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A 63-year-old African American female with history of bilateral breast cancer status after lumpectomy and radiation therapy presented with right hand, wrist, and arm pain. She was found to have a right axillary mass and a large lesion in the right brachial plexus. A biopsy of the brachial plexus mass came back as a malignant peripheral nerve sheath tumor. This case report illustrates the critical value of multiple imaging modalities in definitive diagnosis of this rare pathologic entity.

Endovascular aneurysm repair (EVAR) is a successful technique as well as an excellent alternative to the surgical management of abdominal aortic aneurysms. EVAR has improved the mortality and morbidity of many patients who would have otherwise suffered greatly from the consequences of abdominal aortic aneurysms. However, EVAR is not without complications. Some complications require lifelong surveillance, whereas others may necessitate immediate surgical intervention. We discuss the various modalities available for the surveillance as well as the common complications that can be seen on computed tomography.

The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs.

Quality assurance (QA) is a fundamental component of every successful radiology operation. A radiology QA program must be able to efficiently and effectively monitor and respond to quality problems. However, as radiology QA has expanded into the depths of radiology operations, the task of defining and measuring quality has become more difficult. Key performance indicators (KPIs) are highly valuable data points and measurement tools that can be used to monitor and evaluate the quality of services provided by a radiology operation. As such, KPIs empower a radiology QA program to bridge normative understandings of health care quality with on-the-ground quality management. This review introduces the importance of KPIs in health care QA, a framework for structuring KPIs, a method to identify and tailor KPIs, and strategies to analyze and communicate KPI data that would drive process improvement. Adopting a KPI-driven QA program is both good for patient care and allows a radiology operation to demonstrate measurable value to other health care stakeholders.

Dual-energy computed tomography (DECT) is based on obtaining 2 data sets with different peak kilovoltages from the same anatomical region, and material decomposition based on attenuation differences at different energy levels. Several DECT technologies are available such as: the dual-source CT, the fast kilovoltage-switching method, and the sandwich detectors technique. Calculi are detectable using iodine subtraction techniques. DECT also helps characterization of renal stone composition. The advanced postprocessing application enables differentiation of various renal stone types. Calculation of water content using spectral imaging is useful to diagnose urinary obstruction.

PURPOSE To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center. MATERIALS AND METHODS This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident. RESULTS A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290). CONCLUSION MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

Aim We aimed to study luxatio erecta humeri using advanced imaging modalities. Method Patients with luxatio erecta humeri and a subsequent magnetic resonance imaging (MRI) and/or computed tomography (CT) scan were included in this study. Results Among 10 identified cases, we detected 2 rotator cuff, 4 labral, and 2 inferior glenohumeral ligament tears as well as 2 glenohumeral cartilage defects. We observed six comminuted displaced greater tuberosity fractures, four anterior inferior glenoid fractures, and four impaction fractures of humeral head. Conclusion This study provides detailed radiologic findings associated with luxatio erecta humeri using MRI and CT.

The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.

To report the authors' experience with the administration of four gadolinium-based contrast agents (GBCA; gadopentetate dimeglumine, gadofosveset trisodium, gadoxetate disodium and gadobenate dimeglumine) in a large study population at a single, large academic medical centre.The institutional review board approved this retrospective study in which data in the electronic incident reporting system were searched. A total of 194, 400 intravenous administrations of linear ionic GBCAs were assessed for the incidence of adverse reactions and risk factors from 1 January 2007 to 14 January 2014. The severity of reactions (mild, moderate, and severe), patient type (outpatients, inpatients, and emergency), examination type, and treatment options were also investigated.In total, 204/194400 (0.1%) patients (mean age 45.7 ± 14.9) showed adverse reactions, consisting of 6/746 (0.80%), 10/3200 (0.31%), 14/6236 (0.22%) and 174/184218 (0.09%), for gadofosveset trisodium, gadoxetate disodium, gadobenate dimeglumine, and gadopentetate dimeglumine, respectively. An overall significant difference was found between different GBCAs regarding the total number of reactions (p0.0001). When comparing the GBCAs together, significant differences were found between gadofosveset trisodium versus gadopentetate dimeglumine (p0.0001), gadofosveset trisodium versus gadobenate dimeglumine (p = 0.0051), gadoxetate disodium versus gadopentetate dimeglumine (p0.0001) and gadopentetate dimeglumine versus gadobenate dimeglumine (p = 0.0013). Rate of reaction was higher in females (F: 146/113187, 0.13%/M: 58/81213, 0.07%; p0.0001). Rate of reactions was higher in outpatient (180/158885, 0.11%), emergency (10/10413, 0.10%), and inpatients (14/25102, 0.05%), respectively (p0.0001). Most of the patients had mild symptoms 171/204 (83.8%). Abdomen-pelvis, liver, and thoracic examinations had highest rates of reactions (0.17 versus 0.16 versus 0.15).The overall rate of adverse reaction to GBCAs was 0.1%. The rates of reactions were highest in gadofosveset trisodium with (0.80%), followed by gadoxetate disodium (0.31%), gadobenate dimeglumine (0.22%) and gadopentetate dimeglumine (0.09%).

Aim To present the authors' experience of contrast medium extravasation (CME) during both CT and MRI examinations in a large academic medical centre. Materials and methods The present retrospective investigation was conducted between June 2008 and June 2013. The radiology data and medical records of patients in whom CME had occurred were reviewed. Results The extravasation rate for CT and MRI was 0.11% (541/502 391); the % was 0.13% during CT and 0.06% during MRI. There was a statistically significant difference between females and males in the overall % ( p = 0.0062), and the number of extravasations between CT and MRI ( p 60 years was statistically significant when compared to the 18–60 year age group ( p = 0.0072). Of 90 MRI patients with extravasation, CME occurred in 51 (0.048%, 51/105,578) patients from manual injections, and 39 (0.087%, 39/44,688) patients from automated injection with statistical significance ( p = 0.0048). A statistical significance was found between females receiving automatic injections and males receiving manual injections ( p = 0.0161). The majority of CME during CT and MRI occurred in the outpatient department [64.5% (291/451) and 64.4% (58/90), respectively], but the overall incidence of CME was highest in inpatients [0.29%, (160/54,664) in CT and 0.16% (32/20,048) in MRI]. Conclusion Patients undergoing CT are at higher risk of developing CME than MRI patients. Females and inpatients were also were more likely to develop CME at both CT and MRI. At MRI CME is more likely in patients above the age of 60 years and for those receiving automated power injections.

Objectives To compare image quality, visibility of anatomic landmarks, tubes and lines, and other clinically significant findings on portable (bedside) chest radiographs acquired with wireless direct radiography (DRw) and computed radiography (CR). Methods In a prospective IRB-approved and HIPAA-compliant study, portable DRw (DRX-1C mobile retrofit portable wireless direct radiography, CareStream Inc., Rochester, NY) and portable CR (AGFA CR (DXG) version; NIM2103, AGFA Healthcare, Ridgefield Park, NJ) images of the chest were acquired within 24-hours in 80 patients in the intensive care unit (ICU). Image pairs of 75 patients (37% female) with a mean age of 60.7±16 years were independently compared side-by-side by 7 experienced thoracic radiologists using a five-point scale. When tubes and lines were present, the radiologist also compared an edge-enhanced copy of the DRw image to the CR image. Results Most radiologists found significantly fewer artifacts on DRw images compared to CR images and all readers agreed that when present, these artifacts did not significantly preclude the ability to evaluate anatomic landmarks, tubes and lines, or clinically significant findings. None of the radiologists (0/7) reported superior visibility of anatomic structures on CR images compared to DRw images and some radiologists (3/7) found DRw images significantly better for visibility of anatomic landmarks such as the carina (p=0.01–0.001). Most radiologists (6/7) found DRw images to be better or clearly better than CR images for position of tubes and lines, and edge-enhanced DRw images to be especially helpful for evaluation of central venous catheters and esophageal tubes (p=0.027-0.001). None of the radiologists deemed CR images superior for visibility of clinically significant findings. Conclusions Critical care chest radiography with a portable DRw system can provide similar or superior information compared to a CR system regarding clinically significant findings and position of tubes and lines.

OBJECTIVE. We implemented an outpatient falls guideline in 2008 in the department of radiology. Here, we describe our multiyear experience. MATERIALS AND METHODS. This was a retrospective study conducted between April 2006 and September 2013 to investigate outpatient falls. The span of the study was divided into eight periods. The incident reporting system was searched for the falls and the fall-related variables. RESULTS. A total of 327 falls occurred during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations). The highest rate was in period 6 (0.83/10,000 examinations). The average for periods 1 and 2 is 0.39/10,000 examinations (37 falls/945,427 examinations), and the average for periods 3–6 is 0.77/10,000 examinations (204 falls/2,656,805 examinations). The average rate for periods 7 and 8 is 0.58/10,000 examinations (86 falls/1,478,280 examinations). There was a statistically significant increase in the total number of falls reported between period 2 and period 3 (p = 0.02). There ...

Nephrogenic systemic fibrosis (NSF) occurs in patients with advanced chronic kidney disease (CKD) or acute renal failure, most commonly following exposure to gadolinium-based contrast agents (GBCAs). NSF can be debilitating and associated with increased mortality. The putative association of NSF with GBCAs prompted the development of guidelines to limit the use of these contrast agents in at-risk patients. Indeed, the incidence of NSF has decreased dramatically following application of these guidelines, which appears to be the only effective means of decreasing NSF incidence. Thus, increasing clinician awareness of these updated guidelines is important. The present review introduces and compares updated guidelines for GBCA use and discusses the latest advances in the understanding of the pathogenic mechanisms and treatment of NSF.

In this review article, the authors provide a detailed series of guidelines for effectively performing root-cause analysis (RCA) and health failure mode and effect analysis (HFMEA). RCA is a retrospective approach used to ascertain the "root cause" of a problem that has already occurred, whereas HFMEA is a prospective risk assessment tool whose aim is to recognize risks to patient safety. RCA and HFMEA are used for the prevention of errors or recurring errors to create a safer workplace, maintain high standards in health care quality, and incorporate time-saving and cost-saving modifications to favorably affect the patient care environment. The principles and techniques provided here should allow reviewers to better understand the features of RCA and HFMEA and how to apply these processes appropriately. These principles include how to organize a team, identify root causes, seed out proximate causes, graphically describe the process, conduct a hazard analysis, and develop and implement potential action plans.

OBJECTIVE. Recent technologic advances in MDCT have led to the introduction of dual-energy CT (DECT). The basic principle of DECT is to acquire images at two different energy levels simultaneously and to use the attenuation differences at these different energy levels for deriving additional information, such as virtual monochromatic images, artifact suppression, and material composition of various tissues. CONCLUSION. A variety of image reconstruction and postprocessing techniques are available for better demonstration and characterization of pathologic abnormalities. DECT can provide both anatomic and functional information of different organ systems. This article focuses on the main applications of DECT in emergency radiology.

Background This study compared Gamma knife radiosurgery (GKRS) and repeated transsphenoidal adenomectomy (TSA) to find the best approach for recurrence of Cushing disease (CD) after unsuccessful first TSA. Material and Methods Fifty-two patients with relapse of CD after TSA were enrolled and randomly underwent a second surgery or GKRS as the next therapeutic approach. They were followed for a mean period of 3.05 ± 0.8 years by physical examination and hormone measurement as well as magnetic resonance imaging. Results No significant difference was observed in sex ratio, mean age, adenoma type, follow-up duration, and initial hormone level between the two groups. No significant relationship was found between preoperative 24-hour free urine cortisol and disease-free months or tumor volume among both groups. Our statistical analysis showed higher recurrence-free interval in the GKRS group compared with TSA group. Conclusion With longer recurrence-free interval, GKRS could be considered a good treatment alternative to repeated TSA in recurrent CD.

The aims of this study were to review patients' complaints about their care in radiology and to determine key areas for improvement.An institutional review board-approved, HIPAA-compliant study was conducted to retrospectively evaluate all radiology-related patient complaints received by the authors' institution's Office of Patient Advocacy from April 1999 to December 2010. The internal review classified the complaints into those that concerned medical complications, radiology staff members, failure to provide patient-centered care, and those that related to quality on the basis of radiologic benchmarks of safety, systems, and professionalism. The rate of successful complaint resolution was also tallied. The incidence of complaints per modality was calculated as a fraction of the total number of radiologic examinations performed.A total of 153 radiology-related complaints were identified. The majority of complaints (60.1% [92 of 153]) described a failure to provide patient-centered care. Of the remaining complaints, 26.2% (40 of 153) reported physical discomfort, 10.5% (16 of 153) reported a combination of both physical discomfort and lack of patient-centered care, and 3.2% (5 of 153) were not related to either category. Of the complaints regarding quality, 44.5% (68 of 153) were associated with operational systems, 24.2% (37 of 153) with safety, 17% (26 of 153) with professionalism, and 14.3% (22 of 153) with multifactorial events. Delays accounted for 20.2% of complaints (31 of 153), and 49.6% of complaints (76 of 153) concerned radiology staff members. Complaint resolution was achieved in 83.6% of cases (128 of 153). The overall incidence of complaints per radiologic procedure was 0.238 per 10,000. The incidence of complaints associated with interventional procedures (3.26 per 10,000) was significantly (P.05) higher than the incidence of those associated with noninterventional examinations (0.138 per 10,000).Failure to provide patient-centered care was the most common complaint; most of these complaints could be attributed to systems issues. There was a higher incidence of complaints related to interventional procedures than diagnostic examinations. Delays and providers' interactions with patients were identified as key areas for improvement.

Mechanical testing has been regarded as the gold standard to investigate the effects of pathologies on the structure-function properties of the skeleton. Tensile properties of cancellous and cortical bone have been reported previously; however, no relationships describing these properties for rat bone as a function of volumetric bone mineral density (ρ(MIN)), apparent density or bone volume fraction (BV/TV) have been reported in the literature. We have shown that at macro level, compression and torsion properties of rat cortical and cancellous bone can be well described as a function of BV/TV, apparent density or ρ(MIN) using non-destructive micro-computed tomographic imaging and mechanical testing to failure. Therefore, the aim of this study is to derive a relationship expressing the tensile properties of rat cortical bone as a function of BV/TV, apparent density or ρ(MIN) over a range of normal and pathologic bones. We used bones from normal, ovariectomized and osteomalacic animals. All specimens underwent micro-computed tomographic imaging to assess bone morphometric and densitometric indices and uniaxial tension to failure. We obtained univariate relationships describing 74-77% of the tensile properties of rat cortical bone as a function of BV/TV, apparent density or ρ(MIN) over a range of density and common skeletal pathologies. The relationships reported in this study can be used in the structural rigidity to provide a non-invasive method to assess the tensile behavior of bones affected by pathology and/or treatment options.

Gamma knife radiosurgery is a minimally invasive procedure which can be used for patients with intractable epilepsies as an alternative for surgical corpus callosotomy. We report a 13-year-old boy with intractable epilepsy who underwent radiosurgical callosotomy. The patient demonstrated significant clinical improvement after gamma knife radiosurgery and was free of seizures 10 months after the procedure. However, He developed four short focal seizures with clonic movements during the 20 months post radiosurgery. Corpus callosotomy decreased epileptiform discharges in both hemispheres, indicating a role for the callosal neurons to facilitate an asymmetric epileptogenic susceptible state within the two hemispheres such that bisynchronous and bisymmetrical epileptiform discharges develop. Our result demonstrates that this novel therapeutic approach is a safe and effective option for the treatment of intractable generalised epilepsies.

Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center.This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident.A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290).MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

Intravenous contrast administration has been of great importance in diagnostic radiology, but it is not without risks either due to the local, systemic allergic reactions or due to subcutaneous extravasation of contrast media. Subcutaneous contrast medium extravasationis an infrequent, yet a well-recognized complication. However, most incidents are minor and can be managed conservatively, but there are a few cases that require immediate surgical intervention. This article discusses the risks factors, clinical manifestations, and conservative and surgical approaches of subcutaneous contrast media extravasation for both computed tomography and magnetic resonance imaging.

PURPOSE: To evaluate the effect of localizing radiograph on computed tomography (CT) radiation dose associated with automatic exposure control with a human cadaver and patient study. MATERIALS AND METHODS: Institutional review board approved the study with a waiver of informed consent. Two chest CT image series with fixed tube current and combined longitudinal-angular automatic exposure control (AEC) were acquired in a human cadaver (64-year-old man) after each of the 8 combinations of localizer radiographs (anteroposterior [AP], AP lateral, AP-posteroanterior [PA], lateral AP, lateral PA, PA, PA-AP, and PA lateral). Applied effective milliampere second, volume CT dose index (CTDIvol) and image noise were recorded for all 24-image series. Volume CT dose indexes were also recorded in 20 patients undergoing chest and abdominal CT after PA and PA-lateral radiographs with the use of AEC. Data were analyzed using analysis of variance and linear correlation tests. RESULTS: With AEC, the CTDIvol fluctuates with the number and projection of localizer radiographs (P < 0.0001). Lowest CTDIvol values are seen when 2 orthogonal localizer radiographs are acquired, whereas highest values are seen when single PA or AP-PA projection localizer radiographs are acquired for planning (P < 0.0001). In 20 patients, CT scanning with AEC after acquisition of 2 orthogonal projection localizer radiographs was associated with significant reduction in radiation dose compared to PA projection radiographs alone (P < 0.0001). CONCLUSIONS: When scanning with AEC, acquisition of 2 orthogonal localizer radiographs is associated with lower CTDIvol compared to a single localizer radiograph.

Introduction: The knowledge of the outcome in patients with multiple intra-cranial aneurysms is crucial in the management of these patients. We compared the outcome between patients with single aneurysm and those with multiple aneurysms in a large single referral center. Hypothesis: We assessed the hypothesis that the risk of rupture and mortality is higher in patients with multiple aneurysms compared to patients with a single aneurysm. Methods: In an IRB-approved study, we evaluated 32.100 head CT angiogram examination reports, (from Dec-2001 to Aug-2010) 2.624 patients had n intracranial aneurysm. Patients were classified into a single aneurysm (SA) or a multiple aneurysms (MA)group. The rupture and mortality rate was calculated per total number of patients and aneurysm for each group. Statistical analysis was performed with Student's t-test and chi-square. Results: There was a significant differences in the occurrence of SAH (SA: 22.7% vs. MA: 11%), IVH (SA: 16.4% vs. MA: 6.9%) and IPH (SA: 7.3% vs. MA: 2.1%) when the comparison was made based on aneurysm occurrence. (p0.05). Conclusion: Patients with SA have as individuals a higher incidence of rupture than patients with MA. When rupture rate per aneurysm was calculated, again the SA (0.28) had a higher rate than MA (0.12) in this population. Prospective studies in patients with multiple aneurysms should be initiated.

Recent advances in computed tomography (CT) technology allow for acquisition of two CT datasets with different X-ray spectra. There are different dual-energy computed tomography (DECT) technical approaches such as: the dual-source CT, the fast kilovoltage-switching method, and the sandwich detectors technique. There are various postprocessing algorithms that are available to provide clinically relevant spectral information. There are several clinical applications of DECT that are easily accessible in the emergency setting. In this review article, we aim to provide the emergency radiologist with a discussion on how this new technology works and how some of its applications can be useful in the emergency room setting.

Although the apprenticeship model of medical training has been in use for centuries, there are several problems with its use. The fundamental ethical principle of nonmaleficence requires that no preventable harm come to patients involved in the training process. In addition, changing medical practice patterns with shorter hospital stays and duty-hour restrictions are making it difficult for trainees to be exposed to enough patients to prepare them to deal with the many possible scenarios they may face in practice. Despite these limitations, the apprenticeship model cannot be completely rejected because it is essential for trainees to perfect their technique by caring for real patients with the guidance of experienced practitioners. Simulation-based training can allow novices to learn from their mistakes in a safe environment and in accordance with the principles of deliberate practice, thus allowing simulation to be a bridge to help get trainees from the novice state, in which they have a higher risk of causing harm, to a more experienced state in which they are more likely to do what is needed for patients.

This study investigated the effectiveness of pirfenidone compared with antioxidants, in the prevention of pulmonary fibrosis and increasing the survival in acutely paraquat poisoned rats.Five groups of ten rats were included in this study. Three groups were poisoned with intraperitoneal injection of 15 mg/kg paraquat. Among these poisoned groups, one group was treated with vitamin C (500 mg/kg, intraperitoneal), vitamin E (200 mg/kg, intraperitoneal) and N-acetylcysteine (250 mg/kg, intravenous); two others were treated with either normal saline or pirfenidone (200 mg/kg, intravenous); two groups were not poisoned and received normal saline or pirfenidone (200 mg/kg, intravenous). All injections except paraquat were repeated in four consecutive days. On the 15th day of study a semi-quantitative determination of lung fibrosis was done using Ashcroft staging criteria on the lung sections.Pirfenidone decreased paraquat induced lung fibrosis (p0.001) while antioxidants did not decrease the lung fibrosis (p = 0.413). Life expectancy decreased in paraquat + normal saline (11 days, 95% CI 7.94-14.05) and paraquat + antioxidant (11 days, 95% CI 7.77-14.23) groups. The increase in the survival of rats in paraquat/pirfenidone group was insignificant (13.4 days, 95% CI 11.13-15.67).This study showed that pirfenidone is able to decrease pulmonary fibrosis following paraquat poisoning in a rat model.

In-plane shields have been shown to reduce CT radiation dose to some of the most radiosensitive organs. However, potential for artifacts and changes in attenuation numbers make their universal use controversial for radiation protection purposes. In this chapter, we discuss advantages and disadvantages of use of in-plane shielding for reducing radiation dose associated with CT scanning.

Vesicoureteral reflux (VUR) and Gastroesophageal reflux (GER) are both common disorders in children and could be associated with significant morbidities. Although they appear to be separate entities, their natural history and underlying pathophysiology are the same and they both tend to resolve over time. We aimed to appraise their concurrent occurrence and prevalence of GER in VUR patients to understand whether they can be considered different manifestations of a syndrome mainly caused by developmental delay resulting in dysfunction of the sphincters.Totally, 174 children ≤ 2 years of age were enrolled and 87 of them with primary VUR constituted patients group. The rest of the cases with the same age and sex distribution entered control group. All the study population underwent ultrasonographic evaluation to detect GER.GER was more frequent in patients with primary VUR. GER was more prevalent in higher grades of VUR. We observed higher prevalence of GER and higher grades of VUR in younger infants demonstrating the tendency of both conditions to resolve overtime. Bilateral VUR was more prevalent among patients with higher grades of VUR. GER was more prevalent in patients with bilateral VUR and Prevalence of bilateral VUR decreased with increase in age. These findings show that the chance of concomitant GER and VUR is higher in children with more severe developmental defect of sphincters.Regarding the higher prevalence of GER among VUR patients and correlation of VUR severity with co-occurrence of GER, besides the natural tendency of both conditions to resolve overtime, they may be considered parts of developmental delay syndrome of sphincters.

Background Burr-hole is the most frequently used neurosurgical treatment for chronic subdural hematoma (CSDH). Few data can be found in the literature confirming the impact of using drainage after evacuation and irrigation of the cavity containing CSDH on the outcome of the patients. It is not clear whether installing such a drainage system would reduce the recurrence rate. Objective The aim of this study was to compare the postoperative recurrence rates and the chance of occurrence of other possible complications between a group treated by burr-hole irrigation without drainage (BI-D) and burr hole-irrigation with drainage (BI+D). Materials and Methods Forty patients experiencing CSDH were included in a randomized controlled trial conducted between June 2007 and July 2009. All underwent surgery and were analyzed in this preliminary report. Twenty patients were assigned to BI+D group and the other 20 to the BD-I group. Inclusion and exclusion criteria are defined, and the cases happened to be well matched. All the epidemiologic, clinical, radiologic, procedure-related, and outcome variables were saved in the data sheaths and analyzed by the use of SPSS v 14. The patients were followed by an independent observer, who visited the patients at 1- and 6-month intervals. Results There were 28 male and 12 female patients (2.3:1) with the age range between 18 and 96 years (mean, 67 years; SD, 18 years). Glasgow coma scale scores varied between 9 and 15 in 37 patients and less than 9 in the other 3 patients. A history of head trauma was established in 25 patients. Limb weakness, loss of consciousness, and headache were the most common presentations. Recurrence occurred in one patient (5%) in BI+D and in none of the patients in BI-D group after 1-month follow up, without significant statistical difference ( P = 0.31). At the end of 6 months there was one more recurrence (5%) in BI-D group, and the recurrence rates became equal. Both patients who experience a recurrence used antiplatelet drugs, and the one in BI-D group also had diabetes. The morbidity and mortality rates were greater in BI+D group, but these finding were not statistically significant ( P = 0.37 and 0.73, respectively). There were no significant differences between the two surgical approaches regarding their relation with the recurrence of CSDH, the patient's morbidity, or mortality. The relative risk was greater for BI+D when the primary and secondary outcome measures were taken into account, but it was not significant statistically. Conclusion Type of surgical technique does not seem to be a main variable improving the outcome of such patients and may act as a confounding factor. Age, neurological status, and comorbidities seem to have more significant impact upon the surgical outcome.