Antonio Carlos Pires Carvalho

Reversed Halo Sign on Computed Tomography: State-of-the-Art Review

The reversed halo sign (RHS) is a chest computed tomography (CT) pattern defined as a focal round area of ground-glass attenuation surrounded by a crescent or ring of consolidation. The RHS was first described as being relatively specific for cryptogenic organizing pneumonia but was later observed in several other infectious and noninfectious diseases. Although the presence of the RHS on CT may help narrow the range of diseases considered in differential diagnoses, final diagnoses should be based on correlation with the clinical scenario and the presence of additional disease-specific CT findings. However, frequently a biopsy may be needed to establish the diagnosis. Organizing pneumonia is the most frequent cause of the RHS. This is a distinct clinical and pathologic entity that can be cryptogenic or secondary to other known causes. Morphologic aspects of the halo, particularly the presence of small nodules in the wall or inside the lesion, usually indicate an active granulomatous disease (tuberculosis or sarcoidosis) rather than organizing pneumonia. Immunocompromised patients presenting with the RHS on CT examination should be considered to have an infection until further analyses prove otherwise. Pulmonary zygomycosis and invasive pulmonary aspergillosis are typically seen in patients with severe immunosuppression, most commonly secondary to hematological malignancies. Other causes of the RHS include noninvasive fungal infections such as paracoccidioidomycosis, histoplasmosis, and Pneumocystis jiroveci pneumonia. Furthermore, Wegener’s granulomatosis, radiofrequency ablation, and lymphomatoid granulomatosis may also lead to this finding. Based on a search of the PubMed and Scopus databases, we review the different diseases that can manifest with the RHS on CT.

Intraobserver and interobserver agreement of Goutallier classification applied to magnetic resonance images

BACKGROUND Fatty infiltration of the muscle bellies is an important prognostic factor in rotator cuff tears. It was described initially in computed tomography examinations, and there is an ongoing debate about whether magnetic resonance (MR) is a reliable method for staging fatty infiltration. This study sought to determine intraobserver and interobserver agreement for Goutalliers classification of fatty infiltration of the rotator cuff as evaluated through MR imaging. MATERIALS AND METHODS Twenty MR examinations of the shoulder showing full-thickness tear of the supraspinatus tendon, with or without associated lesions, were evaluated by 3 radiologists with experience in musculoskeletal system imaging and 3 fellowship-trained shoulder surgeons. The evaluators classified the fatty infiltration of the supraspinatus muscle according to the guidelines proposed by Goutallier et al. After 8 weeks, they re-evaluated the examinations, without access to their previous reports. Weighted κ index values were determined for intraobserver and interobserver agreement analyses, and intraobserver agreement κ values are reported with 95% confidence intervals (CIs). RESULTS The mean intraobserver agreement was 0.832 among the orthopedists (CI > 95%) and 0.741 among the radiologists (CI > 95%). Interobserver agreement was 0.8214 (evaluation 1) and 0.7231 (evaluation 2) among the orthopedists (P < .0001) and 0.6627 (evaluation 1) and 0.6067 (evaluation 2) among the radiologists (P < .0001). Intraobserver agreement was not associated with length of experience or frequency of routine evaluations. CONCLUSIONS When it is applied to MR images of rotator cuff musculature, Goutalliers fatty infiltration staging rubric yielded highly significant intraobserver and interobserver agreement.

Prevalência de alteração morfológica do processo estilóide em pacientes com desordem temporomandibular

OBJETIVO: Avaliar, radiograficamente, a prevalencia de alteracoes morfologicas do processo estiloide em pacientes com desordens temporomandibulares. MATERIAIS E METODOS: Foram analisadas 1.500 radiografias panorâmicas da articulacao temporomandibular de pacientes de ambos os sexos e sem limitacao de idade, que foram atendidos pelo Servico de Desordem Temporomandibular da Faculdade de Odontologia da Universidade Federal de Juiz de Fora, MG, no periodo de 1997 a 2003. RESULTADOS: Oitenta e tres (5,53%) dos pacientes da amostra apresentaram pelo menos um dos lados da articulacao com alteracao morfologica do processo estiloide, sendo 74 do sexo feminino e 9 do sexo masculino, concentrados na faixa dos 41 a 50 anos de idade (32,5%). Com relacao ao tipo morfologico do processo estiloide, verificaram-se 113 alongados, 21 pseudo-articulados e 19 segmentados. Constatou-se, tambem, que as alteracoes morfologicas do processo estiloide desenvolvem-se de forma simetrica. CONCLUSAO: Em pacientes com desordem temporomandibular as alteracoes do processo estiloide ocorrem de forma diferenciada e de maneira simetrica em cada paciente, independentemente do sexo e da idade.

A importância do controle de qualidade de processadoras automáticas

Quality control of automatic processors is an important issue in the implementation of quality assurance programs in diagnostic radiology. A pilot program of quality control for automatic processors using the sensitometric method was implemented in the Radiodiagnosis Service of a University Hospital in Rio de Janeiro, RJ, Brazil. An initial survey of the darkrooms showed that they had high temperature and humidity and several light leaks; fog levels were excessively high requiring an increase in mAs of up to 24% to compensate for contrast loss; dry to dry processing time was out of control with errors of up to 56%; developer temperature was as high as 39°C (4°C higher than the recommended by the manufacturers); replenishment rates presented values as high as 417% above manufacturers recommendations; and rejection rates of radiographic films were of the order of 21% in the mammography service. Sensitometric measurements performed before the implementation of the quality control showed values of base + fog as high as 0.24 optical density and speed and contrast outside recommended limits. The radiographic films presented several artifacts that resulted in low quality images. The pilot program consisted of the implementation of the quality control in the mammography service. Several initiatives were taken including training of the technicians, improvement of maintenance of the processors and increase in the number of patients/day from 7 to 12. This procedure allowed replenishment rates to be lowered to acceptable levels. The implementation of the quality control maintained chemical products stable keeping the sensitometric parameters under control. However, the most significant result of the program was better image quality, free from artifacts, a significant reduction in costs to the hospital and especially lower doses imparted to the patients due to the reduction in rejection rates to 7.7%.

Avaliação dos riscos ocupacionais de trabalhadores de serviços de radiologia

OBJETIVO: Avaliar as condicoes de biosseguranca e de trabalho de profissionais de servicos de radiologia e tecer recomendacoes sobre as modificacoes necessarias, a fim de adequar os servicos as normas vigentes no pais. MATERIAIS E METODOS: Foram feitas entrevistas com funcionarios e observadas as seguintes atividades, executadas pelos tecnicos em radiologia ou enfermeiras no local de trabalho: processo de revelacao de radiografias dentro das câmaras escuras; tempo medio de permanencia dos funcionarios nas câmaras escuras; preparacao de solucoes de fixador e revelador para o processamento radiografico e tipo de ajuda prestada aos pacientes durante os exames de raios X. Foi avaliada a eficiencia do sistema de ventilacao de duas câmaras escuras. Foram medidas as alturas das bancadas das câmaras escuras para verificar suas posicoes e adequacao ergonomica. Quanto aos aspectos de seguranca eletrica e contra incendio, foram avaliados o numero e a localizacao de extintores para verificar se estavam de acordo com as normas legais, e a condicao de aterramento dos equipamentos eletricos. RESULTADOS: O sistema de ventilacao era insuficiente, os profissionais nao utilizavam equipamentos de protecao individual no preparo dos produtos quimicos, os aspectos ergonomicos estavam em desacordo com as recomendacoes nacionais e os funcionarios apresentam estresse relacionado ao trabalho. CONCLUSAO: Com base nessas verificacoes, foram elaborados mapas de risco, para cada setor do servico de radiologia, que servem para tomadas de decisao quanto a melhorias no ambiente.

A Study of the Association Between Sleep Bruxism, Low Quality of Sleep, and Degenerative Changes of the Temporomandibular Joint.

AbstractThe aim of this study was to evaluate the presence of degenerative bone changes of the temporomandibular joint (TMJ) in individuals suffering from sleep bruxism (SB), associating these characteristics with the quality of sleep. For this, we followed the International Classification of Sleep Disorders for the diagnosis of SB, in addition to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the classification of TMD and cone beam computed tomography. It was found that 97.7% of the individuals with bruxism had at least 1 RDC/TMD group III diagnosis, 75.6% of the subjects considered their sleep quality as poor, and the largest group (23%) had centric bruxism. There was no significant association between the pattern of sleep quality (P = 0.36), the type of SB (P = 0.277), and the presence of degenerative changes of the TMJ. Regardless of the quality of sleep and the type of bruxism presented, the prevalence of degenerative bone disorders was high (67%) among women with a mean age of 46 years and a clinical diagnosis of SB.

Exposição de pacientes e qualidade da imagem em radiografias de tórax: uma avaliação crítica

OBJECTIVE: Entrance skin dose, effective dose, and imaging quality in chest radiographs of adult patients have been evaluated. MATERIALS AND METHODS: The study has been developed in eight institutions - seven public hospitals (two of them philanthropic institutions) and one private - in the cities of Agra dos Reis, Cabo Frio, Campos dos Goytacazes, Itaperuna, Niteroi, Recife and Rio de Janeiro. Entrance skin dose and effective dose have been evaluated in 735 chest radiographs obtained in posteroanterior/anteroposterior and lateral projections. As regards imaging criteria, 44 radiographs have been evaluated. RESULTS: Variations of up to nine times in entrance skin dose, and six times in effective dose have been detected for a same type of projection. Also, significant discrepancies have been found in values resulting from radiographic techniques employed. Besides, imaging quality has not been good since the rate of compliance with imaging criteria was only 55%. CONCLUSION: There is a pressing need for improvement/standardization of procedures in conventional radiology; this can be achieved by implementing a quality control and assurance program in the department of radiology, including training of technicians, x-ray equipment calibration, and sensitometric control of films processors.

Relationship between two year PSA nadir and biochemical recurrence in prostate cancer patients treated with iodine-125 brachytherapy

Objective To evaluate the relationship between two year PSA nadir (PSAn) after brachytherapy and biochemical recurrence rates in prostate cancer patients. Materials and Methods In the period from January 1998 to August 2007, 120 patients were treated with iodine-125 brachytherapy alone. The results analysis was based on the definition of biochemical recurrence according to the Phoenix Consensus. Results Biochemical control was observed in 86 patients (71.7%), and biochemical recurrence, in 34 (28.3%). Mean PSAn was 0.53 ng/ml. The mean follow-up was 98 months. The patients were divided into two groups: group 1, with two year PSAn < 0.5 ng/ml after brachytherapy (74 patients; 61.7%), and group 2, with two year PSAn ≥ 0.5 ng/ml after brachytherapy (46 patients; 38.3%). Group 1 presented biochemical recurrence in 15 patients (20.3%), and group 2, in 19 patients (43.2%) (p < 0.02). The analysis of biochemical disease-free survival at seven years, stratified by the two groups, showed values of 80% and 64% (p < 0.02), respectively. Conclusion Levels of two year PSAn ≥ 0.5 ng/ml after brachytherapy are strongly correlated with a poor prognosis. This fact may help to identify patients at risk for disease recurrence.Objective To evaluate the relationship between two year PSA nadir (PSAn) after brachytherapy and biochemical recurrence rates in prostate cancer patients. Materials and Methods In the period from January 1998 to August 2007, 120 patients were treated with iodine-125 brachytherapy alone. The results analysis was based on the definition of biochemical recurrence according to the Phoenix Consensus. Results Biochemical control was observed in 86 patients (71.7%), and biochemical recurrence, in 34 (28.3%). Mean PSAn was 0.53 ng/ml. The mean follow-up was 98 months. The patients were divided into two groups: group 1, with two year PSAn < 0.5 ng/ml after brachytherapy (74 patients; 61.7%), and group 2, with two year PSAn ≥ 0.5 ng/ml after brachytherapy (46 patients; 38.3%). Group 1 presented biochemical recurrence in 15 patients (20.3%), and group 2, in 19 patients (43.2%) (p < 0.02). The analysis of biochemical disease-free survival at seven years, stratified by the two groups, showed values of 80% and 64% (p < 0.02), respectively. Conclusion Levels of two year PSAn ≥ 0.5 ng/ml after brachytherapy are strongly correlated with a poor prognosis. This fact may help to identify patients at risk for disease recurrence.

Análise e gerenciamento de efluentes de serviços de radiologia

OBJECTIVE: With the aim of reducing and preventing environmental damages, handling and disposing practices of chemical effluents from radiology departments were investigated and a service management model was created in order to obtain financial resources for the department. MATERIALS AND METHODS: The proposed model, based on the evaluation of chemical effluents from automatic processors of radiographic films, showed that fixer reprocessing can be an adequate choice to solve environmental and financial problems in these departments. This model also emphasizes that compliance with management guidelines should be observed, i.e. other effluents (developer and water) must be chemically treated before disposal in the natural environment. The economical analysis has confirmed that the income originated from commercializing the silver (of which concentration ranges from 3.5 to 10.2 g/l), recovered from the used fixer, in addition to the income from the reuse of the fixer (after its recovery), is in the worst scenario (when the silver concentration is 3.5 g/l) enough to cover all the expenses with the implementation of the project. CONCLUSION: The proposed model can be a good choice for solution of environmental and financial problems. Moreover, it is ecologically correct, a potential source of financial resources to radiology departments, and can be applied to other institutions due to the similarity of problems and resources.

Radioactive seed migration after prostate brachytherapy with iodine-125 using loose seeds versus stranded seeds.

OBJECTIVES To assess the incidence and clinical parameters that could influence migration of seeds in localized prostate cancer patients treated by stranded versus loose sources by Iodine-125 brachytherapy. MATERIALS AND METHODS 100 patients were treated from January/1998 until December/2006. Age, PSA, clinical stage, Gleason, prostate volume, number of seeds, activity of radioactive seeds, and dosimetric parameters, such as V100, V150 and D90 were evaluated. RESULTS Mean follow-up was 79 months (18 - 120. CI 95%: 72 - 85). Overall, 6 of 100 patients experienced seed migration. Seed migration was found in 4/50 (8%) patients using loose seeds and in 2/50 (4%) treated by stranded seeds. Mean value dosimetric parameters for stranded seeds were greater than those for loose seeds (V100(%): 88.7/82, D90(Gy): 149.2/140.3, D90(%): 104.2/93.8, V150 (%): 53.8/47, respectively). No significant difference in migration of seeds was detected between loose and stranded seeds considering age (p = 0.33), PSA (p = 0.391), prostate volume (p = 0.397), activity of radioactive seeds (p = 0.109), number of seeds (p = 0.338), V100 (p = 0.332), although significant differences were measured in the values of D90(% and Gy) (p = 0.022 and 0.011) and V150 (p = 0.023). CONCLUSIONS Seed migration after brachytherapy might occur and it does affect post-implant dosimetry.