Examination Of Abdomen Research Articles

X-ray examination to measurement radiation doses of patients in three Erbil hospitals

Thermo luminescent dosimeters (TLDs) have been used to measure the entrance surface doses (ESDs) of patients undergoing pelvis, abdomen and lumbar spine diagnostic X-ray examinations in Erbil. A total of three public hospitals and 171 patients were included in this investigation. The ages of the patients involved were from 40 years to 85 years, while their weights ranged from 64 kg to 73 kg. Mean, of ESDs are reported. The results showed that in most cases, for each of the examinations, the individual ESD values are found to be comparable with, and higher than, those from Ghana and Tanzania, respectively. The ranges found in this work are high and this indicates more attention needs to be given to X-ray facilities in the country. This also suggests that radiographic departments need to review their radiographic practices in order to bring their doses to optimum levels. Effective doses were also calculated from the ESD values. The radiographic parameters used for all the patients were also compared with the European criteria. It is recommended that the tube filtration at one hospital be increased. The importance of good regulatory activities and trained personnel is stressed in this work. Apart from the fact that the data provided inthis work will be useful for the formulation of national guidance levels, they also provide patient dosimeter information on healthcare level countries.

Assessment of Pediatrics Radiation Dose from Routine X-Ray Examination at Jimma University Hospital, Southwest Ethiopia.

Given the fact that children are more sensitive to ionizing radiation than adults, with an increased risk of developing radiation-induced cancer, special care should be taken when they undergo X-ray examinations. The main aim of the current study was to determine Entrance Surface Dose (ESD) to pediatric patients arising from routine x-ray examination in the Radiology Department of Jimma University Specialized Hospital (JUSH). Descriptive cross-sectional study was conducted on pediatric patients less than 15 years of age who visited to seek x-ray examinations in JUSH. In this study, chest (AP), skull (AP), Abdomen (AP) and Pelvic (AP) x-ray examinations were analyzed. Radiographic exposure factors were recorded in each examination. ESD was calculated using exposure parameters. The calculated ESD values were weighed against the Diagnostic Reference Level (DRL) recommended doses and similar published studies. Comparison was made among different age groups through mean comparison. The obtained ESD values were mostly higher than the values in internationally published studies and DRL for all age groups. For chest AP, the mean ESD values were 1.82mGy which is higher than similar studies in Nigeria (0.642Mgy), Brazil (o.o62mGy) and NRPB (0.050mGy) for ages of 0-1 years. The higher pediatric patient dose obtained in this study is a further indicator that doses delivered to pediatric patients are not according to ALARA principle, and there is a need to optimize service and patients' radiation exposure in JUSH in particular and in Ethiopia in general.

SimDoseCT: dose reporting software based on Monte Carlo simulation for a 320 detector-row cone-beam CT scanner and ICRP computational adult phantoms

This study aims to develop and test software for assessing and reporting doses for standard patients undergoing computed tomography (CT) examinations in a 320 detector-row cone-beam scanner. The software, called SimDoseCT, is based on the Monte Carlo (MC) simulation code, which was developed to calculate organ doses and effective doses in ICRP anthropomorphic adult reference computational phantoms for acquisitions with the Aquilion ONE CT scanner (Toshiba). MC simulation was validated by comparing CTDI measurements within standard CT dose phantoms with results from simulation under the same conditions. SimDoseCT consists of a graphical user interface connected to a MySQL database, which contains the look-up-tables that were generated with MC simulations for volumetric acquisitions at different scan positions along the phantom using any tube voltage, bow tie filter, focal spot and nine different beam widths. Two different methods were developed to estimate organ doses and effective doses from acquisitions using other available beam widths in the scanner. A correction factor was used to estimate doses in helical acquisitions. Hence, the user can select any available protocol in the Aquilion ONE scanner for a standard adult male or female and obtain the dose results through the software interface. Agreement within 9% between CTDI measurements and simulations allowed the validation of the MC program. Additionally, the algorithm for dose reporting in SimDoseCT was validated by comparing dose results from this tool with those obtained from MC simulations for three volumetric acquisitions (head, thorax and abdomen). The comparison was repeated using eight different collimations and also for another collimation in a helical abdomen examination. The results showed differences of 0.1 mSv or less for absolute dose in most organs and also in the effective dose calculation. The software provides a suitable tool for dose assessment in standard adult patients undergoing CT examinations in a 320 detector-row cone-beam scanner.

Necrolytic Migratory Erythema in a Cat with Glucagonoma Syndrome

Background: Glucagonomas are very rare neuroendocrine tumors of pancreatic endocrine islets alpha cells and they produced excessive amount of glucagon hormone. Necrolytic migratory erythema (NME) is a rare dermatosis that characterized by erosive, ulcerative and crusted lesions in different sites of the skin and the common cause of this situation related to glucagon secreted tumors. NME can occur commonly in man but some rare and recent reports available the occurrence of this situation in pet animals especially dogs. Both gross and histological findings in both human and animals are similar. This paper reports a NME case with glucagonoma and diabetes mellitus (DM) by clinical, histopathological and immunohistochemical examinations.Case: A 12-year-old, cat presented with complaints of skin lesions in neck region, hyperglycemia, weight loss and history of anorexia during the 2 months. Biochemical analysis results revealed high glucose, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and creatinine levels but decreased blood urea nitrogen (BUN), total protein and potassium levels. After 2 weeks of anti-diabetic drug treatment, the blood glucose level became normal and skin lesions ameliorated but anorexia and weight loss continued. The cat exhibited general weakness and pain in abdominal area. Although the clinical sings ameliorated and skin lesions and serum biochemical findings returned the relatively normal levels compared the admission, the cat died after 2 weeks of treatment and necropsy performed. At necropsy, marked cachexia, loss of skin elasticity and decreased skin thickness were observed. During the examination of abdominal cavity of the cat, there was a mass 0.5x0.5 cm in diameter, hard and grayish color was diagnosed at the pancreas. In addition, numerous whitish foci were also present the pancreatic tissue. Additionally, enlargement and paleness were noticed at the liver. Hemorrhages were observed at the liver, stomach and gut. Histopathologically pancreatic mass composed of polygonal neoplastic cells supported by thin, fibrovascular stroma characteristic for neuroendocrine tumor. But type of the cells undistinguished by histopathology for that reason immunohistochemistry performed for to evaluated insulin and glucagon secreting cells. Immunohistochemical examination revealed that only small number of insulin secreting but numerous glucagon secreting cells in the tumoral tissue and the tumor diagnosed as glucagonoma. Marked decrease were also noticed in insulin secretin cells in pancreas and together with high serum glucose levels diabetes mellitus (DM) also diagnosed to the cat. Histopathological examination of the skin revealed that decreased skin thickness, alopecia, slight inflammatory reaction and necrosis of the spinous layer.Discussion: Glucagonomas are rare tumors of pancreas even in human, and the incidence of this tumor is very rare in cat. They are usually silent tumors and they generally caused by paraneoplastic phenomena than primary clinical symptoms. The most prominent features of the “glucagonoma syndrome” are NME and DM. In human NME is commonly diagnosed in patient with glucagonoma syndrome. Very rare NME reports available in cats and dogs. The present cat had obvious clinical symptoms and typical skin lesions for NME. This report includes the very characteristic case of NME in a cat due to glucagonoma and DM, closely resembling the glucagonoma syndrome occurred in humans. Possible cause of the liver damage was also related the DM characterized high serum glucose level. We thought that liver lesions were also supported the occurrence of characteristic skin lesions.

Evaluation of Alvardo score in diagnosis of acute appendicitis

Background: Acute appendicitis is a common cause of abdominal pain for which a prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. Right Iliac fossa pain is the hallmark of acute appendicitis until proven otherwise. Decision making in a case of acute appendicitis may be difficult, especially for junior surgeons. Hence, we aimed at analysing the Alvarado Score in patients with right iliac fossa pain.Methods: A prospective study involving 120 patients with right iliac fossa pain attending KIMS casualty during May 2015- April 2016 were included in the study. Results: The least was in the age group of 56 to 65 years (2%). Out of 120 patients, 84 were males (70%) and 36 were female (30%). The male to female ratio was 1:0.4. Patients with Alvarado score 7-9 (Group I) includes 60 male and 26 females (71% of total study group). Alvarado score 5-6 (Group II) includes 17 males,19 female (22% of total study group). Alvarado score 1-4 (Group III) includes 7 males, and 1 female (7% of total study group). In patients of Group I, among 60 males, 51 were confirmed with acute appendicitis. Among 26 females, 19 were confirmed with acute appendicitis, with a positive appendicectomy rate of 81.3% and negative appendicectomy rate 19.7%. The numbers of patients were highest in the age group 15 to 25 years (38%) followed by 36 to 45 years (30%).Conclusions: The Modified Alvarado scoring system was found to be highly effective in the diagnosis of the acute appendicitis in men and can be widely used to avoid expensive time consuming and non-readily available additional investigations. However, this system was not very effective in women. Therefore, ultra sound examination of abdomen and pelvis and diagnostic laparoscopy are also advised to minimize the high false negative rate in women which excludes common pelvic pathology that mimic clinically acute appendicitis.

Case Report on Intrahepatic Cholestasis of Pregnancy

This case report concerns a primigravida woman (period of gestation-37 weeks) diagnosed with intrahepatic cholestasis of pregnancy (IHCP). She had been married since 2 years and this is her first pregnancy. The patient is an Rh-negative mother. She did not receive anti-D at 28 weeks of gestation. The patient was admitted to antenatal ward of Hakeem Abdul Hakeem Centenary (HAHC) Hospital, New Delhi, with chief complaints of itching all over the body since 15–20 days with severe itching over the umbilical area and presence of rashes on legs and breasts since last 10 days. During the physical examination the rashes were seen on legs and breast. Per abdomen examination revealed cephalic presentation of the fetus with FHR as 140 bpm. Routine blood investigations revealed that the patient was also a case of moderate anemia and the blood group of the patient was AB-negative. After all the required investigations, she was diagnosed with IHCP with moderate anemia with Rh-negative pregnancy. IHCP is a pregnancy-specific liver disorder characterized by pruritus, most often, in the late-second or early third trimester of pregnancy and raised serum bile acids. The maternal outcome after treatment is good but fetal outcomes become adverse in most of the conditions. 1

Establishing national diagnostic reference levels (DRLs) for computed tomography in Egypt

ObjectivesTo establish national diagnostic reference levels (DRLs) in Egypt for computed tomography (CT) examinations of adults and identify the potential for optimization. MethodsData from 3762 individual patient’s undergoing CT scans of head, chest (high resolution), abdomen, abdomen-pelvis, chest-abdomen-pelvis and CT angiography (aorta and both lower limbs) examinations in 50 CT facilities were collected. This represents 20% of facilities in the country and all of the 27 Governorates. Results were compared with DRLs of UK, USA, Canada, Japan, Australia and France. ResultsThe Egyptian DRLs for CTDIvol in mGy are for head: 30, chest (high resolution): 22, abdomen (liver metastasis): 31, abdomen-pelvis: 31, chest-abdomen–pelvis: 33 and CT angiography (aorta and lower limbs): 37. The corresponding DRLs for DLP in mGy.cm are 1360, 420, 1425, 1325, 1320 and 1320. For head CT, the Egyptian DRL for CTDIvol is 2–3 times lower than the DRLs from other countries. However, the DRL in terms of DLP is in the same range or higher as compared to others. The Egyptian DRL for chest CT (high resolution) is similar to others for DLP but higher for CTDIvol. For abdomen and abdomen-pelvis DRLs for CTDIvol are higher than others. For DLP, the DRLs for abdomen are higher than DRL in UK and lower than those in Japan, while for abdomen-pelvis they are higher than other countries. ConclusionDespite lower DRLs for CTDIvol, an important consistent problem appears to be higher scan range as DRLs for DLP are higher.

Quantifying Language Before and After Instituting Structured CT Reports

AimOur aim was to quantify the language in abdominopelvic CT reports before and after implementing structured reporting templates, specifically evaluating the terms normal and unremarkable. MethodsWe performed a search of our database for all CT abdomen and pelvis examinations before and after full template implementation. There were 1,753 studies included—878 “pretemplate” reports, 875 “posttemplate” reports. Pre- and posttemplate reports were analyzed for word count in preliminary report, word count in final report, number of changed words between preliminary and final report, and frequency of normal and unremarkable. The averages of each data point for both pre- and posttemplate reports were calculated and compared. ResultsBetween all pre- and posttemplate reports, the total number of words and number of changes between preliminary and final reports was not significantly changed. The frequency of the word normal increased from an average of 5.29 (pretemplate) to 8.92 (posttemplate) per report (P < .0001). The frequency of the word unremarkable increased from an average of 0.11 (pretemplate) to 0.22 (posttemplate) per report (P < .0001). ConclusionsWhen comparing language before and after implementing structured reports, we found an increase in the frequency of normal, without any significant change in number of words per report. The increase in normal in posttemplate reports reflects a trend toward more definitive reporting, which may increase clarity and satisfaction among referring physicians. The increased use of the less definitive term unremarkable identifies an area in need of further training and improvement in our department.

Diagnosis of Bony Metastasis of Renal Cell Carcioma at a Rare Site on Fine Needle Aspiration Cytology: A Rare Case Report

Fine needle aspiration cytology is cheap, non invasive and time saving procedure in diagnosis and management of patients in developing countries. Metastasis of renal cell carcinoma (RCC) to distant sites and organs at time of presentation is not infrequently encountered in the setting of FNAC for initial diagnosis. Here, we present a case of metastatic RCC to right clavicle initially diagnosed on FNAC and was confirmed on radiological examination of abdomen and histopathological examination. DOI: 10.21276/APALM.1121

Assessment of patients X-ray doses at three government hospitals in Duhok city lacking requirements of effective quality control

PurposeThe research presented in this article aimed at evaluating patient doses including entrance surface dose (ESD) and effective dose (E) in government hospitals that lack the requirements of quality control standards. Materials and methodsThree major government hospitals with 409 patients in Duhok were involved in the study. The X-ray diagnostics included five routine radiographic examinations. ESD was determined indirectly by measuring the entrance surface air kerma with a solid state dosimeter. E was calculated from the tissue weighting factor and the equivalent dose. Results and conclusions: Significant variations between exposure factors recorded in this study and those recommended in the context of quality criteria and standards were shown. The results have also shown that about twenty percent of the patient doses (ESD and E) were equal or below the recommended values of the diagnostic reference levels (DRLs). For abdomen, pelvis and skull examinations, the ESD values were slightly above the diagnostic reference levels. For chest and cervical the ESD values were much higher than diagnostic reference levels. These values were more reasonable only in one hospital. High ESD values can be attributed to the slightly higher tube voltages and lower mAs values that were used. The high patient dose values suggest that any adequate change of the exposure parameters that aims at the reduction of dose must be done without compromising the image quality. This study recommends a quick action toward implementing a quality control program and employing special staff of medical physicists in the evaluated hospitals.

Analysis of effective and organ dose estimation in CT when using mA modulation: A single scanner pilot study

IntroductionEffective dose (ED) estimation in CT examinations can be obtained by combining dose length product (DLP) with published ED per DLP coefficients or performed using software. These methods do not account for tube current (mA) modulation which is influenced by patient size. The aim of the work was to compare different methods of organ and ED estimation to measured values when using mA modulation in CT chest, abdomen and pelvis examinations. MethodOrgan doses from CT of the chest, abdomen and pelvis were measured using digital dosimeters and a dosimetry phantom. ED was calculated. Six methods of estimating ED accounting for mA modulation were performed using ImPACT CTDosimetry and Dose Length Product to ED coefficients. Corrections for the phantom mass were applied resulting in 12 estimation methods. Estimated organ doses from ImPACT CTDosimtery were compared to measured values. ResultsCalculated EDs were; chest 12.35 mSv (±1.48 mSv); abdomen 8.74 mSv (±1.36 mSv) and pelvis 4.68 mSv (±0.75 mSv). There was over estimation in all three anatomical regions. Correcting for phantom mass improved agreement between measured and estimated ED. Organ doses showed overestimation of dose inside the scan range and underestimation outside the scan range. ConclusionReasonable estimation of effective dose for CT of the chest and abdomen can be obtained using ImPACT CTDosimetry software or k-coefficients. Further work is required to improve the accuracy of ED estimation from CT of the pelvis. Accuracy of organ dose estimation has been shown to depend on the inclusion or exclusion of the organ from the scan range.

ESTABLISHMENT OF RADIATION DOSES FOR PEDIATRIC X-RAY EXAMINATIONS IN A LARGE PEDIATRIC HOSPITAL IN TURKEY.

Pediatric patients are more sensitive to ionizing radiation when compared with adults. The aim of this study was to evaluate the radiation doses for some common pediatric x-ray examinations performed with various digital radiography systems. Quality control tests of the digital radiography systems were carried out according to international published protocols before the pediatric dose measurements. Radiation dose measurement was performed by using the x-ray tube outputs and thermoluminescent dosimeter dose measurement methods. In the present study, radiation doses were assessed for 247 chest, 230 pelvis, 194 skull and 73 abdomen x-ray examinations and in total 744 pediatric patients doses were measured. Pediatric patients were classified into four age groups 0-1, 1-5, 5-10 and 10-15 years as given by European Commission guidance. Effective doses were determined for each examination using a PCXMC 2.0 Monte Carlo program. The mean measured entrance skin doses for the age interval 1-5 years and AP projection by using tube output measurement methods were 149 µGy for chest, 304 µGy for pelvis, 387 µGy for skull and 199 µGy for abdomen examinations. The radiation dose results obtained in this study were in the range of the published results in the literature.

Analisis Informasi Citra Anatomi Fase Late Artery dengan Variasi Time Scan Delay pada Pemeriksaan MSCT Abdomen

Background: MSCT Abdomen late arterial phase is a radiological examination to evaluated enhancement in hypervascular lesions, stomach, bowel, pancreas parenchyma, spleen and kidney outer cortex. All the structures get bloodsupply of the artery will show an optimal increase (Smithuis, 2014). Smithuis (2014) used time scan delay 15-20 seconds. However in the Abdomen MSCT examination in the late arterial phase of Radiology Hospital Dr. Kanujoso Djatiwibowo Balikpapan used the different time scan delay. This study aimed to determine differences in contrast enhancement with time scan delay variation of contrast media and to determine the optimal time scan delay in the examination of the Abdomen MSCT late arterial phase.Methods: The research type is quantitative experimental approach. Data are taken in October and November 2016. The research population of abdomen MSCT examination clinical intra-abdominal mass cases. Total sample are 18 people with a predetermined inclusion criteria. Time scan delay variation used are 10 seconds, 15 seconds, 20 seconds. evaluated with respondents the data is processed with statistic analysis by using different test Kruskal-Wallis followed by post hock Mann-Whitney and to get the most optimal assessment visits of mean rank the Kruskal-Wallis test.Result: The results obtained p value 0,001 (p 0,05), there are shown significant differences between time scan delay 10 seconds, 15 seconds, 20 seconds at Abdomen MSCT examination in the late arterial phase of Radiology Dr. Kanujoso Djatiwibowo Balikpapan Hospital. An optimal time scan delay on Abdomen MSCT examination late arterial phase is 10 seconds premises ROI tracking on descenden aorta. From the results of tests conducted using the Kruskal-Wallis test values mean rank at the time scan delay of 10 seconds is 84,75.Conclusison: There is a difference significant anatomical image information between the time scan delay 10 seconds, 15 seconds, 20 seconds. on MSCT Abdomen examination artery in the late phase of Radiology Dr. Kanujoso Djatiwibowo Balikpapan Hospital. assessment results are tested using the Kruskal-Wallis test followed Mann-Whitney post hock obtained p value 0.001 (p 0.05), meaning that there is a difference between the third anatomical image information with time scan delay variations. Time delay optimal scan on Abdomen MSCT examination late artery phase that time scan delay 10 seconds by tracking ROI on descenden aorta. From the results of tests conducted using the Kruskal-Wallis test values mean rank at the time scan delay of 10 seconds 84.75, 56.62 ie 15 seconds, 20 seconds, namely 22.12.

A Study to Determine Whether the Volume-Weighted Computed Tomography Dose Index Gives Reasonable Estimates of Organ Doses for Thai Patients Undergoing Abdomen and Pelvis Computed Tomography Examinations.

Introduction:Values for the CTDIvol, which is displayed on scanner consoles, give doses relative to a phantom much larger than most Thai patients, and the CTDIvol does not take account of differences in patient size, which affect organ doses.Objective:The purpose of this study was to evaluate relationships for size specific dose estimate (SSDE) and volume weighted computed tomography (CT) dose index (CTDIvol) with patient size for CT scanners operating under automatic tube current modulation (ATCM).Methods:Retrospective data from 244 patients who had undergone abdomen and pelvis examination on GE and Siemens CT scanners were included in this study. The combination of anteroposterior (AP) and lateral dimensions at the level of the first lumbar vertebra (L1) was used to represent patient size. Image noise within the liver was measured, and values of the absorbed dose for organs covered by the primary beam such as the liver, stomach and kidney were calculated using methods described in the literature. Values of CTDIvol were recorded and SSDE calculated according to the American Association of Physics in Medicine (AAPM) Report No.204. Linear regression models were used to evaluate the relationship between SSDE, CTDIvol, image noise and patient size.Results:SSDE is 20%-50% larger than the CTDIvol, with values for larger patients being more representative. Both the CTDIvol and image noise decreased with patient size for Siemens scanners, but the decline in SSDE was less significant. For the GE scanner, the CTDIvol was a factor of 3-4 lower in small patients compared to larger ones, while the SSDE only decreased by a factor of two. Noise actually decreased slightly with patient size.Conclusion:Values of SSDE were similar to the doses calculated for the liver, stomach and kidney, which are covered by the primary beam, confirming that it provides a good estimate of organ-absorbed dose.

Reducing radiation exposure with iterative reconstruction: an inter- and intra-scanner analysis

Our purpose in this study was to compare delivered radiation exposure via computed tomography dose index volume (CTDIvol) and dose length production (DLP) measurements from computed tomography (CT) examinations performed on scanners with and without image-quality enhancing iterative reconstruction (IR) software. A retrospective analysis was conducted on randomly selected chest, abdomen, and/or pelvis CT examinations from three different scanners from 1 January 2013 to 31 December 2013. CTDIvol and DLP measurements were obtained from two CT scanners with and one CT scanner without IR software. To evaluate inter-scanner variability, we compared measurements from the same model CT scanners, one with and one without IR software. To evaluate intra-scanner variability, we compared measurements between two scanners with IR software from different manufacturers. CT scanners with IR software aided in the overall reduction in radiation exposure, measured as CTDIvol by 30% and DLP by 39% when compared to a scanner without IR. There was no significant difference in CTDlvol or DLP measurements across different manufacturers with IR software. As a result, IR software significantly decreased the radiation exposure to patients, but there were no differences in radiation measurements across CT manufacturers with IR software.

Systemic lupus erythematosus - diagnostic and treatment challenges

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Incidence & prognosis of acute kidney injury in individuals of snakebite in a tertiary care hospital in India.

Background & objectives:The snakebites are considered to be an occupational hazard in agriculture workers and the snake handlers, resulting in a considerable morbidity, mortality and economical implications. This study was conducted to determine the incidence, clinical presentation, renal injury and clinical outcome in snakebite victims who developed acute kidney injury (AKI).Methods:This hospital-based prospective, observational study was done on 100 cases who were admitted for the management of snakebite and found to develop AKI in a tertiary care hospital at Hyderabad, India. Renal function tests, complete blood picture, urine routine examination, ultrasound examination of abdomen and coagulation profile were done and the prognosis was assessed by noting recovery, mortality, morbidity and/or progress to chronic stage.Results:A total of 100 patients with a mean age of 43.80±12.63 yr (range 18-70); 62 males and 38 females were studied. All had bites on lower limbs. A total of 86 patients arrived in the hospital within 24 h, and 14 arrived after 24 h. Oliguria was found in 60, bleeding tendencies in 64, haemodynamic instability noted - tachycardia in 86. Systolic blood pressure (BP) was <120 mm Hg in 68 and BP was not recordable in four patients. Twelve patients were in stage III kidney disease and needed haemodialysis. Of the 100 cases of snakebite-induced acute kidney failure, 86 recovered and six died. On follow up, after six months eight patients developed chronic kidney failure.Interpretation & conclusions:A cascade of events tends to occur in severe haemotoxic envenomation such as bleeding disorders, hypotension/circulatory shock, intravascular haemolysis, disseminated intravascular coagulation and acute respiratory disease syndrome (ARDS). The findings of this study showed that early hospitalization, quick antisnake venom administration and adequate supporting care provided promising results.

The impact of patient table on size-specific dose estimate (SSDE).

The use of parameters water equivalent diameter (D W ) and size-specific dose estimate (SSDE) are becoming increasingly established as a recognised method to relate patient dose from a CT examination to the dose indicator volume CT dose index (CTDIVOL). However, the role of the attenuation due to the patient table in these estimations requires careful consideration and is the subject of this study. The aim of this study is to investigate the impact of a minimal part of the patient table when calculating the D W and SSDE. We investigated 164 patients who had undergone CT examinations for the pelvis, abdomen, thorax andhead. We subsequently calculated D W and SSDE using two methods: one using a small circular region of interest (ROI) including a minimal part of the patient table and the other using a ROI fitted to the patient border alone. The results showed that the water equivalent diameter calculated with the table included in the ROI (D W,t ) is greater, compared to that without the consideration of the patient table (D W,nt ), by 1.5-6.2% depending on the anatomy being imaged. On the other hand, the SSDE calculated with inclusion of the patient table (SSDEt) is smaller than otherwise (SSDEnt) by 1.0-5.5% again depending on the anatomy being imaged. The effect of the patient table on D W and SSDE in the thorax CT examination was statistically significant, but its effect on D W and SSDE in the other examinations of head, pelvis and abdomen was relatively small and not statistically significant.

Digital Metastasis Presenting as Infection

IntroductionThe skeleton is a favorable site for the development ofmetastasesfromcarcinomasandsarcomascandeveloposseousmetastatic disease. Bone metastasis distal to elbows and kneesare quite rare; metastases to the hand are very rare as well,accountingfor only 0.1% of all metastaticlesions[ 1]. Handleywas the first to report this unusual manifestation in 1906 [ 2].A recent review of the literature revealed 257 published casesinvolving bones of the hand [3]. Acral metastases to thephalanges of the hand usually involve a single bone, whilethose proximal to the phalanges often involve multiple bones[4]. Typically the patient presents with the insidious onset ofpain and swelling in the affected anatomic region [5].Commonly, hand metastases are misdiagnosed as infectionor other inflammatory processes [6].Herein, we report the case of a patient with digitalmetastasis, initially misdiagnosed and treated as infection.The purpose of this case report is to discuss the diagnosticand therapeutic options of this rare clinical manifestation ofmetastatic disease.Case ReportA 75 years old woman referred to our clinic because ofinfectious-osteomyelitis of the distal phalanx of the middleright finger. The patient was under per-os antibiotic therapyfor a week with no signs of clinical improvement. At thetime of referral, the patient had a swollen, erythematousdigit (Fig. 1). Mild tenderness was noticed upon palpation.The patient recalled a progressive fusiform expansion of thepulp of the third digit during the last 3 months, accompa-nied by intermittent pain. Pain became more constant thelast month, and it was more intense during night hours. Thepatient did not have raised temperature during the pastweek. Axillary regional nodes were not palpable. Patient’smedical history was important for diabetes mellitus andnon-small cell lung cancer. Diagnosis of non metastaticlung cancer was established 6 years ago. The patient hadreceived chemotherapy with good clinical response at thattime. X-ray of the hand demonstrated a destructive lesion ofthe last phalanx with diffuse edema of the surrounding softtissues (Fig. 2). Bone scan was hot only at the involvedphalanx and around the proximal inter-phalangeal (PIP)joint. CT examination of lung abdomen and pelvis revealedno obvious metastatic disease. White blood cell count was9,500 K/μl and ESR was 45 mm/hour. Differentialdiagnosis essentially included bone metastasis and infection.A coreneedle biopsywas performed and the sample was sentfor histologic examination and culture. The cultures of thematerial were negative. However, evaluation of the biopticmaterial revealed metastatic adenocarcinoma.Taking into account the severity of bone destruction andthe medical history of the patient, surgical resection of thelesion was considered as the appropriate type of treatment.The patient underwent third ray amputation. The thirdmetacarpal bone and phalanges with their extensor and

Anterior Nutcracker syndrome as a rare cause of hematuria in an 8 year old boy: A case report

Nutcracker syndrome is caused by a compression of the left renal vein between the aorta and the superior mesenteric artery. It results in left renal venous hypertension, and the subsequent development of venous varicosities of the renal pelvis, ureter, and gonadal vein. We report a rare case in an 8-year-old boy who presented with a history of intermittent episodes of hematuria leading to anemia and left flank pain. Ultrasound examination of abdomen revealed bulky left kidney and features of subacute medical renal disease. Computed tomography of abdomen showed compressed left renal vein between aorta and superior mesenteric artery. Authors report the successful operative management of this rare syndrome in a pediatric patient.