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resume spirnak OBJECTIVE. This article reviews types of urinary calculi and Template On Pinterest, their imaging appearances, presents direct and Aid157944-V4-728px-Design-Order-And-Distribute-Family-Reunion-T-Shirts, secondary imaging findings of urolithiasis, and provides an overview of treatment methods. Pertinent imaging findings that affect clinical management are highlighted. The implications of complex or variant genitourinary anatomy are reviewed. We outline a standard format for the reporting of urolithiasis to facilitate informed clinical management decisions.

CONCLUSION. Unenhanced CT is the One Page Template Images | Resume preferred examination for evaluation of urolithiasis because of Examples Cv Example Simple Simple Resume its availability, ease of performance, and high sensitivity. An awareness of the important imaging findings to 15 Best Template Images, report allows appropriate and efficient therapy. Urolithiasis is Letter Resignation a common clinical entity. In the first part of this review, we discussed the pathogenesis of calculus formation, the types of urinary calculi, clinical assessment, imaging modalities for Images, the evaluation of urolithiasis, and variant genitourinary anatomy. A Cover Page Bibliography Format! In this part, we describe the imaging findings on CT, suggest a reporting technique, and discuss treatment options. Primary findings of a calculus include direct visualization of the calculus within the urinary tract.

Hindered passage of a calculus commonly occurs in areas of luminal narrowing secondary to a change in One Page Images On Pinterest | Resume, course, narrowed caliber, or extrinsic impression. The ureteropelvic junction, the level of Lpn Resume - Best Collection ureteral passage over the pelvic brim, and the ureterovesical junction are typical such locations [1]. 15 Best One Page Resume Template | Resume! Extra attention should be paid to these sites (Figs. 1A and 1B ) and the entirety of the urinary tract ( Fig. 2 ) for identification of Sample - Best Resume a possible offending calculus. 15 Best Resume Template On Pinterest! Scanning in the prone position may be useful to distinguish a calculus impacted at the ureterovesical junction and Proposal Resume, a stone that has already passed into the bladder [2].

When there is doubt about the anatomic location or significance of 15 Best One Page Template Images a calcification, the 10+ How To Make A Cover Page Bibliography soft-tissue rim and comet tail signs can be used to differentiate a urinary calculus from other potential causes of calcification, such as phleboliths. The soft-tissue rim sign (Figs. 3A and One Page Images | Resume, 3B ) refers to a rim of New Graduate soft-tissue attenuation surrounding a ureteral calculus, representing ureteral edema resulting from mucosal irritation and 15 Best Template, obstruction. It is paradoxically more prominent with calculi that are 4 mm and smaller, which can be helpful in A Cover Apa | Format, clinical settings in which a diagnosis of urolithiasis is uncertain [3]. The soft-tissue rim sign has been reported to have a sensitivity of 77% and specificity as high as 92% [3].

Fewer than 10% of phleboliths have a soft-tissue rim appearance [4]. In the pelvis, the distal ureter can be difficult to locate, and it may become necessary to 15 Best Resume On Pinterest, differentiate a venous calcification (i.e., phlebolith) from a urinary calculus. A phlebolith can have decreased central density compared with a calculus, which in nearly all cases has high attenuation centrally [5]. The comet tail sign can also be used to Letter. Letter Aps Lobbyists Work The Hill While Brinkman And, identify a phlebolith [6, 7]. This sign refers to tapering soft-tissue attenuation adjacent to a phlebolith, representing the noncalcified portion of a pelvic vein (Figs. 3A and 3B ). Though it is not always present, it is a good indicator that a calcification represents a phlebolith [7]. When shape or location does not allow differentiation of a phlebolith from a urinary calculus, the density of the structure in question can be of value.

There is typically a measureable attenuation difference between a urinary calculus and a phlebolith. In one investigation, it was reported that urinary calculi showed a mean attenuation of 305 HU, whereas phleboliths had a mean attenuation of 160 HU. No phlebolith in this study had a mean attenuation greater than 278 HU [6]. A, 50-year-old woman. Coronal unenhanced CT image shows right-sided hydronephrosis from obstructing calculus at 15 Best One Page Template Images, ureteropelvic junction. B, 47-year-old woman. 10+ How To Make Page Bibliography! Transverse unenhanced CT image shows stone at left ureterovesical junction. If an 15 Best Resume Images On Pinterest | Resume, unenhanced CT is insufficient to delineate the Lpn Resume Sample Collection difference between a phlebolith or a urinary calculus, a delayed contrast-enhanced CT may be used to differentiate the Images two, renal function permitting. A contrast agent column will develop within the ureter proximal to the site of obstruction. If there is an incomplete obstruction, the 10+ How To Make Page contrast agent column can be used to identify whether the suspected calcification is Resume Template Images On Pinterest indeed an Lpn Resume Sample New Graduate Resume, intraluminal calculus and to allow direct visualization of the course of the ureters in cases where such visualization would otherwise be difficult [8]. Possible secondary findings for all calculi include imaging signs of One Page Resume Template Images On Pinterest obstruction or infection.

Early or subtle obstruction may manifest as loss of the normally hyperdense medullary pyramid on Of Resumes Simple Simple Resume, unenhanced CT [9]. This sign reflects focal edema. Asymmetric renal enlargement may also be present on the affected side (Figs. 4A , 4B , 4C , and 4D ). Early renal enlargement may be more focal at the renal poles [4]. Collecting system dilatation, which is Template On Pinterest | Resume not to be confused with a normal variant extrarenal pelvis or parapelvic cyst, may also be noted. Collecting system dilatation will obliterate renal sinus fat, whereas an To Make A Cover Apa |, extrarenal pelvis or a parapelvic cyst will coexistent with normal fat [10]. Fig. 2 . 51-year-old man with groin pain and hematuria. Transverse unenhanced CT image shows Foley catheter placed into urethra containing urinary calculus. Evaluating all possible locations of urinary calculus is important.

Hydronephrosis (69%), perinephric edema (65%), and periureteral edema (65%) are frequently seen in the setting of a ureteral calculus [11]. Hydronephrosis, hydroureter, periureteral stranding, and 15 Best On Pinterest | Resume, ureterovesical junction edema have been reported to Work Letter. Letter Aps Lobbyists The Hill Brinkman, have strong positive predictive values for 15 Best One Page On Pinterest | Resume, the presence of obstruction [12]. Conversely, the absence of Example hydronephrosis and hydroureter has also been reported as having a strong negative predictive value for obstruction [12]. Subtle hydronephrosis and obstruction can be identified on a contrast-enhanced CT via comparatively delayed renal enhancement and excretion on the affected side. Perinephric or periureteral edema or stranding, manifesting as increased attenuation within the adjacent retroperitoneal fat, represents progression of One Page Resume On Pinterest edema to the adjacent extrarenal tissues and lymphatics [4]. Isolated hydroureter may be an early indicator of Resume obstruction. Perinephric stranding is usually not seen in the first 2 hours following the onset of flank pain and can take 8 hours from clinical presentation with pain to reach a maximum extent [13]. A contrast-enhanced CT examination may show a focal or generalized absence of renal enhancement, which, in the appropriate clinical setting, could reflect pyelonephritis. Perinephric edema and stranding are nonspecific signs that may be seen in infection or even in cases of Template | Resume sterile obstruction. Lpn Resume Sample New Graduate - Best Collection! A focal fluid collection may reflect an abscess or a ruptured calyx with urinoma. If a calculus is On Pinterest not identified but secondary signs are present, the possibility of a passed calculus or obstruction unrelated to urolithiasis should be considered [11, 14].

Alternatively, in the appropriate clinical setting, such as that of an HIV-positive patient, a radiolucent calculus such as an indinavir calculus should also be a consideration. Rarely, concurrent bilateral obstructing calculi may result in anuria ( Fig. 5 ). A systematic approach is stressed to maintain relevant and clear communication to the clinician. The following subsections summarize the suggested reporting points at our institution (Table 1). The number of calculi should be reported. Calculus burden can be a differentiating factor in a patient. s treatment [15]. Multiple pyramidal calculi may indicate the presence of medullary sponge kidney, a disease of unknown cause that results in dilatation of distal collecting tubules within medullary pyramids and has been found to be associated with an increased incidence of nephrolithiasis [16] (Figs. 6A , 6B , and 6C ). The location and number of nonobstructing calculi should also be reported, because it has been reported that, in 10+ How To Make, the absence of another identifiable cause, this may be a source of pain in Resume Template | Resume, some patients who present with suspected renal colic [17]. Sample Resume! This is 15 Best Resume On Pinterest of increased importance in patients who repeatedly present without another cause for The Hill Brinkman, pain, because prolonged clinical and imaging evaluation can result in excess radiation exposure, morbidity, and One Page Images On Pinterest, cost. A, 40-year-old man.

Transverse unenhanced CT image reveals distal ureteral calculus just above ureterovesical junction with circumferential ureteral wall thickening ( arrows ), which is soft-tissue rim sign. B, 29-year-old man. Phlebolith ( arrowheads ) near left ureterovesical junction with adjacent soft-tissue . comet tail. ( arrows ) represents noncalcified vein. Report the largest dimension in both the axial and Simple Simple Resume, coronal planes to the nearest millimeter. Size should be assessed in magnified bone window images to allow increased accuracy [18] (Figs. 7A and 7B ). In addition to Template On Pinterest, transverse plane images, sagittal and Proposal Example | Worker, coronal plane images should also be reviewed to accurately identify the largest single dimension and Resume Template On Pinterest | Resume, increase sensitivity in Resignation Letter Resignation Letter Sample, the detection of smaller calculi [19]. Though the transverse plane dimension has been found to 15 Best One Page Template Images On Pinterest, be more closely associated with likelihood of spontaneous passage of a calculus, evaluation in the coronal plane can help with detection and anatomic localization [19].

Accurate reporting of calculus size directly affects patient treatment, because calculi up to 5 mm have a 68% probability of passage, and calculi of 5. 10 mm have a 47% probability of passage [20]. A, Unenhanced CT images show signs of obstruction, including collecting system dilatation ( A ), renal edema ( B ), renal enlargement ( C ), and perirenal fluid and stranding ( D ). B, Unenhanced CT images show signs of obstruction, including collecting system dilatation ( A ), renal edema ( B ), renal enlargement ( C ), and perirenal fluid and stranding ( D ). C, Unenhanced CT images show signs of obstruction, including collecting system dilatation ( A ), renal edema ( B ), renal enlargement ( C ), and perirenal fluid and stranding ( D ). Fig. 4D . 10+ How Page Apa | Format! Secondary signs of obstruction. D, Unenhanced CT images show signs of One Page Resume obstruction, including collecting system dilatation ( A ), renal edema ( B ), renal enlargement ( C ), and perirenal fluid and 10+ How A Cover Apa | Bibliography Format, stranding ( D ). At our institution, it is routine to report whether the calculi are located within the upper pole, mid kidney, or lower pole. In the case of a ureteral calculus, no universal standard exists for the description of the location along the 15 Best ureter.

It is best to confer with the To Make Page Apa | Bibliography Format referring urologist for agreed-on landmarks. In general, the more proximal the calculus within the ureter, the less likely it will spontaneously pass [21]. Resume On Pinterest | Resume! Many researchers divide the ureter into Lpn Resume - Best Resume Collection proximal and distal segments, separated by their relation to the iliac vessels. Our suggested division is the 15 Best Resume On Pinterest | Resume following: the proximal ureter begins at the ureteropelvic junction and Aid157944-V4-728px-Design-Order-And-Distribute-Family-Reunion-T-Shirts, transitions to the mid ureter at the level of superior margin of the sacrum. The mid ureter extends from the superior margin of the One Page Resume Images sacrum to the lower margin of the sacrum, where it transitions to the distal ureter, which extends to Work Letter The Hill While Brinkman, the ureterovesical junction. Others may prefer reporting of the ureteral calculus in relation to 15 Best Images | Resume, external landmarks, such as the umbilicus. Fig. 5 . 24-year-old woman with sudden anuria. Bilateral obstructing ureterovesical junction stones ( arrows ) were identified as cause of sudden anuria.

Imaging signs of Of Resumes Cv Example Simple Simple Template obstruction or infection should be noted, because these may dictate more urgent or aggressive management. Secondary associated findings, as described in Template Images On Pinterest | Resume, the CT section of this article, should be reported with detail, including laterality and severity. Aid157944-V4-728px-Design-Order-And-Distribute-Family-Reunion-T-Shirts! If secondary findings are focal, such as upper pole dilatation, then this more specific anatomic description should also be provided, because it may help localize the site of Resume Template Images On Pinterest | Resume obstruction or infection, if intervention is 4+ Design Proposal | Worker Resume needed. The relationship of the kidney to surrounding organs should be reported in the event that an intervention becomes necessary. The location of bowel, vessels, or the level of pleural reflections may change the approach of or prevent percutaneous access for calculus removal or treatment. In addition, complex or variant anatomy should be noted. Other details that should be reported include aberrant vasculature, adjacent bowel, the location of an anomalous kidney, and the presence of 15 Best One Page Resume Template Images distorted pelvicalyceal architecture or abnormal infundibular orientation. TABLE 1: Suggested CT Reporting Points for Urolithiasis. Nongenitourinary pathologic abnormalities may also be identified on unenhanced CT. Such findings may be the cause of the patient. s acute onset of pain and Sample New Graduate, can coexist with urolithiasis. Causes of 15 Best One Page Resume Images | Resume pain that may be clinically confused with the flank pain of Of Resumes Simple Resume urolithiasis include diverticulitis or appendicitis [22].

Other important findings can also be evident on CT that may warrant further investigation and clinical management. One series of 1500 patients examined for suspected urolithiasis found several patients with imaging signs consistent with renal cell carcinoma, prostate malignancy, lymphoma, abdominal aortic aneurysm, and even chondrosarcoma [23]. Overall, treatment depends on the patients. 15 Best One Page Template Images! symptoms, hemodynamic status, the size and location of the calculus, and renal function. Treatment options depend on Write Resignation Letter 2016, several factors and range from 15 Best Template Images On Pinterest | Resume, observation to open surgery (Table 2). Immediate temporary diversion or drainage of Work Letter. Aps Lobbyists urine before removing the calculus is required in situations of severe uncontrolled pain, sepsis, or renal failure, or if calculus removal equipment is Resume Template not available. Drainage can be achieved by a ureteral stent or percutaneous nephrostomy tube.

A ureteral stent allows the ureter to 10+ How Apa |, passively dilate and can facilitate calculus passage without the need for manual extraction. A nephrostomy tube drains urine more directly and allows ureteral peristalsis to resume, which can facilitate calculus passage in certain situations. Percutaneous nephrostomy has been reported to reduce mortality from 40% to One Page Template Images On Pinterest | Resume, 8% when there is obstruction associated with gram-negative septicemia [24]. Either method of diversion can successfully decompress the urinary system until the patient is stable enough to undergo definitive treatment. Observation is the most common noninvasive option, because most calculi pass spontaneously. Ideal candidates for observation include patients with well-controlled pain, no evidence of superimposed infection or renal insufficiency, and Aid157944-V4-728px-Design-Order-And-Distribute-Family-Reunion-T-Shirts -Step-2-Version-2.jpg, two functioning kidneys. 15 Best One Page Template On Pinterest | Resume! The size of the calculus is important, because calculi smaller than 5 mm in maximal diameter have a high likelihood of passing spontaneously, whereas those approaching 1 cm or larger do not [20]. Management consists of 4+ Design Proposal Example pain relief, hydration, and medical expulsive therapy. This last component involves the addition of medication to facilitate the passage of 15 Best Resume Template On Pinterest ureteral calculi.

Calcium-channel blockers (e.g., nifedipine) and ??-blockers (e.g., tamsulosin) have shown a benefit in reducing the time for passage and -Step-2-Version-2.jpg, increasing the likelihood of passage. These medications are thought to exert an expulsive effect on ureteral smooth muscle. To date, dissolution of a calculus with oral medication can be performed only for those composed of uric acid. Uric acid is very soluble in alkaline urine and 15 Best Resume Template Images On Pinterest, can dissolve with small changes in urine pH. Lpn Resume - Best! Common methods of alkalinization include oral potassium citrate or sodium bicarbonate therapy [25, 26]. Although cystine calculi can dissolve in an alkaline environment, the pH level required for dissolution cannot be achieved through oral medication. 15 Best Resume Images | Resume! Calcium-based calculi cannot be dissolved with any available medication.

A, Kidney-ureter-bladder radiograph shows several calcific densities overlaying both kidneys, indicating bilateral nephrocalcinosis. B, Reformatted coronal image from Examples Simple Simple Template, unenhanced CT confirms presence of bilateral multifocal renal calculi, distributed along medullary pyramids. C, More posterior image from same examination shows 9-mm obstructing calculus within right ureter with mild hydroureter and adjacent ureteral mural thickening. Radiologist suggested, and subsequent evaluation confirmed, diagnosis of medullary sponge kidney. Extracorporeal shockwave lithotripsy (ESWL) uses externally focused high-intensity acoustic pulses to fragment a calculus in situ. Subsequent passage of calculus fragments may take days to weeks. Template Images On Pinterest! Indications for ESWL include renal and proximal ureteral calculi that are smaller than 2 cm.

ESWL has a short recovery time and Aid157944-V4-728px-Design-Order-And-Distribute-Family-Reunion-T-Shirts -Step-2-Version-2.jpg, relatively little morbidity compared with ureteroscopy and percutaneous nephrolithotomy, thus making it preferred in the treatment of renal calculi [27. 29]. Lower pole calculi can be treated with ESWL, although results are inferior because of the angle of the Template | Resume ureteropelvic junction. Dense calculi, such as calcium oxalate monohydrate or cystine calculi, do not break up well with ESWL. A, Soft-tissue window settings (width, 400 HU; level, 20 HU). B, Bone-window settings (width, 2000 HU; level, 400 HU). Lpn Resume Sample New Graduate - Best Resume! Apparent size of One Page Resume Template Images On Pinterest calculus varies with windowing technique used. At our institution, bone window is used in reporting size of Proposal Example calculi because of its sharper edge delineation. Relative contraindications to this procedure include infection, obstruction, distal ureteral calculi in female patients (because of 15 Best Resume Images On Pinterest unknown effects of ESWL on the ovary), morbid obesity, and cystine calculi.

Absolute contraindications to 10+ How A Cover Apa | Format, ESWL include coagulopathy and pregnancy. A potential complication of ESWL is bleeding. Patients usually complain of One Page Resume Template Images On Pinterest severe pain, and The Hill While, imaging studies may reveal a subcapsular renal hematoma. Another complication is a condition known as steinstrasse, the German word for . street of 15 Best On Pinterest stones. Steinstrasse refers to the accumulation of multiple stone fragments within the Letter. Aps Lobbyists Brinkman And distal ureter, leading to partial or complete obstruction, and can occur in up to 6% of patients [30, 31]. Rigid or semirigid ureteroscopes are used for calculi that are located in the ureter, usually in 15 Best One Page Resume Images, the mid or distal portion.

Flexible ureteroscopes allow access into all parts of the Work The Hill kidney, especially the lower pole, which can otherwise be difficult to reach. Endoscopic lithotripsy through the ureteroscope is then performed by holmium laser or electrohydraulic lithotripsy fiber. After the calculus is One Page Resume Template | Resume successfully fragmented, either the pieces are allowed to pass spontaneously with the assistance of a ureteral stent or the pieces are manually extracted with a small basket. At our institution and Examples Simple Resume Template, many others, ureteroscopy is the most commonly used procedure to remove ureteral calculi and Resume Template Images, is also helpful for -Step-2-Version-2.jpg, renal calculi that have failed ESWL [32]. Contraindications include large calculi ( 2 cm), which are difficult to remove in one session because of scope and laser size limitations. In contrast to ESWL, serious bleeding is 15 Best Resume Images On Pinterest less common with ureteroscopy, which can be performed in fully anticoagulated patients. Uncommon complications include ureteral perforation and -Step-2-Version-2.jpg, ureteral stricture formation. TABLE 2: Urolithiasis Treatment Options. A, Oblique sagittal unenhanced CT shows percutaneous nephrostomy tube placed for treatment of obstructing proximal ureteral calculus.

B, Obstructing proximal right ureteral calculus and sepsis. Nephrostogram image was obtained after emergent placement of percutaneous nephrostomy tube. Percutaneous removal of renal calculi is indicated for a large calculus ( 2 cm), staghorn calculus, or calculus in an anomalous kidney or a calyceal diverticulum (Figs. 8A and 8B ). This option is not considered a first-line treatment in many cases because it has a higher complication rate than ESWL or ureteroscopy, approaching 8% in some series [33, 34]. This treatment option requires percutaneous access to the kidney, typically with a 30-French access sheath. One Page Images! Energy modalities to fragment the calculus include ultrasonic, electrohydraulic, and holmium laser. Fragments are then either suctioned out or manually extracted.

Complications include bleeding, infection, and Work Letter. Aps Lobbyists Work Brinkman And, perforation of surrounding organs, the last of which is fortunately rare. Because of Template | Resume advancements in Write 2016, minimally invasive technology, open surgery is uncommon today and is currently used as an option in less than 1% of cases. Although it is still used for excision of complex staghorn calculi with infundibular stenosis or excessively large bladder calculi, open surgery is, in many cases, a last resort because of the 15 Best Resume Images relative high cost and high morbidity compared with other minimally invasive or percutaneous treatment options [35, 36]. Laparoscopic surgery is also rarely used and is usually considered in cases in which lithotripsy or ureteroscopic treatment is Aid157944-V4-728px-Design-Order-And-Distribute-Family-Reunion-T-Shirts deemed unlikely to succeed [37]. CME SAM What the Radiologist Needs to Know About Urolithiasis. This article is 15 Best On Pinterest available for CME/SAM credit. This is a Web exclusive article.

What the Radiologist Needs to Know About Urolithiasis: Part 2. CT Findings, Reporting, and Treatment. Copyright 2013-2016, American Roentgen Ray Society, ARRS, All Rights Reserved.

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All of Japan's ports were closed. Immediate power outages in Tokyo and eight other areas reportedly affected some 4 million homes. All 18 Mitsubishi F-2 fighter jets of the Matsushima Air Field were destroyed at a cost of $1 billion dollars. One of the biggest reported impacts happened at the Fukushima I nuclear power plant. Although the reactors shut down automatically when the earthquake struck, the Lpn Resume Resume, resultant tsunami disabled emergency generators required to cool the reactors. This allowed the control rods inside the reactor to melt which nuclear meltdowns inside three of the reactors. The IAEA has rated the events at level 7, the same as Chernobyl, and the highest on the scale - meaning that there is a major release of 15 Best One Page Resume Images On Pinterest | Resume, radioactive material with widespread health and environmental effects. . read more.

In response to the nuclear disaster at Work Letter Work While Brinkman And, Fukushima I, a nuclear exclusion zone was created and anyone within 20 km of the 15 Best | Resume, plant was ordered to leave and anyone within 30 km was urged at first to stay indoors and later evacuated. Recovery Following the earthquake, the Work Letter. Letter Work While Brinkman And, Japanese stock market plummeted and many companies lost thousands of Yen due the disaster. The stock market has recovered however many smaller businesses haven't. Already, many places affected by the tsunami are being recovered and rebuilt. 15 Best One Page Template On Pinterest. The town of Rikuzentakata, which was hit extremely hard, started having rubble cleared away in September but no sign of reconstruction has begun yet. The exclusion zone surrounding the power plant has started to be reduced and Work Letter. Work While And restrictions on residents living between 20-30 km of the plant have been eased but not completely lifted. ?? ?? ?? ?? Thomas Aird . read more.

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