Radiographic Resolution Research Articles

MP69-05 PREDICTORS OF FAILURE IN 90 COMPLEX URETERS USING ROBOT-ASSISTED LAPAROSCOPIC SURGERY

You have accessJournal of UrologyPediatrics: Urinary Tract Infection & Vesicoureteral Reflux1 Apr 2018MP69-05 PREDICTORS OF FAILURE IN 90 COMPLEX URETERS USING ROBOT-ASSISTED LAPAROSCOPIC SURGERY Maria Veronica Rodriguez, Aaron Wallace, Nimrod Barashi, William Boysen, and Mohan S Gundeti Maria Veronica RodriguezMaria Veronica Rodriguez More articles by this author , Aaron WallaceAaron Wallace More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , William BoysenWilliam Boysen More articles by this author , and Mohan S GundetiMohan S Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2229AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robot-assisted laparoscopic ureteral (RALUR) reimplantation has been adopted as an alternative surgical approach to treat children with persistent high-grade vesicoureteral reflux (VUR). The debate continues in regards to the safety, feasibility and standardized technique. We performed a retrospective analysis of perioperative outcomes in patients undergoing RALUR; using our recent technique modifications to identify predictors of surgical failure. METHODS We reviewed a prospectively maintained database of children undergoing RALUR at a single-institution from 2010-2017. Only patients with high-grade VUR at age 5, urinary tract infections, or renal scarring were selected for surgical correction. This series included patients who received the previously reported LUAA technique, which stands for length of detrusor tunnel (L), U stitch (U), ureteral alignment suture (A), and the inclusion of ureteral adventitia (A). Patients with ureterovesical junction obstruction were excluded. Radiographic failure was defined as persistent VUR on postop VCUG. Complications were grade using Clavien-Dindo scale. Logistic regression analysis was used to determine predictors of failure. Significance was set at p<0.05. RESULTS A total of 63 patients (90 ureters) met inclusion criteria. Mean age was 68.41 months (4.32 yrs) and 75.38% were female. Our cohort included patients with complex anatomies, such as duplex ureters, bladder diverticulum, and post-deflux injection. Of the 90 ureters reimplanted 85.56% showed radiographic VUR resolution at 4-months. In our cohort of 63 patients, 10 (15.87%) presented with grade II complications and 1 (1.59%) with grade I. However, none presented grade III, IV or V complications. Out of the 13 ureters that failed surgery, 9 had preoperative high-grade VUR (IV-V) and concomitant complex anatomy features. On univariate analysis, length of the detrusor tunnel was associated with increased odds of radiographic failure after RALUR (p=0.01). (Table 1) CONCLUSIONS Using the LUAA technique, RAL surgery has shown to improve operative outcomes in children undergoing extravesical ureteral reimplantation for persistent high-grade and complex VUR. We observed that the length of the detrusor tunnel is a critical step to optimize outcomes and prevent complications while doing this operation. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e926-e927 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Maria Veronica Rodriguez More articles by this author Aaron Wallace More articles by this author Nimrod Barashi More articles by this author William Boysen More articles by this author Mohan S Gundeti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Osteology and Radiology of the Back and Upper Extremity: an Integrated Exercise for a Large Medical School Class

Curriculum reform in 2015 for our medical school class of 230+ students provided an opportunity to revise teaching of osteology and to integrate it with an introduction to radiographic anatomy. This new exercise is part of an integrated Human Structure course (Anatomy, Radiology, Embryology) for pre‐clerkship students, consisting of live and online lectures, cadaver dissections, online modules, team‐based learning modules, and several hands‐on exercises, such as the one presented here. The course is divided into 3 blocks, each of which ends with the assessment of didactic and dissection laboratory material.This 2‐hour long osteology/radiology exercise is presented at the beginning of the 1st block (Back and Upper Extremity). The purpose of the exercise is to provide an overview of the osteology/radiology of these regions as a guide to further studies. Half the class at a time first attends an “Introduction to Radiology” lecture, and then does the exercise.A significant adjunct to the osteology/radiology learning experience is a 17,600 ft2 classroom designed for small group learning for our large class. This room is optimized for working in groups of 6–7 per table. Each table has a 42‐inch monitor, to which students can connect their laptops wirelessly.In a self‐paced exercise, the students familiarize themselves with the detailed osteology of the vertebral column and upper extremity by using high quality, plastic bone models. They are encouraged to view a digital version of the exercise on the tabletop monitors. Difficult structures can be demonstrated to the entire group via a mounted video camera, which projects to 90‐inch monitors on the sides of the room and/or to the tabletop monitors. In addition to studying the bone models, students are directed to palpate on themselves clinically relevant osseous landmarks. After studying the osteology of a subregion (e.g., hand, scapula), students compare the bone models with corresponding structures on high resolution radiographs and CT images displayed on their tabletop monitors. Throughout the exercise, articulated skeletons, other bones (including real), and anatomical atlases are readily available and heavily utilized. Faculty members from Anatomy and Radiology, course Teaching Assistants, and Radiology residents engage the students and answer questions.In conclusion, this hands‐on, self‐paced osteology/radiology exercise for the back and upper extremity provides students with a concise introduction to these areas. This topic is further developed in our 3‐week block over these areas, including further discussion of osteology and radiology in lectures and access to real skeletal material in the dissection laboratory. Students (and instructors facilitating) provide very positive feedback about the experience, and students do well on their assessments.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Resolution of Chest X-Ray Opacities in Patients with Ventilator-associated Pneumonia.

Chest Radiograph accompanied by clinical and laboratory findings are required for diagnosis and follow-up of patients with suspected ventilatorassociated pneumonia (VAP). However, there are no reliable data whether follow-up chest-X-ray (CXR) is needed or not, moreover, when the physicians request CXR and how many times CXR is required. We aimed to determine association of the clinical improvement with resolution of pulmonary infiltrates as well as time of resolution. The patients with a diagnosis of VAP based on Clinical Pulmonary Infection Score (CPIS) were enrolled in this study. Clinical evaluation and follow-up were continued and CXR was performed sequentially in two-day intervals until clinical improvement or occurrence of other events including death. Fischer test was used to analyze the association of clinical improvement with radiographic resolution. Out of the seventy -five patients, pneumonia was clinically improved in 48 cases. Mean duration of the clinical improvement was 5.3±4.5 days. Among these patients, pulmonary infiltrations in 44 patients were resolved completely (13.8±5.8 days). Twentyseven patients had no clinical improvement and all of them revealed no infiltration resolution according to the sequential imaging studies. Resolution of radiographic involvement significantly was associated with clinical improvement (p=0.000). Radiographic resolution occurs in most of patients who survived VAP and there is strong relationship between radiographic resolution and clinical improvement. Moreover, our data revealed that CXR clearance occurred earlier than anticipated previously. Thus, sequential follow-up CXR in VAP had no further clinical value.

The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs

Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P=0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P=0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.

The viability of ADVANTG deterministic method for synthetic radiography generation

Fast simulation techniques to generate synthetic radiographic images of high resolution are helpful when new radiation imaging systems are designed. However, the standard stochastic approach requires lengthy run time with poorer statistics at higher resolution. The investigation of the viability of a deterministic approach to synthetic radiography image generation was explored. The aim was to analyze a computational time decrease over the stochastic method. ADVANTG was compared to MCNP in multiple scenarios including a small radiography system prototype, to simulate high resolution radiography images. By using ADVANTG deterministic code to simulate radiography images the computational time was found to decrease 10 to 13 times compared to the MCNP stochastic approach while retaining image quality.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

Emittance Growth in the DARHT-II Linear Induction Accelerator

The Dual-Axis Radiographic Hydrotest (DARHT) facility uses bremsstrahlung radiation source spots produced by the focused electron beams from two linear induction accelerators (LIAs) to radiograph large hydrodynamic experiments driven by high explosives. Radiographic resolution is determined by the size of the source spot, and beam emittance is the ultimate limitation to spot size. Some of the possible causes for the emittance growth in the DARHT LIA have been investigated using particle-in-cell (PIC) codes, and are discussed in this article. The results suggest that the most likely source of emittance growth is a mismatch of the beam to the magnetic transport, which can cause beam halo.

Endoureterotomy for Ureteral Stricture: A Retrospective Study of Holmium Versus Thulium Lasers

Background: To compare the results of endoureterotomy for benign ureteral strictures by using holmium: yttrium-aluminum-garnet (Ho:YAG) and thulium lasers. Methods: A total of 25 patients (15 men and 10 women, mean age: 49.16 years) underwent endoureterotomy with either Ho:YAG or thulium lasers for benign ureteral strictures (13 proximal, 3 middle, and 9 distal), using semirigid ureteroscopy and a 365-μm fiber (Ho-YAG laser) at 1.2 J/pulse and 10 Hz, or a 300-μm fiber (thulium laser) at 8W to 15W. Following incision, a 7-Fr double-J ureteral stent was left for 4 to 6 weeks. Thereafter, patients were followed-up using ultrasonography and/or intravenous urography at 3- to 6-month intervals. Results: Success was defined as the absence of symptoms, plus radiographic resolution of obstructions, as assessed by diuretic renography and/or intravenous urography. With a mean follow-up of 43 months, success was achieved in 10 (52.6%) of 19 patients treated with Ho:YAG laser and in 5 (83.3%) of 6 patients treated with thulium laser. A total of 10 patients developed recurrent strictures and were considered to have treatment failures. Stricture length and the severity of hydronephrosis were correlated with successful outcome. Sex, etiology, side, and stricture location did not predict outcome. Conclusions: Although endoureterotomies using Ho:YAG and thulium lasers had equal efficacy, our analysis revealed that a patient with longer stricture length or severe hydronephrosis is more suitable to receive thulium laser. This general laser procedure is recommended as a safe therapeutic option for the initial management of patients presenting with benign ureteral strictures because it is less invasive.

Clinical Course of Sarcoidosis in World Trade Center-Exposed Firefighters

Sarcoidosis is believed to represent a genetically primed, abnormal immune response to an antigen exposure or inflammatory trigger, with both genetic and environmental factors playing a role in disease onset and phenotypic expression. In a population of firefighters with post-World Trade Center (WTC) 9/11/2001 (9/11) sarcoidosis, we have a unique opportunity to describe the clinical course of incident sarcoidosis during the 15 years postexposure and, on average, 8 years following diagnosis. Among the WTC-exposed cohort, 74 firefighters with post-9/11 sarcoidosis were identified through medical records review. A total of 59 were enrolled in follow-up studies. For each participant, the World Association of Sarcoidosis and Other Granulomatous Diseases organ assessment tool was used to categorize the sarcoidosis involvement of each organ system at time of diagnosis and at follow-up. The incidence of sarcoidosis post-9/11 was 25 per 100,000. Radiographic resolution of intrathoracic involvement occurred in 24 (45%) subjects. Lung function for nearly all subjects was within normal limits. Extrathoracic involvement increased, most prominently joints (15%) and cardiac (16%) involvement. There was no evidence of calcium dysmetabolism. Few subjects had ocular (5%) or skin (2%) involvement, and none had beryllium sensitization. Most (76%) subjects did not receive any treatment. Extrathoracic disease was more prevalent in WTC-related sarcoidosis than reported for patients with sarcoidosis without WTC exposure or for other exposure-related granulomatous diseases (beryllium disease and hypersensitivity pneumonitis). Cardiac involvement would have been missed if evaluation stopped after ECG, 48-h recordings, and echocardiogram. Our results also support the need for advanced cardiac screening in asymptomatic patients with strenuous, stressful, public safety occupations, given the potential fatality of a missed diagnosis.

Effectiveness of Colonic Decompression in Patients Hospitalized With Acute Colonic Pseudoobstruction: Propensity-Matched Analysis

Introduction: Colonic decompression (CD) is recommended for treatment of acute colonic pseudoobstruction (ACPO) when pharmacologic and conservative management fails. The efficacy of CD has not been evaluated in RCTs. Furthermore, current studies are limited by size. This is the largest study to address the effectiveness of CD. Methods: The EMRs of inpatients at the Cleveland Clinic with a clinical and radiographic diagnosis of ACPO between 2000 and 2016 were reviewed. Patients were divided into two groups based on treatment with or without CD. These patients were propensity matched with Greedy-algorithm by age, electrolyte imbalance, sepsis, Charleson comorbidity score, symptoms, hypothyroidism, renal insufficiency, use of opiate or anti-cholinergic medicines, use of neostigmine, recent surgery, recent trauma, and maximum colonic diameter. Chi-square or t-test were used to compare matched and unmatched groups with respect to percent change in maximum colonic diameter, resolution per radiologist, and change in symptoms (distension, abdominal pain, nausea, and ability to tolerate diet) within 48 hours. Results: 113 patients had confirmed ACPO; mean age was 70.1 ±14.5 and 79 (69.9%) were male. In unmatched analysis, the CD group achieved a greater reduction in maximum diameter (30.1% ±16.8 v.non-CD group 20.3% ±14.1; p=0.001) with a lower proportion of individuals who had no improvement in abdominal pain (CD- 3.6% v. non-CD 31.8%; p=0.013). Propensity matching yielded 36 matched subjects with a mean age of 70 ±13.9 and 27 (75%) males. After propensity matching, no significant difference was noted between mean colon diameter or radiographic resolution between both groups. Conclusion: Colonic decompression results in a significant decrease in mean colonic diameter and abdominal pain compared to conservative and medical management. However, these benefits are no longer noted after propensity matching.Table: Baseline characteristics of patients with ACPO.Table: Efficacy of colonic decompression (without propensity score matching).Table: Efficacy of colonic decompression (propensity matched).

Unilateral extravesical ureteral reimplantation via inguinal incision for the correction of vesicoureteral reflux: a 10-year experience.

ABSTRACTIntroduction and Objective:Multiple options exist for the surgical management of vesicoureteral reflux (VUR). We report on our 10-year experience using the inguinal approach to extravesical ureteral reimplantation (EVR).Materials and Methods:Patient characteristics of age, gender, and reflux grade were obtained and outcomes of operative time, hospital stay, and radiographic resolution were assessed.Results:71 girls and 20 boys with a mean age of 74 months (range 14-164) underwent inguinal EVR via a 3.5-cm inguinal mini-incision. Mean follow up was 10.9 months (range 0.4-69.7). Average grade of reflux was 2.80. Average operative time was 91 minutes (range 51-268). The procedure was successful in 87 of 91 patients (95.6%). The 3 cases of reflux that persisted were all grade 1 and managed expectantly. Contralateral reflux developed in 9 cases, all of which resolved after treatment with either Deflux or ureteral reimplant. There were 4 case of urinary retention that resolved after a brief period of CIC or indwelling catheterization. There were no cases of ureteral obstruction. Most patients were discharged on post-operative day 1 (85/91) and no hospitalization extended beyond 3 days.Conclusions:The inguinal approach to extravesical ureteral reimplantation should be considered as a potentially minimally invasive alternative to endoscopic and robotic treatment of VUR with a success rate more comparable to traditional open approaches. We feel it is the method of choice in cases of unilateral VUR requiring surgical correction.

Changes in pulmonary artery systolic pressure correlate with radiographic severity and peripheral oxygenation in adults with community-acquired pneumonia.

The aim of this prospective observational study was to evaluate the relationship between changes in pulmonary artery systolic pressure (ΔPASP) and both severity of community-acquired pneumonia (CAP) and changes in peripheral blood oxygen partial pressure (PaO2 ). Seventy-five consecutive adult patients hospitalized for treatment of CAP were recruited in this single-center cohort study. Doppler echocardiographic measurement of PASP was performed by 2 staff cardiologists. Follow-up assessment was performed within 2 to 4 weeks of ending antibiotic treatment at radiographic resolution of CAP. Fifteen patients were excluded during follow-up due to confirmation of chronic obstructive pulmonary disease. Pneumonia was unilateral in 40 (66.7%) and bilateral in 20 (33.3%) patients. Radiographic extent of pneumonia involved 2 pulmonary segments in 31 patients (51.7%), 3 to 5 pulmonary segments in 25 (41.7%), and 6 pulmonary segments in 4 patients (6.6%). ΔPASP between hospital admission and follow-up correlated with the number of pulmonary segments involved (Rho = 0.953; P < .001) and PaO2 (Rho = -0.667; P < .001). The maximum PASP was greater during pneumonia than after resolution (34.82 ± 3.96 vs. 22.67 ± 4.04, P < .001). Changes in PASP strongly correlated with radiological severity of CAP and PaO2 . During pneumonia, PASP appeared increased without significant change in left ventricular filling pressures. This suggests that disease-related changes in lung tissue caused by pneumonia may easily and reproducibly be assessed using conventional noninvasive bedside diagnostics such as echocardiography and arterial blood gas analysis.

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

BackgroundThe ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.MethodsFrom March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.ResultsWith a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.ConclusionsThe SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

Single center experience with intralesional bleomycin sclerotherapy for lymphatic malformations.

The purpose of our study was to evaluate the efficacy of percutaneous sclerotherapy using bleomycin in treatment of lymphatic malformations. Between January 2009 and January 2013, ten patients with lymphatic malformations who were admitted to the interventional radiology department were included in this retrospective study. Intralesional bleomycin was administered by percutaneous injection through 21-23 Gauge needles with a dose of 1mg/kg body weight. Patients were clinically and radiologically assessed at baseline and followed at first and third months after treatment. Response to treatment was measured visually by using photographs and by radiological images. Symptomatic improvement was also evaluated either by patients or parents. Excellent resolution was obtained visually in 80% of patients with lymphatic malformation. Significant resolution was achieved in 20% of patients. The percentage of radiographic resolution in size and the improvement in symptoms evaluated by patients or parents were similar with visual outcomes. No side effects were recorded except for fever in one patient and transient erythema in another patient. Intralesional bleomycin is a safe and effective treatment for patients with lymphatic malformations.

The enigma of granulomatous mastitis: A series

Granulomatous mastitis is a chronic inflammatory breast disease with an enigmatic clinical presentation that can delay diagnosis and perpetuate ineffective treatments. We report our experience with the diagnosis and management of eighteen cases of granulomatous mastitis in the setting of an urban public hospital. The patients were identified after a retrospective review of pathology and surgery databases. Demographic, clinical, radiographic, histopathological data and treatment responses were reviewed. Out of a total of 18 patients, 8 patients were noted to be from Mexico. The mean age at presentation was 35 years and 11 of the 18 patients reported a pregnancy in the last four years. Most cases were unsuccessfully managed as bacterial breast infections initially; definitive treatment involved surgical excision and steroids. A complete symptomatic and radiographic resolution was documented in 8 of the 18 patients. Despite posing a challenge for the unsuspecting physician, an early diagnosis of granulomatous mastitis improves patient outcomes.

The use of thrombolytics in the management of complex pleural fluid collections.

To determine the efficacy of thrombolytics for the management of complex pleural fluid collections. We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d). One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20-91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1-32 days) and 16.2 days (range, 4-48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1-11 days). The time from alteplase to chest tube removal was 4.5 days (1-21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest. Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.

Pleural Effusions and Pneumothoraces.

1. Katherine Cashen, DO* 2. Tara L. Petersen, MD† 1. *Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI 2. †Division of Critical Care, Department of Pediatrics, The Children’s Hospital of Wisconsin/The Medical College of Wisconsin, Milwaukee, WI * Abbreviations: BTS: : British Thoracic Society CHF: : congestive heart failure CT: : computed tomography VATS: : video-assisted thoracoscopic surgery 1. Clinicians should be aware of the causes and clinical presentation of pleural effusions and pneumothoraces. 2. Clinicians should understand the current role of diagnostic tests, imaging modalities, and timing of minimally invasive treatments. After completing this article, readers should be able to: 1. Describe the pathogenesis of pleural fluid accumulation. 2. Identify the most likely causes of pleural effusion and pneumothorax. 3. Understand the basic clinical presentation, diagnostic tests, and management of pleural effusions and pneumothoraces. 4. Differentiate between transudative and exudative pleural effusions. 5. Understand the natural history of spontaneous pneumothorax. The pleural space is created by the parietal and visceral pleura that line the chest wall and the lung surface, respectively. Normally, only a small amount (0.3 mL/kg) of hypotonic fluid is present within the pleural space due to homeostatic balances in physiologic fluid production and absorption. Various infectious and noninfectious processes can lead to pathologic filling of the pleural space with fluid (effusion) or air (pneumothorax). Such pathologic changes create a true space that can interfere with normal lung mechanics and, in severe cases, cardiac function. Although much less common in pediatric than adult populations, pleural effusions and pneumothoraces in both groups can lead to substantial complications, resulting in significant morbidity and mortality if unrecognized or untreated. Overall, the cause of pleural effusions and pneumothoraces differs in children compared to adults. In adults, congestive heart failure (CHF) and malignancy account for a substantial number of pleural effusions, but these are uncommon causes in children. Infectious pleural effusions in the setting of pneumonia (parapneumonic effusions) remain the most common cause of effusions in both children and adults. Unlike the adult population, children experience spontaneous …

High-resolution extremity cone-beam CT with a CMOS detector: Task-based optimization of scintillator thickness.

CMOS x-ray detectors offer small pixel sizes and low electronic noise that may support the development of novel high-resolution imaging applications of cone-beam CT (CBCT). We investigate the effects of CsI scintillator thickness on the performance of CMOS detectors in high resolution imaging tasks, in particular in quantitative imaging of bone microstructure in extremity CBCT. A scintillator thickness-dependent cascaded systems model of CMOS x-ray detectors was developed. Detectability in low-, high- and ultra-high resolution imaging tasks (Gaussian with FWHM of ~250 μm, ~80 μm and ~40 μm, respectively) was studied as a function of scintillator thickness using the theoretical model. Experimental studies were performed on a CBCT test bench equipped with DALSA Xineos3030 CMOS detectors (99 μm pixels) with CsI scintillator thicknesses of 400 μm and 700 μm, and a 0.3 FS compact rotating anode x-ray source. The evaluation involved a radiographic resolution gauge (0.6-5.0 lp/mm), a 127 μm tungsten wire for assessment of 3D resolution, a contrast phantom with tissue-mimicking inserts, and an excised fragment of human tibia for visual assessment of fine trabecular detail. Experimental studies show ~35% improvement in the frequency of 50% MTF modulation when using the 400 μm scintillator compared to the standard nominal CsI thickness of 700 μm. Even though the high-frequency DQE of the two detectors is comparable, theoretical studies show a 14% to 28% increase in detectability index (d'2) of high- and ultrahigh resolution tasks, respectively, for the detector with 400 μm CsI compared to 700 μm CsI. Experiments confirm the theoretical findings, showing improvements with the adoption of 400 μm panel in the visibility of the radiographic pattern (2× improvement in peak-to-through distance at 4.6 lp/mm) and a 12.5% decrease in the FWHM of the tungsten wire. Reconstructions of the tibial plateau reveal enhanced visibility of trabecular structures with the CMOS detector with 400 μm scinitllator. Applications on CMOS detectors in high resolution CBCT imaging of trabecular bone will benefit from using a thinner scintillator than the current standard in general radiography. The results support the translation of the CMOS sensor with 400 μm CsI onto the clinical prototype of CMOS-based extremity CBCT.

Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort. We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale. A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients with either duplex ureter (42), failed endoscopic treatment (40) or concomitant diverticulectomy (8). Of the 280 ureters with postoperative voiding cystourethrogram or radionuclide cystogram available radiographic resolution was seen in 246 (87.9%). There were 25 complications overall (9.6%), with 7 grade 3 complications (2.7%) and no grade 4 or 5 complications. Four patients (3.9%) had transient urinary retention following bilateral reimplantation. Robot-assisted laparoscopic extravesical ureteral reimplantation has a low complication rate consistent with published series of open ureteral reimplantation. Radiographic success rates are approaching those of the open procedure but continue to fall short of the gold standard approach. These findings necessitate critical thinking regarding potential technique improvements and further prospective investigation into the efficacy of this procedure.

Detector characterization and electron effect for laser-driven high energy X-ray imaging

High energy X-ray sources based on laser-wakefield accelerated electron beams have several important advantages, including high photon energy and small source size, and have many important applications such as high resolution radiography in non-destructive testing. Firstly, the thickness of electron converter is optimized with the targets Ta, W and Pb each with an optimal thickness of 2 mm. We calibrate the intrinsic spatial resolution of CsI needle-like scintillation screen, bismuth germanium oxide (BGO) scintillation array and DRZ scintillation screen with an X-ray tube. And the spatial resolution of CsI needle-like scintillation screen is as high as 8.7 lp/mm. The energy deposition responses of these three detectors to high X-ray are also simulated. Experiments show that the features of a two-layer object can be resolved up to an area density of 33.0 g/cm2 by using the high X-ray source generated by injecting laser-wakefield accelerated electron beam into a Ta convertor target. Experiment that compares X-ray radiography, mixed radiography of X-ray and electron, and electron radiography, is also carried out. Since low X-ray yield and low detection efficiency are two serious problems in high energy X-ray radiography based on laser-wakefield accelerated electron beams, we propose and prove a method of improving image signal intensity greatly at the cost of image contrast by adopting the mixed radiography of X-ray and electron.