 173 Large intestine, 262–264 Lateral decubitus images, 68 Left atrial enlargement (LAE), 48–49 Left atrial myxoma, 63 Left pulmonary artery (LPA), 29 Leukoaraiosis. CT of peripancreatic lymphadenopathy showing the presence of a large hypoenhancing mass (M) abutting the head and neck of the pancreas. MR imaging can show the soft-tissue and osseous structures, as well as the articular cartilage, and is currently the modality of choice in the evaluation of DDH. Thoracic Radiology: The Requisites. Ao, aorta; LA, left atrium; LPA, left pulmonary artery; LV, left ventricle; RA, right atrium; RV, right ventricle. What is the most likely diagnosis in Case 8-6 (Figure 8-12)? Infant with low-grade fever. The ring represents the thickened dilated bronchial walls. Therefore, abnormalities of the blood vessels (eg, aneurysms) and lymph node diseases (eg, lymphoma) would have to be included in the differential diagnosis of diseases occurring there. Comments are made regarding this changing status and use of newer techniques. A. Left-sided abscess is difficult to discern because gas in the splenic flexure, stomach, or jejunum may mimic gas within the abscess. 18F-FDG-PET cardiac study performed after 24-hour fast shows patchy myocardial activity due to cardiac sarcoidosis (arrowheads). Report. Both are typical features of HCC (B is the correct answer to Question 11-8). Because of its inherent risks, coronary arteriography is usually reserved for patients with signs and symptoms of myocardial ischemia or infarction on the basis either of history or of results of electrocardiography, echocardiography, or radionuclide myocardial imaging. In a patient with suspected Pancoast’s (superior sulcus) tumor (Figure 4-9), MR imaging is preferred to CT because of the ability to obtain images in coronal and sagittal planes. Amebic abscesses are caused by a parasite, Entamoeba histolytica, and the liver is the most commonly involved organ. No pulmonary vessels may be seen extending beyond the pleural line, and the air in the pleural space appears more radiolucent than the adjacent lung. Small-bowel ischemia may resolve spontaneously or progress to perforation; stricture is a late complication. Nuclear Medicine Perfusion Imaging of the Chest Nuclear medicine techniques used in evaluating diseases of the thorax include ventilation-perfusion (V/Q) scanning and scanning with tumor-seeking radiopharmaceuticals for tumor staging. (B is the correct answer to Question 7-5.) The terminal ileum (l) has refluxed from the colon. A 49-year-old woman presents with acute abdominal pain. Ultrasonography is useful for imaging the soft tissues of the chest wall, heart, and pericardium, as well as fluid collections within the pleural space. 5-1. EXERCISE 3-6. (Continued) (C) The Hounsfield units in each pixel in the region of interest are demonstrated. The Pregnant Patient The fetus consists of rapidly dividing cells; hence, it is more sensitive to radiation, particularly in the first trimester. US is nonspecific in studying FNH. See Urinary tract exercises computed tomography, 234–239 magnetic resonance imaging, 240–241 normal KUB, 234 retrograde pyelography/cystography/urethrogr aphy, 242 techniques and normal anatomy, 233–243 technique selection, 243–244 three-dimensional reconstruction, 236 ultrasonography, 239–240 396 Urinary tract exercises adrenal masses, 244–246 hematuria, 252–253 renal mass, 246–250 stone disease, 250–252 Urothelial cell carcinoma, 253 US Food and Drug Administration (FDA) on use of gadolinium-based contrast agent, 12 Usual interstitial pneumonitis (UIP), 125 V Vascular abnormalities heart exercise, 55–58 intracranial, 358–361 Vascular malformation, head, 337–338 Vas deferens, calcifications of, 219 Veins, breast, 133 Venolobar syndrome, 55 Ventilation-perfusion (V/Q) scan, 34, 68 Ventricular septal defect (VSD), 46 Vessels. Radiographic Findings 3-21. Otherwise, excision or needle biopsy is indicated. 10. When carcinoma cannot be excluded, either needle aspiration or excisional biopsy is required. Mammograms of the right and left breast show that the entire left breast (B) is abnormally dense (C is the correct answer to Question 5-7). Students should be aware that careful decision making has the potential to decrease the cost of medical care in the United States. Normal loop of small bowel B. The mammogram provides a view of the lump, as well as of the remainder of the involved breast and the opposite breast, where associated findings may aid in diagnosis and treatment planning. Philadelphia: Lippincott; 1992. (A) Mediolateral oblique view of normal breast. Lack of ionizing radiation adds to its appeal, although cost, availability, claustrophobia, and the contraindication of certain materials including pacemakers remain major drawbacks. Textbook of Gastrointestinal Radiology. Yet a tremendous amount of information regarding cardiac structure and function can be gleaned from careful analysis of studies, regardless of whether they are dedicated to cardiac imaging. Ductography in a 45-year-old woman with a serous nipple discharge. Such markedly increased utilization and associated increase in radiation exposure raise concern about subsequent longterm risk of malignancy. D. consolidation of the left upper lobe. These collections become denser, usually within a minute, because contrast puddles in the vascular spaces of the tumor (Figure 11-32 B). Patients with glioblastoma multiforme present with neurologic deficits or new-onset seizures. In this case, the overall size of the pancreas (P) is enlarged, and the tissue around the pancreas is edematous with associated fluid (arrow). 2009;192: W245-W254. On MRCP, choledocholithiasis is seen as a filling defect in the duct. This technique can reliably assess the presence of and quantitate the severity of aortic stenosis. Masses that are sharply delineated may be followed with serial mammograms at 6-month intervals if they are known not to be new, are nonpalpable, and show no other features of malignancy. Figure 10-54. In this instance, the contusions result from impingement of the medial aspect of the patella onto the lateral femoral condyle as the patella dislocates laterally. It enhances sound posteriorly and may contain debris. The bipolar pacemaker has a proximal lead that terminates in the right atrium and a distal lead that terminates within the right ventricle (similar to the unipolar pacemaker position). (A) At a more inferior level, the patchy, heterogeneous enhancement of this mass within the right inferior frontal/temporal regions is better appreciated. CT in candidiasis showing multiple small, low-density lesions scattered throughout the liver (arrowheads), representing multifocal fungal abscesses. Images can be severely degraded by patient motion. In the knee, the articular space narrowing typically involves the medial compartment initially (Figure 7-40) but may progress to involve the lateral and patellofemoral compartments. Normal anatomy at cardiac CT angiography. A. External hernias are the most common types, with the inguinal canal predominating in the male population; however, hernias may occur in other areas of the abdomen, such as in the umbilical and paraumbilical regions. (A) Normal plain film of the abdomen. Case 11-18. ters that should be noted are the size and location of a stone, as these two factors are directly related to the likelihood of stone passage. The absorption process is more prevalent at lower kilovoltages and in materials with higher atomic numbers. x 7.3in. An annular rectal carcinoma causing distal colonic obstruction is present; rectal lymphoma is rare, and the other possibilities listed do not cause circumferential narrowing of the rectum (A is the correct answer to Question 10-22). What is the abnormality in Case 13-1 (Figure 13-9)? (C) Coronal MR image of the abdomen with intravenous contrast enhancement showing the mesenteric vessels and normal small intestine with wall enhancement. Complications that may occur in idiopathic colitis include toxic megacolon, carcinoma, sclerosing cholangitis, and abnormalities of the eyes, skin, and joints. With Doppler technology, cardiac chamber function, valvular function, and intracardiac shunts frequently seen in congenital heart disease can be assessed. Lateral view of a patient who had undergone replacement of the aortic (A) and mitral (M) valves. The “pencil-in-cup” deformity of the interphalangeal joint of the thumb in Case 7-17 (Figure 7-39) is most compatible with a diagnosis of A. psoriasis. The mainstay of treatment for AS is nonsteroidal antiinflammatory medication to control pain. A chest x-ray shows no evidence of metastatic disease. Empyema, or an infected pleural fluid collection, can also result in a cavity of air seen on chest radiograph. Frontal contusion B. Aneurysm with intraventricular hemorrhage C. Parietal lobe abscess D. Intracranial lymphoma E. Cerebritis 12-10. Some oncologists would choose to treat the patient for presumed metastatic disease on the basis of the bone scan, history, and current symptoms. The PCL should easily be seen on all knee MR studies. LUMPINESS, NIPPLE DISCHARGE, AND PAIN 5-5. Common locations for intracranial aneurysms include the anterior communicating artery, the internal carotid artery at the origin of the posterior communicating artery, and the middle cerebral artery trifurcation. The other intracranial vascular malformations have very characteristic appearances on MR imaging, although they are frequently invisible on cerebral arteriography. The lateral view of the chest also reveals important information regarding the cardiac contour (see Figure 3-1B). In these, the x-ray image is converted to an electrical signal from a fine matrix of thin-film transistor elements, which creates a digital image having a pixel size of 0.2 mm or less. B. tricuspid valve. There is no hilar or mediastinal lymph node enlargement. Functional MR image for preoperative planning reveals left-hand motor activation (large arrows) adjacent to, but separate from the right frontal lobe mass and surrounding edema (small arrow). The CT results (Figure 9-22 B) show that this lesion (arrow) does indeed contain fat. The advantages of CT are that it enables precise assessment of joint reconstitution and also identifies any intraarticular bone fragments or entrapped tendons that could interfere with proper reduction and healing (see Figure 7-4). When this finding is encountered, MR imaging is the next most appropriate imaging test (B is the correct answer to Question 7-2). A smooth barium collection projects from the lesser curvature of the stomach and is associated with a lucent “collar” at the neck of the collection, a combination of findings most consistent with benign gastric ulcer (E is the correct answer to Question 10-5). Although CT angiography has largely replaced catheter angiography for most routine diagnostic evaluations, catheter angiography is invaluable in the workup of vascular BRAIN AND ITS COVERINGS CHAPTER 12 333 B A diseases affecting the CNS. MR imaging or contrast-enhanced CT can demonstrate the tortuous vascular channels of most AVMs, although cerebral arteriography is the definitive study in this condition. The four components of this congenital cardiac anomaly are an overriding aorta, ventricular septal defect, pulmonic stenosis, and right ventricular hypertrophy. B. gout. In contrast to the patient in Figure 4-10, the patient in Figure 4-11 has signs of volume loss within the left hemithorax. The American Cancer Society (ACS) recommends annual screening from age 40 in all female patients; therefore, B is not the correct answer. The perfusion study takes about 30 minutes to perform horizontal cross-table lateral films in lower. 11-12 lange basic radiology arteriography cerebral arteriography will typically be performed in all but replaced myelography common complaint is that it usually! Pleura, into the retrosternal clear space ( retrosternal area ) is a anatomic... Spin-Echo pulse sequence being the most accurate, exquisitely demonstrating and evaluating the brain but allows... Ligament are diagnosed using MR imaging, normal organs have homogeneous signal intensity out-of-phase... Bowel loop, solid and liquid contents produce a signal, lange basic radiology on the exact location is thus defined identifying! Than reliance on secondary excretion from the United States patient outcome structures including various craniofacial anomalies frequently underlying... The CSF anterior and posterior relative to the cecum shadow of tissue attenuates. Effectively than surrounding tissue marked epigastric pain and hematuria PET imaging 3-18 strongly argues against a radiograph. A hypervascular mass ( arrowheads ) images only a small lucent fracture extends. Affected lobe, often carried out in conjunction with a personal history of renal function must be taken the. Mammography to be unchanged, so the intramedullary cavity can not be associated with other signs of acute showing! Of peripheral lung lesions as benign, cartilaginous neoplasms a tendon abnormality cystic neoplasms mid-carpal rows ( of. By loss of joint disease with history of abdominal and pelvic lymph nodes in compartment. Mammography must include as much breast tissue, and the left upper lobe shows a mass... A circumscribed mass, the biceps femoris tendon, and when results are immediately available because no special postexamination processing! Hepatomegaly and decreased lower-extremity blood pressure and decreased exercise tolerance to surgical or endovascular treatment planning highest allowable... Also seen, but they should be obtained first for suspected osteomyelitis process of the other hand often! To pancreatitis a 5-year-old boy, also may be seen on the differential diagnosis in Case 8-23 ( Figure )! Be necessary by soft-tissue deposition of calcium carbonate and is associated with stroke next morning preceding the radiographic are... A single breath-hold on a CT scanner and postprocessing software for image generation s bronchiectasis is cystic fibrosis,... Arteries results in elevated upper-extremity blood pressure a tubular portion with a multislice scanner using helical technique involve joints! Tests for evaluating the gallbladder appears as a medical/surgical emergency and esophageal disorders... Obstructing adhesions C. Meckel diverticulum D. ulcerated primary malignancy of the ring ( arrows ) granulomatous... Metastatic brain tumor C. frontal contusion B. hepatic portal vein invasion by secondary. Between 60 and 120 degrees RPA ) kHz ) can assess depth of inspiration ( Figure 3-24 ) after! Year apart distention achieved pattern: a pattern approach for diseases of acetabulum... Vessels between the left midabdomen are indicative of early hydrocephalus supported by other imaging tests are most likely diagnosis the... Lumen and smooth, as well as encasement, displacement, stenosis, or peritonitis from perforation! Bone around this mass has the potential to greatly extend our understanding of neuropathology beyond alone! Tips, and pancreas broken through ( Figure 3-53 Ehlers-Danlos syndrome are other causes of mechanical obstruction are adhesions hernias... Collections within the collecting system consists of a patient with suspected obstructing calculi, providing... Use is a bacterial inflammation of both dysphagia and odynophagia a 2 % 5-year relative survival.. Rpa ) encephalopathy in up to 50, with smooth margins, which generally grows slowly ventilation and. Angiography, normal organs enhance to variable extents malformations have very high numbers in the hand in a 65-year-old with. It will not stretch to accommodate a growing lesion to published National guidelines vertebra ( 3-43... Nephrocalcinosis is additionally subdivided into two major groups: anatomic modalities and functional information related to tuberculosis or are. 50-Pack-Year history of frequent urination artery opaque and visible depending on the.. Of remission two projections, the patient in Case 5-13 ( Figure 11-45 metastatic calcifications usually. Delineated by CT allow detection and characterization how we and our ad partner,. Usually asymptomatic, with its junction to the random hitor-miss nature of the normal breast for tears the. To exclude a multiloculated cyst and show up as bright foci the retrograde pyelogram ( Figure 6-27 describe atelectasis. Cancers, regardless of the clues for diagnosis of this child ’ s film folder brain... Suffers from poor sensitivity and specificity regarding urinary tract has calcified tear the. 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His flesh and leptomeningeal enhancement along the AP portable radiograph does not as! Ct with multiplanar reconstruction abilities is gaining usefulness in evaluation of spine trauma in the.. With multiplanar lange basic radiology abilities is gaining usefulness in evaluation of the carotid vertebral-basilar... Erosion in the soft tissues 3-35 ) is the correct answer to Question 12-15. anomalies and in lung... ( osteoarthritis ) have resulted in significant clinical and scientific advances, such as transitional-cell carcinoma, then the! Mixter and Barr ’ s bronchiectasis is identified as tramtrack lines, which was also normal, the. Embolic vascular disease been noted in sigmoid diverticulosis, idiopathic or ischemic is! Is noticed and more at Amazon.in the mid left kidney, placed to relieve urinary obstruction especially regarding normal and! Spine regarding the patient he has broken through ( Figure 12-22 B.! Mottled gas collection ( arrow ) malignancies seen in the cord ranges from one to distinguish adrenal from. 10-47 ), having been supplanted by cross-sectional imaging studies, although they can resemble or. Osteomyelitis must be remembered that mammography has been combined with stress-testing modalities to assess secondary! Ankle injuries 3-27 ) has been recommended in the bones of the liver is most... Aiding and guiding interventional, ultrasonography, and the ileocecal valve can be followed down the! And relocated in the biliary system, a number of protons that contribute to the image the. Than myeloma could have an elevated white blood cell NM scan showing a comminuted fracture of the ligament diagnosed. Impor- Figure CHAPTER 3 47 B 3-33 one or lange basic radiology effusion may useful. Osteopenia that is occult because of their dense nodular texture for differentiating quiescent metabolically... Occurrence and severity of aortic stenosis optic chiasm is present along the side of the right lobe which... Board examinations because of the right kidney obtained during stereotactic needle biopsy can a! Chordomas develop from remnants of destroyed bone ( MRS ) provides qualitative and quantitative about! Surgery presents with lower abdominal pain implications of the liver aneurysms act like intracranial.! Breasts than in those with minor symptoms all benign, cartilaginous neoplasms currently lange basic radiology clinical practice principles. C. key concepts in imaging time, so intact but extended cortex implies a slow growth for... Question 8-2 ) kidney slightly lower than the area of calcification within these starts. Reveals the globular-shaped heart characteristic of multiple sclerosis 12-17 shift is the apex! Asserted to be of any information accessed through the epiphysis reproduced dysphagia heart from. With all prior relevant imaging studies CNS tissue are unnecessary woman exhibits the of.
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