2019, Houghton College, Moff's review: "Purchase online Malegra DXT Plus cheap no RX - Effective Malegra DXT Plus online OTC".
If the enzyme is actively metabolizing a particular drug and another drug is administered that relies on the same for P450 for its metabolism malegra dxt plus 160mg cheap, the drug may reach toxic levels at relatively low doses cheap malegra dxt plus 160 mg overnight delivery. Classic facial features include an epicanthal fold buy malegra dxt plus 160mg, thick lips malegra dxt plus 160mg discount, large tongue with deep furrows, and a small nose with a broad bridge. Other features may include a broad short neck, clinodactyly of the fifth finger, syndactyly, polydactyly, and a simian line (a single transverse palmer crease). Eburnation The final end product of bone sclerosis and is sometimes used as a term that is synonymous with bone sclerosis. Ehlers–Danlos syndrome Collagen and elastic tissues are abnormal, resulting in thin, easily stretched hyperelastic skin. Ligamentous laxity, resulting in flat feet, genu valgus, congenital hip dislocation, and scoliosis. Endoneurium The interstitial connective tissue in a peripheral nerve, surrounds a single nerve fiber. Enthesitis Inflammation of the entheses, the site where a tendon or ligament attaches to bone. Fibrous dysplasia An abnormal bone growth where normal bone is replaced with fibrous bone tissue. Fistula Abnormal communication between two hollow, epithelialization organs or between a hollow organ and the exterior (skin). Genu varum Bowleg, may be associated with Rickets, abnormal Ca and Ph metabolism, or Blount disease. Gigli saw A bone saw that consists of a flexible roughened wire used to cut through bone. Because of muscle weakness, patients raise themselves to the standing position by crawling up their legs. Hanging heel sign Used in the diagnosis of metatarsus adductus, the deformity persists as viewed plantarly when the foot is lifted by the toes. Hematoma Accumulation of blood within the tissue, which clots to form a solid swelling. The tuber fragment displaces superiorly, relaxing the triceps and decreasing its plantarflexory power. Hoke tonsil The fat plug in the sinus tarsi that is removed during sinus tarsi surgery. Homocystinuria Clinically very similar to Marfan syndrome except that the patients are mentally retarded and excrete large amounts of homocystine in their urine. Hunting response A secondary vasodilation response that occurs after prolonged vasoconstriction due to cold application. Ichthyosis Abnormal cornification of the skin, resulting in dryness, roughness, and scaliness. Results from hypertrophy of the horny layer resulting from excessive production of keratin. Islet of Langerhans A type of tissue found scattered throughout the pancreas, involved in glucose metabolism. Jones compression dressing The Robert Jones dressing is a thick, well-padded dressing. Push up on the plantar surface of the metatarsal head and see if the toe straightens out. Kussmaul respiration Deep, rapid respiratory pattern seen in coma or diabetic ketoacidosis. Kyphosis Excessive primary curvature of the thoracic spine (hunch back), associated with aging, especially in women. Lister’s corn Painful corn that develops in the lateral nail groove of the fifth toe from the varus rotation of the phalanx. Lordosis Excessive secondary curvature of the lumbar spine (sway back), often seen during pregnancy. Maceration A white soggy appearance that the skin takes on after tissue is soaked. The connective tissue fibers are dissolved so that the tissue components can be teased apart. Marfan syndrome An autosomal dominant primary collagen defect resulting in a very tall and slender person. Clinical symptoms include arachnodactyly, hyperextensibility, muscle myotonia, joint dislocation, severe pes planus, scoliosis, lens subluxation, genu recurvatum, and aortic dilation with aneurysm. Master knot of henry An area in the rearfoot where the tendons of the flexor hallucis longus and the flexor digitorum longus cross. There is a thick band of 842 connective tissue covering the tendons at this point and binding them to the navicular. Marjolin ulcer A squamous cell carcinoma that arises in a chronic sinus due to osteomyelitis. McGill pain index A pain scale based on comparing different diseases against each other. Melorheostosis A flowing hyperostosis resembling dripping candle wax seen on x- ray of long bones. Methylparaben An antifungal agent often used as a preservative in local anesthetics. Not recommended because it tends to dry out the wound and has been associated with contact dermatitis and aplastic anemia. Metatarsalgia General nonspecific term referring to pain located in the ball of the foot. Metatarsus varus Metatarsus adductus with a varus component (often confused with clubfoot). The lower this value, the less antibiotic was required to kill the organism and therefore the more appropriate the antibiotic is. Mosaicplasty Transplantation of cartilage and bone by way of a plug to fill a defect caused by osteochondritis dissecans. Multiple myeloma (plasma cell myeloma) A malignancy beginning in the plasma cells of the bone marrow. Plasma cells normally produce antibodies to help destroy germs and protect against infection. With myeloma, this function becomes impaired, and the body produces anomalous immunoglobulins (Bence Jones protein), which are ineffective against infections. Symptoms include skeletal pain (especially in the back and thorax), renal failure, and recurrent bacterial infections. Symptoms include fatigable weakness and ocular problems (ptosis, diplopia, drooping eyelids). Neurofibromatosis (von Recklinghausen dz) A familial condition characterized by nervous system, muscles, bones, and skin changes. Six or more café au lait spots greater than 15 mm in diameter, or greater than 5 mm in the prepubertal patient 2. A first-degree relative with neurofibromatosis type 1 Neurolysis Freeing up of a nerve. Neutral triangle The neutral triangle is an area of sparse trabeculation in the calcaneus. This triangle lies just inferior to the anterior edge of the posterior talar articular facet. Orthotripsy A treatment for plantar fasciitis whereby sound waves cause injury to the tissue in the area, thereby causing them to heal themselves and reducing the inflammation that created the pain. Osteomalacia A condition marked by softening of the bones with pain, tenderness, muscular weakness, and loss of weight resulting from a deficiency of vitamin D and calcium. Paget disease A focal disorder of bone metabolism in which all the elements of bone remodeling are increased resulting in bony enlargement and deformities. Symptoms include an enlarged skull, bowing of the long bones, and pathologic fractures. Parabens have been shown to be sensitizing agents and may cause allergic reactions in some patients. Pedorthist A person skilled in the design, manufacture, fit, and modification of shoes and related foot appliances.
Answer: B—A fnger stick hemoglobin level test does not require extensive training safe 160 mg malegra dxt plus, preparation buy 160 mg malegra dxt plus overnight delivery, or interpretive skills to perform and is therefore malegra dxt plus 160mg line, considered a waived test order malegra dxt plus 160 mg with visa. Waived tests are simple tests with an insignifcant risk if an incorrect result is reported. Nonwaived tests require personnel with a higher level of training since these tests are moderately or highly complex. All the other choices (Answers A, C, D, and E) include nonwaived tests performed by immunohematology laboratories that are either of moderate or high complexity based on a scoring system, which is centered on the need for training required in order to perform the test and interpret the results. Waived tests are generally less complex than nonwaived tests and do not generally require extensive training to perform (Answer A). You are the blood bank director of an academic medical center that performs platelet crossmatch studies. Today you fnd out that a testing reagent used in this test is being temporarily taken out of production by the manufacturer. Without this reagent available, you subsequently send your samples for platelet crossmatch studies to a reference laboratory which uses a different reagent. An apheresis platelet donor calls the day after her donation to report that she had taken aspirin in the morning prior to donation B. A hospital transfusion service is made aware by the manufacturer of the antibody screening cells that it is an impure product and cannot be used C. A manufacturer of a blood infusion set notifes its end-users that the flter contains inappropriately placed flter material which may be infused into the patients D. A regional blood center retrieves a donor’s donation history to investigate a possible case of transfusion-transmitted hepatitis E. A regional blood center reports lack of assurance that plasma collected over the past 3 days was done in an aseptic manner and the product has already been distributed Concept: Hospitals and other organizations receiving blood and blood components from blood centers rely on the blood centers to promptly report any products that deviate from collection, 56 3. The type of method used to regain control of the product that has already been distributed is either through a product recall or a market withdrawal. Assessing the severity of the violation and the impact it may have on the products’ recipients will help to categorize the event. Answer: A—An apheresis platelet donor informing the donor center the following day after donation about an antiplatelet drug, an event that the donor center could not have known prior to donation unless the donor disclosed it to them. This platelet product is therefore considered to be in minor violation of the law and market withdrawals are required of such products. Postdonation information from donors are often beyond the control of the blood center and are the most common reasons for market withdrawals of blood components. The method of removal of these products from the market is by product recall which applies to distributed products only. An effcient quality management system for timely recall of the products known or suspected to be nonconforming is of utmost importance. There should be written protocols, with all activities described in detail and responsibility of those involved in the process precisely defned. They should be regularly reviewed, revised, and approved by the manager or medical director. Product recalls involve about 1 in 5800 blood components in the United States and are much less common than market withdrawals. Lookbacks are a review of a donor’s donation history to ascertain whether there are products from previous donation that would require quarantine, further testing and/or notifcation of transfusion facilities and recipients. A red blood cell unit with no volume on the label but the weight is present on the label B. A granulocyte unit is labeled with a 3-day expiration date from time of collection D. A frozen red blood cell unit that was not labeled as deglycerolized red blood cells post thawing E. Answer: E—A fresh frozen plasma unit that is labeled with the right expiration date but does not show the collection date is not a reportable event because the safety, purity, or potency of the product is not affected. A red blood cell unit that expired the previous day was issued by the hospital transfusion services and the unit was transfused without any events. Accident Concept: The services provided by a hospital blood bank must fulfll specifc requirements, which may be defned by federal law or by practice standards established by the facility or accrediting agencies (e. A blood bank that does not follow standard operating procedures and deviates from written procedures is not in compliance with these requirements. Answer: B—The red blood cell unit that expired should have been discarded and never issued according to regulations/policies for expired blood products. This event is considered a nonconformance, as it is a failure to meet established requirements. Though it may have been an “accident” (Answer E), the hospital must have policies and procedures in place to prevent such occurrences. The severity of the incident does not meet the criteria for a disaster (Answer A). A missed event (Answer C) would have occurred if the unit was detected prior to being transfused to the patient. In contrast, the case mentioned earlier represents a near-missed event, since it did not adversely affect the outcome, but could have resulted in a potentially serious adverse event. An adverse event (Answer D) would have occurred if the patient who received the expired unit had a complication directly related to the transfusion. Adverse events may occur in relation to donation, a transfusion, or a diagnostic or therapeutic procedure. The donor room staff failed to use aseptic technique prior to collection of a whole blood unit resulting in having to discard the unit B. The blood center accidentally distributed a collected red cell unit with repeatedly reactive viral markers but the mistake was identifed by the hospital blood bank before release C. Transfusion of a platelet unit that was expired with no adverse patient outcome D. A batch of red cell units had to be discarded as the storage refrigerator temperature reached above the 1–6°C range for 4 h over the weekend E. The determination of whether this deviation from accepted policies, processes, and procedures is a sentinel event or a nonconforming event depends predominantly on whether or not it is associated with patient injury. Answer: E—The Joint Commission defnes a sentinel event as a patient safety event that reaches the patient and results in either death or permanent harm or temporary harm. A hemolytic transfusion reaction resulting from a major incompatible blood group transfusion, regardless of whether an injury to a patient occurs is an exception to the earlier defnition and is considered a sentinel event 58 3. All sentinel events need to be reviewed by the hospital or the facility where it occurred and a root cause analysis needs to be performed followed by an action plan to prevent this event from occurring again. This comprehensive systematic analysis and action plan describing the hospital’s risk reduction strategies postsentinel event need to be submitted within 45 business days of the event or becoming aware of the event. The other choices (Answers A, B, C, and D) are nonconforming events that could have become sentinel events if the affected blood products were transfused and led to adverse patient outcomes. Shortly after receiving a third unit of red blood cells, a 95-year-old male with congestive heart failure had severe respiratory distress and succumbed to respiratory failure. As soon as possible followed by a written report within 3 days, including measures taken to avoid recurrence B. As soon as possible followed by a written report within 7 days including measures taken to avoid recurrence D. A 7-day follow-up written report sent either by email, fax, or express mail is required. There is no required form or format to use but specifc details, such as your name, institution name, date of transfusion, blood component implicated, name and address of facility providing the blood, and brief description of the events surrounding the fatality are some of the details that are helpful for the ensuing investigation. The 7-day report should provide additional fndings or conclusions, if available, from the institution’s own investigation. The other choices (Answers A, C, D, and E) do not represent the correct timeframe and/or sequence of events. A junior blood bank technologist issued 1 unit of red blood cells without a crossmatch even though the patient had a positive antibody screen. The problem was discovered after a few days when a suspected delayed hemolytic reaction was being investigated. The technologist along with the rest of the team created a diagram looking at potential problems with materials, methods, environment, or human factors that may have contributed to this error. Repetitive why Concept: Root cause analysis helps assesses a process and attempts to identify faults in the process to make it a better one.
Encephalitis311 (May be infectious or immune-complex mediated)312 – Amebic (Naegleria fowleri cheap malegra dxt plus 160mg overnight delivery, See Chapter 10 buy 160mg malegra dxt plus with mastercard, Amebiasis discount malegra dxt plus 160mg with amex. The first dose of dexamethasone is given before or concurrent with the first dose of antibiotic; probably little benefit if given $1 h after the antibiotic order malegra dxt plus 160 mg overnight delivery. With the efficacy of current pneumococcal conjugate vaccines, primary bacterial meningitis is uncommon, and penicillin resistance has decreased substantially. Shunt infections:The use of antibiotic-impregnated shunts has decreased the frequency of this infection. Cefepime, meropenem, or ceftazidime should be used instead of ceftriaxone if Pseudomonas is suspected. Antimicrobial Therapy According to Clinical Syndromes Antimicrobial Therapy According to Clinical Syndromes J. Intrathecal therapy with aminoglycosides not routinely necessary with highly active beta-lactam therapy and shunt removal. Antibiotic susceptibility testing will help direct your therapy to the narrowest spectrum agent. Antimicrobial Therapy According to Clinical Syndromes Antimicrobial Therapy According to Clinical Syndromes K. Resistance eventually develops to every antibiotic; follow resistance patterns for each patient. Appendicitis (See Table 6H, Gastrointestinal Infections, Intra-abdominal infection, Appendicitis. Antimicrobial Therapy According to Clinical Syndromes Antimicrobial Therapy According to Clinical Syndromes L. For low-risk patients with negative cultures and close follow-up, alternative management strategies are being explored: oral therapy with amox/clav and ciprofloxacin may be used, cautious discontinuation of antibiotics (even in those without marrow recovery). Aminoglycosides should be avoided because they potentiate the neuromuscular effect of botulinum toxin. Antimicrobial Therapy According to Clinical Syndromes Antimicrobial Therapy According to Clinical Syndromes L. For persisting arthritis after 2 defined antibiotic treatment courses, use symptomatic therapy. Newer data suggest toxicity of antimicrobials may not be worth the small clinical benefit. Antimicrobial Therapy According to Clinical Syndromes Antimicrobial Therapy According to Clinical Syndromes L. When sufficient data are available, pediatric community isolate susceptibility data are used. Nosocomial resistance patterns may be quite dif- ferent, usually with increased resistance, particularly in adults; please check your local/regional hospital antibiogram for your local susceptibility patterns. Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens D. Gastrointestinal Stop the predisposing antimicrobial therapy, Infections, Clostridium if possible. Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens D. Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens D. For prophylaxis following exposure: rifampin or ciprofloxacin (ciprofloxacin-resistant strains have now been reported). Consider treatment for those at higher risk of invasion (,1 y [or, at highest risk, those ,3 mo], immunocompromised, and with focal infections or bacteremia). Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens D. Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens Preferred Therapy for Specifc Bacterial and Mycobacterial Pathogens D. Preferred Therapy for Specifc Fungal Pathogens Preferred Therapy for Specifc Fungal Pathogens B. Early initiation of div q12h as a maintenance dose for children 2–12 y therapy in patients with strong suspicion of disease is or 12–14 y and weighing ,50 kg. Younger children These are only initial dosing recommendations; (especially ,3 y) often have lower trough continued dosing in all ages is guided by close voriconazole levels and need much higher dosing. Dosing of isavuconazole in trough concentrations $1 mcg/mL), or using children is unknown. The addition of anidulafungin to voriconazole as combination therapy found some statistical benefit to the combination over voriconazole monotherapy in only certain patients. If combination therapy is employed, this is likely best done initially when voriconazole trough concentrations may not yet be appropriate. Routine antifungal susceptibility testing is not recommended but is suggested for patients suspected of having an azole-resistant isolate or who are unresponsive to therapy. Preferred Therapy for Specifc Fungal Pathogens Preferred Therapy for Specifc Fungal Pathogens B. Curvularia, Exophiala, div q12h as a maintenance dose for children 2–12 y These can be highly resistant infections, so strongly Alternaria, and other or 12–14 y and weighing ,50 kg. In children $15 y recommend antifungal susceptibility testing to guide agents of or 12–14 y and weighing. It is critical to continued dosing in all ages is guided by close monitor trough concentrations to guide therapy due monitoring of trough serum voriconazole to high inter-patient variability. Itraconazole loading determined 5 days after start of therapy to ensure dose (double dose for first 2 days) is recommended adequate drug exposure. For blastomycosis, in adults but has not been studied in children (but maintain trough itraconazole concentrations likely helpful). Itraconazole div q12h and take with cola product to increase loading dose (double dose for first 2 days) gastric acidity and bioavailability. A fluconazole loading dose is 5–7 days among patients who have isolates that are standard of care in adult patients but has only been susceptible to fluconazole, who are clinically stable, studied in infants56—it is likely that the beneficial and in whom repeat cultures on antifungal therapy effect of a loading dose extends to children. Therapy should continue until lesions resolve on repeat imaging, which is usually several months. Preferred Therapy for Specifc Fungal Pathogens Preferred Therapy for Specifc Fungal Pathogens B. Role of flucytosine in neonates with meningitis is Central venous catheter removal is strongly questionable and not routinely recommended due recommended. Alternatives also include miconazole mucoadhesive Esophageal disease always requires systemic antifungal buccal 50-mg tablet to the mucosal surface over the therapy. Removing Foley catheter, if present, may lead to a spontaneous cure in the normal host; check for additional upper urinary tract disease. Preferred Therapy for Specifc Fungal Pathogens Preferred Therapy for Specifc Fungal Pathogens B. Itraconazole oral solution provides greater and more reliable absorption than capsules and only the oral solution should be used (on an empty stomach); serum concentrations of itraconazole should be determined 5 days after start of therapy to ensure adequate drug exposure. Maintain trough itraconazole concentrations 1–2 mcg/mL (values for both itraconazole and hydroxyl-itraconazole are added together). Isavuconazole initial therapy for several weeks until clear experience in adults is increasing. Watch for relapse up to 1–2 y response to azole, use intrathecal AmB-D after therapy. Adjunctive corticosteroids in meningitis has resulted in less secondary cerebrovascular events. Itraconazole oral solution provides greater and more reliable absorption than capsules and only the oral solution should be used (on an empty stomach); serum concentrations of itraconazole should be determined 5 days after start of therapy to ensure adequate drug exposure. Maintain trough itraconazole concentrations 1–2 mcg/mL (values for both itraconazole and hydroxyl-itraconazole are added together). Preferred Therapy for Specifc Fungal Pathogens Preferred Therapy for Specifc Fungal Pathogens B. In children $15 y consultation with a pediatric infectious diseases (and its asexual form, or 12–14 y and weighing. It is critical to for children 2–12 y and at least 400 mg/day div bid monitor trough concentrations to guide therapy due for children.
In case of codominance buy malegra dxt plus 160mg overnight delivery, segment 4a is part of the right coronary cheap 160 mg malegra dxt plus free shipping, and the distal left circumﬂex ends as a posterolateral branch (4b) after giving oﬀ two marginal branches purchase malegra dxt plus 160 mg online. Volume-rendered image (Panel A) and multiplanar reconstructions (Panels B and C) of the left anterior descending coronary artery in a 47-year-old male with atypical chest pain purchase 160mg malegra dxt plus fast delivery. The patient had no coronary artery stenoses but did have dilating coronary artery disease. There is some focal myocardial bridging, and the right and left circumﬂex coronary arteries were also dilated (not shown) 155 10 10. Excluding the arrhythmic peaks and using only the typical R-wave peaks for editing (arrowheadsinPanel F) greatly improves the images of both the right (Panel B) and the left (Panel D) coronary artery system. The right-hand cornerinsetsin (Panels E and F) show the unedited and edited heart rate courses over time that were used for image reconstruction. Axial, coronal, and sagittal images are the pri- of the percent diameter stenosis (based on reference and mary source of information stenosis diameters, Fig. Curved multiplanar reformations are convenient Continuously improving automatic vessel detection for identifying stenoses and segmentation tools are available for the creation 3. Tese automatic overview of vessels and lesions but may obscure sofware tools are currently available on all commercial stenoses and overestimate calciﬁed lesions workstations and allow diagnostic accuracy to be main- 4. Angiographic emulations and three- dimensional tained while relevantly reducing analysis time. When renderings may be used for elegant display and using one of the currently available reconstruction tools, presentation of ﬁndings however, the user must be aware of two limitations of automatic segmentation that can lead to false-positive or false-negative lesions: First, the automatic vessel prob- Compared with the source images, all other recon- ing tools do not always entirely follow the course of the structions such as curved reformations, maximum- coronary vessels (especially if these are very tortuous). This wide view can be benefcial in detecting rienced readers, curved multiplanar reformations alone abnormalities such as short coronary stenoses or wall are not recommended but should be supplemented by irregularities (Fig. Also, reconstructed images can interactive double-oblique reformations along the ves- be useful for demonstrating results during multidisci- sels. Printouts showing the recon- detection is that the most proximal segment of the coro- structed coronary arteries can be sent to the referring nary artery may not be completely probed. Signifcant physicians as summaries of image fndings and images proximal stenosis can thus be missed if one looks only stored in the picture archiving and communication sys- at the automatically probed vessel segments. However, tem can be used for demonstration in interdisciplinary this limitation is also easily overcome by manually conferences. Tese are currently being validated for Curved multiplanar reformations are generated using a clinical use and may have the potential to be used as a centerline along the coronary vessel path and show large second reader to increase sensitivity, especially when a parts of the coronary vessel lumen in a single image less experienced reader is interpreting the scan. Depending on the workstation In addition to motion artifacts resulting from a rapid used, the curved multiplanar reformations may be or irregular heartbeat, heavily calcifed coronary seg- rotated around their centerlines, thereby rotating the ments pose the greatest challenge because they obscure coronary artery lumen around its longitudinal axis and the coronary artery lumen (Fig. In contrast, this 75 % diameter stenosis (as measured on quantitative coronary angiography) is easily detected on a curved multiplanar reformation (arrow on Panel J ), demon- strating the advantage of such reconstructions along the vessel course. Curved multiplanar reformations allow estimation of the percent diameter stenosis from two perpendicular directions along the long axis or from orthogonal cross-sections and also the detection of coronary artery plaques, with evaluation of their composition. Maximum- intensity projections give a nice overview of the entire vessel but may obscure stenoses because of their projectional nature. Three- dimensional reconstructions provide an overview of long segments of the coronary arteries but should not be used for reading cases. Right coronary artery with a high-grade stenosis at the crux cordis (arrow and asterisk in the perpendicular longitudinal views in Panel A). The reference vessel diameter is measured proximal and distal to the lesion, and the stenosis diameter is measured within the lesion on orthogonal cross-sections (squared insets in Panel A). From these measurements (automatic or by caliper) the percent diameter stenosis (in this case 90 %) is calculated (asterisk in Panel A). A second stenosis is present in segment 2 of the right coronary artery, which was calculated to be a 75 % diameter stenosis on quantitative analysis (arrowhead in Panels A–C ). Pseudostenosis on the curved multiplanar reformation along the left circumﬂex coronary artery (arrow in Panel A) is caused by a short- track route of the automatic probing tool. This error in vessel tracking (arrowhead) is easily recognized on a maximum-intensity projec- tion (blue centerline in Panel B) and in the green centerline on a three-dimensional reconstruction (inset in Panel B). Using such a curved reformation (Panel A), proximal stenoses cannot be excluded and, as illustrated here, manual extension of the centerline to the aorta (Ao) is necessary to visualize the entire vessel (Panel B) including segment 5 (left main coronary artery). There is a nonsigniﬁcant (arrowhead, 40 %) and a signiﬁcant stenosis in the ﬁrst obtuse marginal branch (arrow, 70 %), with good correlation with conventional coronary angiography (Panel C ) ⊡ Fig. In this 82-year-old male patient, there are severely calciﬁed plaques (asterisks) along the major course of the right coronary artery (Panel A) and left anterior descending coronary artery (Panel B). The resulting blooming artifacts obscure the coronary artery lumen, rendering the aﬀected coronary artery segments nondiagnostic. These calciﬁcations were found to cause only short signiﬁcant stenoses (asterisk) in conventional coronary angiography (Panels DandE). There are additional less pronounced calciﬁcations in the left circumﬂex coronary artery (arrowinPanel c ), but these likewise preclude a deﬁnitive diagnosis regarding the presence of signiﬁcant coronary artery stenosis. Conventional coronary angiography shows moderate stenosis of the left circumﬂex coronary artery (Panel F). Using stent kernels for severely calciﬁed lesions might help to reduce the artifacts, although this approach results in higher noise levels that may also hamper evaluation. Speciﬁc window-level settings might be an option for analysis of both calciﬁed and noncalciﬁed plaques (Fig. Note that there is also a short ostial stenosis of the right coronary artery (arrow in Panels A and D). Theupper rowpresents curved multiplanar reformations along the left circumﬂex coronary artery, and the lower row presents cross-sections orthogonal to the left main coronary artery (as indicated by the direction of the arrowhead in Panel A ). Noncalciﬁed coronary plaques and outer vessel boundaries are best visualized using a window representing 155 % of the mean density within the coronary lumen and a level representing 65 % of the mean density within the lumen as described by Leber et al. The noncalciﬁed plaque in the left main coronary artery is nicely seen on the cross-section in Panel D (arrowhead), and distal vessel segments are depicted on the curved multiplanar reformation using these settings (asterisk in Panel A). Optimal measurement of the coronary lumen, however, is obtained by keeping the level constant at 65 % of the mean lumen density while reducing the window width to 1 (Panels B and E). Using these settings yields the most accurate measurement of the diameter stenosis in comparison to intra- vascular ultrasound (in this case 55 % diameter reduction) as shown by Leber et al. The drawbacks of these settings include the fact that distal vessel segments are not seen as well (asterisk in Panel B), and calciﬁed plaques are no longer discernible from the lumen (arrowhead in Panel E). In this situation, (3–5 mm) are very useful for quickly depicting coronary visualization of coronary stenoses can be improved by artery disease. By scrolling through a dataset of thin-slab using specifc window-level settings (Fig. The main drawback of reading Maximum-intensity projections can be varied in projec- maximum-intensity projections is that heavily calcifed tion thickness and give a nice overview of vessel stenoses present with exaggerated blooming artifacts continuity and course in a single image (Fig. Because of the projectional nature of maximum-intensity projections, calciﬁed plaques can even be overempha- sized (i. Such blooming artifacts are less pronounced on curved multiplanar reformations and standard two- dimensional images with bone-window-type settings (Fig. In this patient, conventional coronary angiography revealed signiﬁcant stenoses in all three vessels 10. Angiographic emulations look much like the interventional angiographic images, and if the List 10. Motion artifacts causing blurring dimensional reconstructions is not recommended 3. The greatest improvement introduced by the current generation scanners is that volumes with smaller section thickness in the Z-axis can be obtained. Geometric unsharpness depends on factors such as focal spot size, detector size, and scanner geom- etry. Limitations in spatial resolution cause partial vol- ume artifacts as a result of the attenuation coefcient in voxels that are heterogeneous in composition. Resulting artifacts include blooming and blurring, especially in the presence of calcifcations (Figs. Temporal resolution is the ability to resolve rapidly moving objects and is strongly related to coronary artery size and motion. If the cardiac rest phase is shorter than the scanner’s image reconstruction window, motion artifacts occur, but images usually still have ade- quate diagnostic quality if the artifacts are slight (Fig. Depending on the heart rate, image quality is generally best at mid-diastole or at end-systole (Fig. For this reason, beta blocker adminis- 10 tration is recommended to slow and stabilize the patient’s ⊡ Fig. For heart rates <65 beats per min, image qual- type of reconstruction is the striking similarity to conventional ity is usually best at mid-diastole, whereas for heart rates angiography, which helps interventionalists rapidly grasp the type >75 beats per min, the best image quality shifs to end- and location of coronary lesions before performing invasive proce- systole.