The Diagnosis of Unilateral Diaphragmatic Paralysis Using M-mode: A Case Report from Palestine

Background: Diaphragmatic paralysis is one the causes of dyspnoea and difficulty in breathing. There are many causes of diaphragmatic paralysis, especially trauma and iatrogenic injury of phrenic nerve. Usually, diaphragmatic paralysis diagnosis depends on fluoroscopic examination of diaphragmatic displacement during sharp sniffs. However, due to disadvantages of fluoroscopic examination, the trend for less radiation examination by using ultrasound is increasing especially using M-mode for detection of diaphragmatic motion during respiration. Case: A new-born baby boy with uneventful pregnancy and normal delivery with good general condition, developed severe respiratory distress at 3rd day of life and was diagnosed to have bilateral pneumothorax. Bilateral chest tubes were inserted with improvement of his condition. The baby then started to develop desaturation with serial chest x-rays done and showed elevated left hemi-diaphragm. Suspicion toward left hemi-diaphragm paralysis increased and due to his general condition, fluoroscopic examination was difficult. So that, Ultrasound with M-mode was used with diagnosis of the patient with left hemi-diaphragmatic paralysis. Conclusion: Ultrasound and the using of M-mode in detection of diaphragmatic motion is one of the most important and applicable diagnostic procedure for diagnosis of diaphragmatic weakness and paralysis.

Characterization of Small Dosimeters Used for Measurement of Eye Lens Dose for Medical Staff during Fluoroscopic Examination

This study aimed to evaluate the property of small dosimeters used for measuring eye lens doses for medical staff during fluoroscopic examination. Dose linearity, energy dependence, and directional dependence of scattered X-rays were evaluated for small radiophotoluminescence glass dosimeters (RPLDs), those with a tin filter (Sn-RPLDs), and small optically stimulated luminescence dosimeters (OSLDs). These dosimeters were pasted on radioprotective glasses, and accumulated air kerma was obtained after irradiating the X-rays to a patient phantom. Strong correlations existed between fluoroscopic time and accumulated air kerma in all types of dosimeters. The energy dependence of Sn-RPLD and OSLD was smaller than that of RPLD. The relative dose value of the OSLD gradually decreased as the angle of the OSLD against the scattered X-rays was larger or lower than the right angle in the horizontal direction. The ranges of relative dose values of RPLD and Sn-RPLD were larger than that of OSLD in the vertical direction. The OSLDs showed lower doses than the RPLDs and Sn-RPLDs, especially on the right side of the radioprotective glasses. These results showed that RPLDs, Sn-RPLDs, and OSLDs had different dosimeter properties, and influence measured eye lens doses for the physician, especially on the opposite side of the patient.

Accuracy of fluoroscopic examination in the treatment of Bennett’s fracture

Background Restoration of joint congruity is an important factor for the prevention of subsequent arthritis in patients with Bennett’s fracture. Surgical treatment of Bennett’s fracture is thus generally recommended for displaced intra-articular fractures to the proximal aspect of the thumb metacarpal. Fluoroscopic examination is used to evaluate the adequacy of closed reduction after pinning of Bennett’s fracture. The purpose of this study was to determine the accuracy of fluoroscopy to determine the reduction of Bennett’s fractures. Methods A model was created, to mimic a Bennett’s fracture utilizing ten fresh-frozen cadaveric hands. An oblique cut was made in the proximal aspect of the thumb metacarpal using an oscillating saw. The small oblique fragment involved 1/4–1/3 of the joint surface was then shifted in position creating a step-off or gap at the fracture site. An anatomical reduction model, gap models (1 mm, 2 mm, 3 mm), and step-off models (1 mm, 2 mm, 3 mm) were created using percutaneous fixation with two 1.0 mm Kirschner wires for each cadaveric hand. Fluoroscopic assessment then took place and was reviewed by 2 attending hand surgeons blinded to the actual position. Their estimated fluoroscopic position was then compared to the actual displacement. Results The step-off and gap on fluoroscopic examination showed a significant difference compared to the step-off and gap from direct visualization. The frequency of underestimation for the 3 mm displacement models from the fluoroscopic examination was 60%. The frequency for overestimated was 9% for the models in which displacement was within 2 mm (0, 1, 2 mm). Conclusions The assessment of articular gap and step-off using PA (postero-anterior), AP (antero-posterior), and lateral view of fluoroscopic examination is not accurate as compared to the examination by direct visualization. Surgeons need to be aware that PA, AP and lateral view of fluoroscopic examination alone may not be sufficient to judge the final position of a reduced Bennett’s fracture. Other methods such as live fluoroscopy in multiple different planes, 3-dimensional fluoroscopy or arthroscopic examination should be considered.

Diaphragm ultrasound examination for congenital diaphragmatic eventration in two premature neonates

Congenital diaphragmatic eventration (CDE) is always diagnosed by fluoroscopic examination. However, this technique is inappropriate for premature neonates because of risks of transport, hypothermia and ionising radiation. Herein, we describe two cases of premature neonates suspected to have CDE on radiography. We could not perform fluoroscopic examination due to their prematurity status. Therefore, we performed ultrasound examination and succeeded in diagnosing CDE without any risks. Using ultrasound examination, we could evaluate movement and thickness of the diaphragm. We consider this additional information useful for CDE diagnosis. This is the first report on CDE diagnosis using ultrasound examination.

Evaluation of radiation exposure from fluoroscopic examination in small animal veterinary staff using thermoluminescent dosimeters

The purpose of this study was to evaluate the occupational radiation exposure levels of veterinary staff during fluoroscopic examination using thermoluminescent dosimeters (TLDs). A prospective study was conducted to measure radiation doses in three positioned persons (two restrainers and one observer) using TLDs. The TLDs were placed on the inside and outside of the lead-equivalent protective devices of the panorama mask, thyroid shield, apron and arm shield. The TLDs were placed at five anatomic sites (eye, thyroid, breast, gonad and hand). Radiation exposure was measured in 65 fluoroscopic examinations at 80 kVp and 100 mAs. The doses (mSv) (outside/inside the shield) measured in restrainers A and B and observer C were 3.09/0.59, 3.80/0.65 and 0.63/0.44 in the eye; 2.20/0.73, 1.88/1.10 and 0.79/0.45 in the thyroid; 3.42/0.44, 3.94/2.35 and 0.61/0.34 in the breast; 1.84/0.45, 1.69/0.23 and 0.46/0.36 in the gonad; and 5.56/3.16, 8.29/2.99 and 0.79/0.34 in the hand, respectively. Out of all the lead protection devices, the radiation dose of the hand was the highest in all three participants, with the thyroid radiation dose value being the same as the hand in the observer C. Radiation doses received by the eyes of all three participants were also not negligible. Veterinary workers exposed to radiation through not only radiography but also fluoroscopy should wear protective gear, especially for the eyes.