Pontine Myelinolysis Caused by Hypovolemic Hypernatremia.

Introduction. Central pontine myelinolysis is characterized by the occurrence of acute demyelinating lesions of cells in the pons secondary to abrupt oscillations of serum osmolarity. Its exact incidence is not well defined, but studies show a prevalence of 0.25 to 0.5% in the general population, 2.5% in the intensive care unit, and up to 10% in patients with risk factors, such as chronic liver disease and hepatic transplantation, alcoholism, malnutrition, diuretic therapy, electrolyte imbalance, hypoglycemia, and hyperglycemia. Case Report. A 70-year-old white female with extranodal diffuse large B-cell non-Hodgkin's lymphoma (extensive mass on the left anterior chest wall), stage IVA, developed pontine myelinolysis secondary to hypovolemic acute hypernatremia, which occurred due to diarrhea caused by chemotherapy (rituximab, cyclophosphamide, doxorubicin, and vincristine). Discussion. Pontine myelinolysis occurs most often due to the rapid correction of chronic hyponatremia. But here, we describe a case of the disease secondary to the occurrence of hypovolemic acute hypernatremia in a patient with a hematological malignancy under treatment, who was on chronic treatment with thiazide diuretics and who presented with other electrolyte disturbances as risk factors for the development of pontine myelinolysis.

Upper bound dose values for meson radiation in heavy-ion therapy.

Radiation treatment of cancer has evolved to include massive particle beams, instead of traditional irradiation procedures. Thus, patient doses and worker radiological protection have become issues of constant concern in the use of these new technologies, especially for proton- and heavy-ion-therapy. In the beam energies of interest of heavy-ion-therapy, secondary particle radiation comes from proton, neutron, and neutral and charged pions produced in the nuclear collisions of the beam with human tissue atoms. This work, for the first time, offers the upper bound of meson radiation dose in organic tissues due to secondary meson radiation in heavy-ion therapy. A model based on intranuclear collision has been used to follow in time the nuclear reaction and to determine the secondary radiation due to the meson yield produced in the beam interaction with nuclei in the tissue-equivalent media and water. The multiplicity, energy spectrum, and angular distribution of these pions, as well as their decay products, have been calculated in different scenarios for the nuclear reaction mechanism. The results of the produced secondary meson particles has been used to estimate the energy deposited in tissue using a cylindrical phantom by a transport Monte Carlo simulation and we have concluded that these mesons contribute at most 0.1% of the total prescribed dose.

Anomalous Coronary Artery Origin in a Young Patient with Marfan Syndrome.

Marfan syndrome is an autosomal dominant genetic disorder that affects connective tissue and is caused by mutations in the fibrillin 1 gene present at chromosome 15. Aortic aneurysm is its main complication, and along the dilation of the aorta root and its descending portion (60-100%), with secondary aortic insufficiency, it increases risk of acute aortic dissection and death. Coronary artery anomalies affect between 0.3% and 1.6% of the general population and are the second leading cause of sudden death in young adults, especially if the anomalous coronary passes through aorta and pulmonary artery. The anomalous origin of the left main coronary artery in the right Valsalva sinus has a prevalence of 0.02%-0.05% and is commonly related to other congenital cardiac anomalies, such as transposition of great vessels, coronary fistulas, bicuspid aortic valve, and tetralogy of Fallot. Its association with Marfan syndrome is not known, and there is no previous report in the literature. We describe here a case of a female with Marfan syndrome diagnosed with symptomatic anomalous origin of the left coronary artery in the right Valsalva sinus.

Association between subjective evaluation and physical parameters for radiographic images optimization.

PURPOSE: The purpose of this study was to develop a methodology to optimize computed radiographic techniques to image the skull, chest, and pelvis of a standard patient. METHODS: Optimization was performed by varying exposure levels with different tube voltages to generate images of an anthropomorphic phantom. Image quality was evaluated using visual grading analysis and measuring objective parameters such as the effective detective quantum efficiency and the contrast-to-noise ratio. Objective and subjective evaluations were compared to obtain an optimized technique for each anatomic region. RESULTS: Gold standard techniques provided a significant reduction in X-ray doses compared to the techniques used in our radiology service, without compromising diagnostic accuracy. They were chosen as follows 102 kVp/1.6 mAs for skull; 81 kVp/4.5 mAs for pelvis and 90 kVp/3.2 mAs for chest. CONCLUSION: There is a range of acceptable techniques that produce adequate images for diagnosis in computed radiography systems. This aspect allows the optimization process to be focused on the patient dose without compromising diagnostic capabilities. This process should be performed through association of quantitative and qualitative parameters, such as effective detective quantum efficiency, contrast-to-noise ratio, and visual grading analysis.

Quality and dose optimization in hand computed radiography.

The objective of the present study was to optimize a radiographic technique for hand examinations using a computed radiography (CR) system and demonstrate the potential for dose reductions compared with clinically established technique. An exposure index was generated from the optimized technique to guide operators when imaging hands. Homogeneous and anthropomorphic phantoms that simulated a patient's hand were imaged using a CR system at various tube voltages and current settings (40-55 kVp, 1.25-2.8 mAs), including those used in clinical routines (50 kVp, 2.0 mAs) to obtain an optimized chart. The homogeneous phantom was used to assess objective parameters that are associated with image quality, including the signal difference-to-noise ratio (SdNR), which is used to define a figure of merit (FOM) in the optimization process. The anthropomorphic phantom was used to subjectively evaluate image quality using Visual Grading Analysis (VGA) that was performed by three experienced radiologists. The technique that had the best VGA score and highest FOM was considered the gold standard (GS) in the present study. Image quality, dose and the exposure index that are currently used in the clinical routine for hand examinations in our institution were compared with the GS technique. The effective dose reduction was 67.0%. Good image quality was obtained for both techniques, although the exposure indices were 1.60 and 2.39 for the GS and clinical routine, respectively.

Application of wavelets to the evaluation of phantom images for mammography quality control.

The main goal of this work was to develop a methodology for the computed analysis of American College of Radiology (ACR) mammographic phantom images, to be used in a quality control (QC) program of mammographic services. Discrete wavelet transform processing was applied to enhance the quality of images from the ACR mammographic phantom and to allow a lower dose for automatic evaluations of equipment performance in a QC program. Regions of interest (ROIs) containing phantom test objects (e.g., masses, fibers and specks) were focalized for appropriate wavelet processing, which highlighted the characteristics of structures present in each ROI. To minimize false-positive detection, each ROI in the image was submitted to pattern recognition tests, which identified structural details of the focalized test objects. Geometric and morphologic parameters of the processed test object images were used to quantify the final level of image quality. The final purpose of this work was to establish the main computational procedures for algorithms of quality evaluation of ACR phantom images. These procedures were implemented, and satisfactory agreement was obtained when the algorithm scores for image quality were compared with the results of assessments by three experienced radiologists. An exploratory study of a potential dose reduction was performed based on the radiologist scores and on the algorithm evaluation of images treated by wavelet processing. The results were comparable with both methods, although the algorithm had a tendency to provide a lower dose reduction than the evaluation by observers. Nevertheless, the objective and more precise criteria used by the algorithm to score image quality gave the computational result a higher degree of confidence. The developed algorithm demonstrates the potential use of the wavelet image processing approach for objectively evaluating the mammographic image quality level in routine QC tests. The implemented computational procedures could also enable the performance of advanced analyses to study potential dose reduction in a routine service.

Phantom development for radiographic image optimization of chest, skull and pelvis examination for nonstandard patient.

The construction of the adapted patient equivalent phantom (APEP) to simulate the X-ray scattering and absorption by chest, skull and pelvis of nonstandard patient in conventional radiographic equipment is presented. This APEP system is associated to the pre-existing realistic-analytic phantom (RAP) [Pina, D.R., Duarte, S.B., Ghilardi Netto, T., Trad, C. S., Brochi, M.A.C., Oliveira, S.C. de, 2004. Optimization of standard patient radiographic images for chest, skull and pelvis exams in conventional X-ray equipment. Phys. Med. Biol. 49, N215-N226] forming the coupled phantom (RAP-APEP), which is used to establish an optimization process of radiographic images of chest, skull and pelvis for nonstandard patients. A chart of the optimized radiographic technique is established covering a wide range of nonstandard patient thickness, and offering a dose reduction in comparison with those techniques currently used. Different validation processes were applied to confirm the improving of the radiographic image quality when techniques of the established chart are used.

Development of phantom for radiographic image optimization of standard patient in the lateral view of chest and skull examination.

We present the construction of a homogeneous phantom to be used in simulating the scattering and absorption of X-rays by a standard patient chest and skull when irradiated laterally. This phantom consisted of lucite and aluminium plates with their thickness determined by a tomographic exploratory method applied to the anthropomorphic phantom. Using this phantom, an optimized radiographic technique was established for chest and skull of standard sized patient in lateral view. Images generated with this optimized technique demonstrated improved image quality and reduced radiation doses.

Optimization of standard patient radiographic images for chest, skull and pelvis exams in conventional x-ray equipment.

Optimized radiographic techniques for clinical images of chest, skull and pelvis using conventional single-phase, three-phase and high-frequency x-ray units for a standard patient have been developed. Optimization of image contrast and optical density was obtained by using a homogeneous phantom (PEP) and an Anderson Rando anthropomorphic phantom. Image quality was evaluated by nine radiologists in independent analyses, leading to the choice of the optimized technique. A course of action to implement and validate these techniques in other radiographic systems has also been introduced. A realistic-analytic phantom (RAP) was constructed to certify the validation process. The optimized radiographic technique was implemented in the routine of our home hospital radiodiagnostic routine, enabling a reduction in patient doses around 25, 14 and 72%, respectively, for chest, skull and pelvis exams when compared with the previously used techniques. In addition, a corresponding reduction in the x-ray tube load of 68, 14 and 62% for the respective mentioned exams has been observed. In conclusion, implemented optimal techniques can lead to a reduction in the rate of film rejection, thus contributing to a better risk-benefit relationship for the patient and cost-benefit for the radiodiagnostic facility.