[Certification according to ISO 9001--waste of time or necessity?]. / Zertifizierung nach ISO 9001--Zeitverschwendung oder Notwendigkeit?

Quality management (QM) systems are widely established management tools in the industry and business world today. In the health care sector, the need for quality, the implementation of quality management systems and economic orientation of the hospital management are strongly encouraged. Centers of excellence are created to offer special medical services of the highest possible quality. Furthermore, there is a worldwide tendency to establish standards in clinical medical settings, in teaching profession and medical science. These trends make the implementation of a quality management system in health care system highly desirable. The present manuscript reviews the fundamental principles and concepts and the aims of internationally accepted QM systems. It focuses on the ISO-9000 certificates and the European Foundation of Quality Management (EFQM) model. The advantages and disadvantages are discussed. The resources necessary for installation of a QM system and the different phases of implementation are reported. According to the experience of several groups, QM systems can be reliably used in a radiology department and lead to continuous improvement of the quality of services.

[Intravenous administration of iodinated, non-ionic, low or isoosmolar contrast media: safety aspects]. / Intravenöse Anwendung von jodiertem, nichtionischem, nieder- bis isoosmolarem Kontrastmittel: Sicherheitsaspekte.

It is the purpose of this review to provide information about the safe use of intravenously administered, iodinated, non-ionic, low or isoosmolar contrast media for radiological examinations, how to avoid adverse events, and how to react professionally in case of an anaphylactic reaction. Methods of prophylaxis and therapy for anaphylactic and chemotoxic effects of contrast media administration as well as absolute and relative contraindications are discussed. Medico-legal considerations of contrast agent administration, informed consent of patients, and methods of risk management for undesired contrast media reactions are considered in this article. Establishment of adminstration standards for contrast media is of tremendous importance to standardize radiological procedures. This basic radiological documentation is part of the institutional and individual legal safety management.

Thrombopoietin induces rapid resolution of thrombocytopenia after orthotopic liver transplantation through increased platelet production.

Thrombopoietin (TPO) deficiency has been proposed as an important etiologic factor for thrombocytopenia in advanced-stage liver disease. To clarify the contributions of platelet production, platelet consumption, coagulation activation, and splenic sequestration to thrombocytopenia in liver disease, we studied TPO serum levels and markers of platelet production, platelet activation, and coagulation activation before and 14 days after orthotopic liver transplantation (OLT) in 18 patients with advanced liver cirrhosis. Thrombocytopenia before transplantation occurred with low-normal serum levels of TPO, normal levels of platelet and coagulation activation markers, and no increase in bone marrow production of platelets. TPO serum levels increased significantly on the first day after OLT, preceding the increase of reticulated platelets by 3 days and peripheral platelets by 5 days. Normalization of the peripheral platelet count occurred in most patients within 14 days of OLT, irrespective of the change in spleen size assessed by computed tomography volumetry. Normalization of platelet counts was not hampered by a certain degree of platelet activation observed during the steepest increase in the peripheral platelet count. Bone marrow production of platelets increased significantly within 2 weeks of transplantation. Low TPO serum levels with low platelet counts and without platelet consumption suggests low TPO production in end-stage liver disease. The rapid increase in TPO serum levels after transplantation induces an increase in the bone marrow production of platelets. Decreased TPO production in the cirrhotic liver is an important etiologic factor for thrombocytopenia in liver disease that is rapidly reversed by transplantation.

Umbilicoplasty in neonates with primary omphalocele closure.

A new technique of umbilicoplasty in neonates who underwent primary omphalocele repair is described and illustrated. The procedure resulted in a nearly-normal appearance of the umbilicus.

Bronchobiliary fistula after hemihepatectomy: cholangiopancreaticography, computed tomography and magnetic resonance cholangiography findings.

A bronchobiliary fistula (BBF), which is defined by an abnormal communication between the biliary system and the bronchial tree, is an uncommon complication after hemihepatectomy, trauma, hydatid disease, choledocholithiasis and other causes of biliary obstruction. We report the case of a 56-year-old man with colon cancer, who developed a BBF 2 months after right hemihepatectomy for liver metastases. The findings at endoscopic retrograde cholangiopancreaticography (ERCP), computed tomography (CT) and magnetic resonance cholangiography (MRC) included a stricture of the common bile duct and biliary leakage from the liver resection plane with biliary infiltration of the right lower lobe of the lung. The patient was treated successfully by endoscopic insertion of a biliary plastic stent which bridged the stricture and lead to closure of the fistula.

Ligamentous instabilities of the wrist.

Carpal ligament instabilities are conditions in which the individual carpal bones have become unstable due to abnormal ligament support. Early diagnosis of ligamentous wrist instabilities is important because late diagnosis or failed diagnosis may lead to severe complications such as osteoarthritis. This article reviews the most common ligamentous instability patterns of the wrist and focuses on how to perform and obtain radiograms which will allow reliable diagnosis of wrist instabilities.

[Functional anatomy and biomechanics of the ankle joint]. / Funktionelle Anatomie und Biomechanik des Sprunggelenks.

Functional anatomy is fundamental for understanding motion in the ankle joint. Biomechanical studies try to evaluate the forces and torque affecting biological tissue under various conditions and therefore the cause and effects of disorders of joint structures. Conclusions based on this research permit preventive arrangements to reduce force and risk of injury to the joints. Biomechanical models describe the function of joint movements. A knowledge of biomechanical models may affect therapy management of patients with joint disorders. For the radiologist the results of this basic research are of major importance. Knowledge of pathological joint movements allows more accurate diagnosis of complex disorders or injuries of the ankle joint and structural alterations in bony or soft tissue structures, as demonstrated by MRI. In this article, we summarize the results of functional anatomy and biomechanics of the ankle joint reported in the literature.

Comparison of magnetic resonance tomography with computerized axiography in diagnosis of temporomandibular joint disorders.

This study compared the accuracy of two noninvasive methods, computerized axiography and magnetic resonance tomography (MRT), in diagnosing temporomandibular joint (TMJ) disorders. Forty-seven subjects underwent axiography and subsequent assessment of the TMJ by MRT. The statistical analysis referred to the correlations of the most relevant clinical diagnoses, i.e., no appreciable disease, disk displacement with reposition, disk displacement without reposition, morphologic alterations, and hypermobility of the condyle. In 70% of the disk-displacement-with-reposition and disk-displacement-without-reposition patient groups, axiography and MRT gave the same information. In other patient groups, the axiography findings agreed with the MRT findings in 45% of the cases. It was concluded that although a large percentage of morphologic alterations could be detected by MRT, axiography determined the dysfunctional dynamics more clearly.

Visualization and quantitative analysis of talocrural joint kinematics.

The three dimensional (3D) in vivo kinematic behavior of the ankle joint was evaluated using spiral volumetric CT scanning of a normal adult foot. The CT data were reconstructed and interpolated to create an isotropic 3D data volume. These data were rendered, visualized, segmented into their bony elements, labeled, and exported to disk using Mayo Analyze software. The labeled 3D CT datasets were analyzed to determine relative orientation, translation, and rotation of the tibia-talus, tibia-calcaneus and calcaneus-talus. Using these results, the 3D motion characteristics during normal adult foot flexion/extension were described quantitatively.

Wide scapholunate joint space in lunotriquetral coalition: a normal variant?

The radiologic appearances of 70 lunotriquetral coalitions in 52 patients were evaluated to determine whether a wide scapholunate joint space in subjects with this congenital abnormality reflects a scapholunate ligament disruption or is a normal variant. When the middle of the scapholunate joint space was larger than the capitolunate or third carpometacarpal joint space widths, it was considered to be abnormally wide. In 32 of 70 wrists (46%), a wide scapholunate joint space was detected. Results of instability radiographic series (n = 28) and arthrography (n = 11) were normal with respect to the scapholunate ligament in all cases, but the scapholunate joint space was markedly widened in six cases (55%) in which arthrography was performed. Arthroscopy, performed in one case, showed an intact scapholunate ligament. Because of the high prevalence of a wide scapholunate joint space and because of negative arthrographic and arthroscopic examinations, the authors conclude that widening of the scapholunate joint space is a normal variant that is common in patients with lunotriquetral coalition.

[The percutaneous aspiration and drainage of infected fluid retention after organ transplantation]. / Perkutane Aspiration und Drainage infizierter Flüssigkeitsretentionen nach Organtransplantation.

Local postoperative infections in immunosuppressed patients carry a high mortality rate. In this group of patients interventional radiological procedures are particularly valuable in diagnosis and treatment. We report on the results of radiologically controlled aspirations (11 cases) and drainage (37 cases) of infected fluid collections in 47 patients following transplantation of various organs. By percutaneous aspiration or drainage, 91.7% of infected fluid collections were successfully treated or the clinical condition of the patient improved so that surgical intervention could be avoided. The causative organism was identified and antibiotic treatment carried out in 72.9% (35 cases). Surgical intervention was necessary in only 4.3% (2/48). Needle aspiration or drainage of percutaneously accessible fluid collections thought to be infected appears to be particularly useful for transplant patients at increased risk and is a good alternative to surgical treatment.

[MRI of the temporomandibular joint. Demonstrability and significance of the retro-articular vascular plexus]. / MRT des Kiefergelenks. Darstellbarkeit und Bedeutung des retroartikulären vaskulären Plexus.

The retro-articular vascular plexus of the temporomandibular joint (TMJ) is of great importance for the function of this joint. Aim of this study was to determine the amount of increase of signal intensity in the retro-articular vascular plexus after intravenous injection of contrast medium and to figure out potential advantages of this procedure. The posterior band of the articular disc--a landmark in the diagnosis of disc dislocations--becomes prominent after injection of contrast medium. Forty-five temporomandibular joints were studied before, and after intravenous injection of contrast medium with magnetic resonance imaging (MRI) using T1-weighted images in parasagittal plane. In all cases a measurable increase of signal intensity was demonstrable in healthy volunteers as well as in patients with normal or pathological TMJ findings. In 53.3% of cases the posterior band was better differentiable after administration of contrast medium. In patients with suspicion of pathological features in series without contrast medium, in 27.3% of those cases administration of contrast medium led to a more precise--"diagnostic"--evaluation of disc location. The study emphasizes the use of contrasts medium for evaluations of disc dislocation with MRI in cases of pathological or unclear findings in precontrast MRI series.

MRI of cartilaginous tumours of the larynx.

Cartilaginous lesions of the larynx are uncommon, approximately 250 cases being documented in the literature. In general, these tumours grow slowly, exhibiting only local aggressiveness. Distant metastases are rare. Up until now CT has been the best diagnostic tool for the evaluation of these tumours because it demonstrates intratumoral calcification so well. To the best of our knowledge there are no reports of the use of MRI for these lesions. Three cases of cartilaginous laryngeal tumours are presented, emphasizing the MRI features.

[The value of thoracic and abdominal computed tomography with intensive care patients]. / Wertigkeit der thorakalen und abdominellen Computertomographie bei Intensivpatienten.

We evaluated in a retrospective study the therapeutic relevance of thoracic and abdominal CT examinations on 157 intensive-care patients with previously inconclusive radiological examinations. Indications for CT were sepsis (n = 105), rarely a decrease in haematocrit (n = 30), multiorgan failure (n = 16) or suspected aortic aneurysm (n = 6). In 83.4% of examinations CT detected clinically relevant features, in 44.3% positive CT studies resulted in invasive therapy within 72 hours and therefore changed patient management decisively. Our results justify the use of CT, enabling if necessary an on-target intervention, the advantages outweighing the inherent risks if the patient is exposed to the relatively small risk of being temporarily removed from the intensive-care unit for immediate invasive treatment.

CT-guided percutaneous drainage and fluid aspiration in intensive care patients.

Fifty-two intensive care unit (ICU) patients with clinical signs of sepsis who were considered to be at extremely high risk for operation were subjected to CT-guided interventions. Bedside ultrasound (US) had been performed prior to CT in all patients but diagnoses were equivocal or US-guided interventions had failed. Nineteen patients solely underwent CT-guided diagnostic aspiration of fluid collections to rule out infection. Eighteen patients (72%) with abscess formations after surgery or trauma were cured by catheter drainage alone; 4 patients required additional surgery. Out of 8 patients suffering from acute pancreatitis (after several necrosectomies), abscesses could be cured in 5 (62.5%). Three patients with acute necrotizing pancreatitis (no surgery) were not cured by the interventional procedure and all required surgical debridement. Even patients who required additional surgery after drainage improved clinically after the interventional radiologic procedure. Our overall success rate was 64%, emphasizing the need for CT in the case of equivocal US results or if US-guided procedures have failed in ICU patients with signs of sepsis.

[Sudeck's disease--MRT as a new diagnostic procedure]. / Morbus Sudeck--MRT als neues diagnostisches Verfahren.

In this prospective study, we determined the value of MR as an imaging technique in diagnosis and therapy with the option of simultaneous assessment of bone and soft tissue. 20 patients with clinical diagnosis of reflex sympathetic dystrophy syndrome (RSDS) and positive results in radiogram and three-phase radionuclide bone scanning were examined by MR, using T1- and T2-weighted images before and after Gadolinium-DTPA i.v. Soft tissue and bone signal intensity changes can be classified in our diagnostic-therapeutic scheme and proven by histopathological changes. The differentiation between clinical stages is possible and allows an evaluation of course and therapy. The higher costs are justified by shorter examination time without using radiation.

[Comparative clinical, roentgenologic, scintigraphic and nuclear magnetic resonance tomography studies in sympathetic reflex dystrophy]. / Vergleichende klinische, röntgenologische, szintigraphische und kernspintomographische Untersuchungen bei der sympathischen Reflexdystrophie.

The results of clinical, radiological, three phase bone scan and magnetic resonance imaging (MRI) examinations in 17 patients with reflex sympathetic dystrophy (RSD) are reported. Characteristic clinical symptoms, positive radiographic and scintigraphic findings were compared with the MRI. Soft tissue and bone signal intensity changes in MRI as well as bone scan demonstrated significant correlation to the duration of RSD. In conjunction with scintigraphy soft tissue diagnostic sensitivity and specificity are 1, 0.67 or 0.71 respectively. Bone signal diagnostic sensitivity and specificity are 0.5 or 0.67 respectively and 0.93 or 0.87 respectively. According to the results MRI appears to be of much value in establishing the diagnosis of RSD. In consequence a diagnostic schedule is evaluated.