Management of fetal mediastinal shift: a practical approach

The purpose of this article is to review the technique of fetal chest ultrasound screening evaluation, the diagnostic work-up in the presence of fetal mediastinal shift and which ultrasound imaging features to look for. The first step in evaluating the fetal thorax is to confirm situs. Then, a median sagittal line is drawn from a four-chamber view to assist in spatial orientation followed by echotexture analysis of the structures of the thorax in the presence of mediastinal shift. We propose a systematic approach based on the direction of the mediastinal shift and echogenicity of the compressing hemithorax. When the hemithorax contralateral to the mediastinal shift is enlarged, which is the most frequent situation, diaphragmatic hernia and macrocystic congenital cystic adenomatoid malformation are the most likely etiologies when the mass is heterogeneous. Microcystic congenital cystic adenomatoid malformation, sometimes associated with sequestration, is the most frequent etiology when the mass is homogeneous. When the hemithorax ipsilateral to the mediastinal shift is small, which is less frequent, and the contralateral hemithorax is homogeneously isoechoic, then a diagnosis of lung hypoplasia-agenesis-aplasia should be considered.     

Finding early invasive breast cancers: a practical approach

Detection of early invasive breast cancer is important, as patient survival is high when the cancer is 2 cm or smaller. Invasive breast cancers typically manifest mammographically as focal asymmetries or masses. Strategies for detecting focal asymmetries and masses on screening mammograms include side-by-side comparison, looking for parenchymal contour deformity, close inspection of the retromammary fat, identifying the presence of associated findings, and comparison with prior mammograms. Focal asymmetries are often normal but are concerning when there is distortion of the normal breast architecture. Masses and focal asymmetries are best evaluated in the diagnostic setting by using spot compression and true lateral views and, frequently, ultrasonography. Management of a lesion depends on the worst imaging feature. Indications for an assessment of probably benign findings are very specific but are often misapplied. This review for residents provides a practical approach to the detection and management of breast masses and focal asymmetries.     

The latest on carbohydrate loading: a practical approach

High dietary carbohydrate (CHO) intake for several days before competition (CHO loading) is known to increase muscle glycogen stores, with subsequent ergogenic performance benefits often seen in events longer than 90 min in duration. CHO-loading strategies vary in characteristics such as type and duration of dietary manipulation and the accompanying exercise/training activities. Additionally, glycogen concentration may remain elevated for up to 5 d. This versatility in CHO-loading strategies allows the athlete greater flexibility in tailoring pre-event preparation. Women who attempt to CHO load should be particularly attentive to both total energy intake and relative CHO intake; dietary CHO should exceed 8 g x kg body mass(-1) x d(-1) or 10 g x kg lean body mass(-1) x d(-1). As long as the amount ingested is adequate for loading, the type of CHO is less important, with the exception of 1-d loading protocols where the glycemic index may be an important consideration.     

MR imaging of the pancreas: a practical approach

This article reviews the current practical MRI techniques in assessment of the pancreas. With the comprehensive "one-stop-shopping" approach, the great majority of pancreatic diseases can be detected and characterized by the use of a combination of T1, T2-weighted, MRCP, and fat-suppressed T1-weighted dynamic post-gadolinium SGE sequences. This approach may provide the clinician with information regarding the site, nature, and staging of pancreatic tumor in a single setting. In many institutions worldwide, however, including our own, CT remains the main imaging method for the assessment of acute pancreatic diseases, due largely to its wide availability. MR imaging is reserved for the indications listed above, most importantly, the detection of small and non-organ-deforming pancreatic ductal adenocarcinoma, islet cell tumors, choledocholithiasis and pancreatic duct calculi, cholangiocarcinomas, and in cases of pancreatic head enlargement with no mass discernable on CT.     

MR imaging of cervical carcinoma: a practical staging approach.

Cervical carcinoma is the third most common gynecologic malignancy and is typically seen in younger women, often with serious consequences. The International Federation of Gynecology and Obstetrics (FIGO) staging system provides worldwide epidemiologic and treatment response statistics. However, there are significant inaccuracies in the FIGO staging system, and magnetic resonance (MR) imaging, although not included in that system, is now widely accepted as optimal for evaluation of important prognostic factors such as lesion volume and metastatic lymph node involvement that will help determine the treatment strategy. MR imaging examination obviates the use of invasive procedures such as cystoscopy and proctoscopy, especially when there is no evidence of local extension. Brachytherapy and external beam therapy are optimized with MR imaging evaluation of the shape and direction of lesion growth. In general, T2-weighted MR imaging more clearly delineates cervical carcinoma and is preferred for evaluation of the lymph nodes. Dynamic gadolinium-enhanced T1-weighted imaging may help identify smaller tumors, detect or confirm invasion of adjacent organs, and identify fistulous tracts. MR imaging staging, when available, is invaluable for identifying important prognostic factors and optimizing treatment strategies.     

Applications and rewards of cost accounting: a practical approach.

This article is organized to present the full process of cost accounting. Cost behavior characteristics will be explained to provide a foundation for classifying specific types of cost. An overview of cost accounting applications is presented with discussions of productivity monitoring, contract pricing, program evaluation and strategic planning.     

Defining a new annotation object for DICOM image: a practical approach.

In this article, we present a new way of creating annotation objects for DICOM images, using the redundant data channel. Various types of annotations, including types containing color information, are possible and annotation objects can overlap the original DICOM image on a screen. Annotation objects can be created easily using a digital pen. Scanned images used in an electronic patient record can be added to objects. Although there are various ways of manipulating annotation objects, such as insertion, addition and modification of annotation objects in the DICOM image, the original clinical image is not affected because a redundant data channel is used for the annotation. The proposed method is expected to be very useful to medium and small clinics that cannot afford picture archiving and communication systems, as the DICOM standard makes provision for the annotation of clinical images in various ways.     

MR imaging of the chest: a practical approach at 1.5T

Magnetic resonance imaging (MRI) is capable of imaging infiltrative lung diseases as well as solid lung pathologies with high sensitivity. The broad use of lung MRI was limited by the long study time as well as its sensitivity to motion and susceptibility artifacts. These disadvantages were overcome by the utilisation of new techniques such as parallel imaging. This article aims to propose a standard MR imaging protocol at 1.5T and presents a spectrum of indications. The standard protocol comprises non-contrast-enhanced sequences. Following a GRE localizer (2D-FLASH), a coronal T2w single-shot half-Fourier TSE (HASTE) sequence with a high sensitivity for infiltrates and a transversal T1w 3D-GRE (VIBE) sequence with a high sensitivity for small lesions are acquired in a single breath hold. Afterwards, a coronal steady-state free precession sequence (TrueFISP) in free breathing is obtained. This sequence has a high sensitivity for central pulmonary embolism. Distinct cardiac dysfunctions as well as an impairment of the breathing mechanism are visible. The last step of the basic protocol is a transversal T2w-STIR (T2-TIRM) in a multi-breath holds technique to visualize enlarged lymph nodes as well as skeletal lesions. The in-room time is approximately 15min. The extended protocol comprises contrast-enhanced sequences (3D-GRE sequence (VIBE) after contrast media; about five additional minutes). Indications are tumorous lesions, unclear (malignant) pleural effusions and inflammatory diseases (vaskulitis). A perfusion analysis can be achieved using a 3D-GRE in shared echo-technique (TREAT) with a high temporal resolution. This protocol can be completed using a MR-angiography (3D-FLASH) with high spatial resolution. The in-room time for the complete protocol is approximately 30min.     

MRI evaluation of bone marrow changes in the diabetic foot: a practical approach

One of the most important roles of magnetic resonance (MR) in imaging of the diabetic foot is to differentiate between the common and often comorbid pathologies that present with abnormal bone marrow signal. The primary diagnostic challenges in this setting are to distinguish osteomyelitis from reactive bone marrow edema, neuroarthropathy from osteomyelitis, and the sterile from the superinfected neuropathic joint. Whereas both osteomyelitis and reactive marrow edema share increased T2 signal, osteomyelitis is confirmed by T1 hypointensity in the bone marrow and reactive edema demonstrates isolated T2 signal hyperintensity. In distinguishing osteomyelitis from neuroarthropathy, a localized or contiguously spreading forefoot focus of abnormal bone marrow away from the subchondral surface and adjacent to a skin ulcer, cellulitis, abscess, or sinus tract would be indicative of osteomyelitis. A midfoot, subchondral, periarticular, or polyarticular distribution of findings in the absence of a contiguous focus of skin disruption would strongly support neuroarthropathy. Parameters that have been successfully correlated with acute infection superimposed on neuroarthropathy include diffuse bone marrow signal abnormality, progressive subarticular enhancement, loss of subchondral cysts, and the presence of the MRI "ghost sign."