OBJECTIVE: A second medical opinion can aid in the investigation of a health problem as well as in the definition of the therapeutic approach. The present study is aimed at demonstrating a process of second medical opinion by means of a web-based multispecialty system adapted for radiology. MATERIALS AND METHODS: The system was utilized by 49 residents at Universidade Federal de São Paulo, Brazil, who gave their medical opinion on 52 second opinion requests. Questionnaires were utilized as an evaluation tool. RESULTS: A total of 1704 medical second opinions were evaluated and 514 (29.1%) of them were defined as satisfactory. In 64.4% of cases, the answers of the questionnaires indicated that the images quality did not affect the diagnosis. On average, 6 minutes and 26 seconds was the time required to issue a remote second medical opinion. CONCLUSION: A process of second medical opinion by means of a web-based multispecialty system adapted for radiology has shown to be an excellent tool in the management of therapeutic approaches.

Keywords: Telemedicine, Remote consultation, Referral and consultation, Radiology, Imaging diagnosis

OBJECTIVE: The present study was aimed at developing a thermoluminescent dosimetric system capable of assessing the doses delivered to the rectum of patients submitted to high-dose-rate brachytherapy for uterine cervix cancer. MATERIALS AND METHODS: LiF:Mg,Ti,Na powder was the thermoluminescent material utilized for evaluating the rectal dose. The powder was divided into small portions (34 mg) which were accommodated in a capillary tube. This tube was placed into a rectal probe that was introduced into the patient's rectum. RESULTS: The doses delivered to the rectum of six patients submitted to high-dose-rate brachytherapy for uterine cervix cancer evaluated by means of thermoluminescent dosimeters presented a good agreement with the planned values based on two orthogonal (anteroposterior and lateral) radiographic images of the patients. CONCLUSION: The thermoluminescent dosimetric system developed in the present study is simple and easy to be utilized as compared to other rectal dosimetry methods. The system has shown to be effective in the evaluation of rectal doses in patients submitted to high-dose-rate brachytherapy for uterine cervix cancer.

Keywords: Rectum, Brachytherapy, HDR, Thermoluminescent dosimetry, Uterine cervix cancer

OBJECTIVE: To develop an acceptance testing protocol for magnetic resonance imaging systems and to show which and how phantoms could be used to collect data. MATERIALS AND METHODS: The definition, procedure, analysis and the acceptation criteria were created for each of 15 selected tests. RESULTS: These tests allow the evaluation of technical specifications stated on the manufacturer's sales proposal and to establish reference values to be used in subsequent constancy tests. CONCLUSION: Future quality assurance programs in magnetic resonance imaging should consider employing tests similar or equal to the ones described in this paper.

Keywords: Magnetic resonance imaging, Quality control

Quality control tests, according to "Portaria 453/98" of the Brazilian Health Ministry, were applied in seven public hospitals of Rio de Janeiro including 29 X-ray tubes, 30 cassettes and 20 individual protection garments. These tests evaluate mainly the X-ray generator and system geometry. Other tests in the accessories were also performed, such as: cassettes, screens, viewing boxes, darkrooms and clear rooms. In the kVp tests, 55% of the equipments were disapproved in exactitude and 15% in reproducibility. Time exactitude and reproducibility were not approved in 53% and 31% of the equipments, respectively. The percentages of disapprovement were: for the HVL (half-value layer) 30%, for beam alignment 18%, for field coincidence 30%, for exposure linearity 40% and for focal spot 64%. It has also been observed that frequently the lead aprons were not kept in appropriate hangers and this procedure may cause damage to these accessories. The results of the test suggest the need of implementation of quality assurance tests in these services. The cost benefit analysis of the results reinforces the importance of the implementation of the recommendations contained in this paper.

Keywords: Quality assurance, Quality control, Radiodiagnostic

In view of the great importance of quality control in radiotherapy services, this paper aimed primarily to evaluate the tests recommended by international protocols TG40 and ARCAL XXX for teletherapic equipments (cobalt, linear accelerator and simulator). A second objective was to evaluate the tests currently used in some radiotherapy services in Brazil and Latin America and to compare these tests with the ones recommended by the international protocols. Our results suggest that ARCAL is more complete than TG40, although the latter includes all the essential basic tests. We concluded that radiotherapy services should implement all basic quality control tests and that all other complementary tests should be implemented according to the need of each service. Finally, suggestions of protocols are presented, elaborated from the official and routine protocols used.

Keywords: Teletherapy, Protocols, Quality control

We present the results of a study for the development of a computational program for the evaluation and control of medium size medical radiological facilities in agreement with the recent guidelines of radiological protection of the Brazilian Ministry of Health. The routine procedures of the Radiology Department of Hospital São Vicente de Paulo, Passo Fundo, RS, Brazil, were analyzed and a computer program was developed using Windows tools. The program named "Sistema Radiológico" (Radiological System) was implemented and tested with data and measurements. The results proved that the methodology employed allows fulfillment of the requirements of the Directive nº 453 of the Brazilian Ministry of Health, and moreover, increases the efficiency of several other activities in the radiology department.

Keywords: Radiology, Quality control, Software

High dose rate brachytherapy has been increasingly recognized in most countries, and radiotherapy services using this equipment are encouraged to have a very efficient quality assurance program to ensure protection for patients, workers and other personnel involved. The objective of this paper was to determine the types of tests for high dose rate equipment required by official protocols (TG40, TG56 and ARCAL XXX) and to compare them with the types of tests utilized by some radiotherapy services. We concluded that: a) the protocol TG56 is more extensive and complete than the other official protocols (TG40 and ARCAL XXX); b) the protocols used by the services evaluated on this study were based on the protocol TG56, and were concordant with the other official protocols. In these protocols annual tests were frequently replaced by tests performed quarterly or twice a year. This study established the types of test used and their frequency of utilization, and permitted the design of an optimized protocol that may help in the implementation of basic and indispensable tests in order to ensure patient adequate treatment and safety to personnel involved, and consequently improve high dose rate brachytherapy quality assurance

Keywords: Dosimetry. Brachytherapy. High dose rate brachytherapy (HDR). Quality control

Technetium-99m labeled radiopharmaceuticals are currently the main diagnostic agents used in nuclear medicine. Radiopharmaceuticals are prepared locally through a reaction between a complexant agent (pharmaceutical) and technetium-99m. These reactions may generate impurities resulting into the production of radiopharmaceuticals with substandard quality or with different characteristics from those considered ideal. In this article we discuss some of the factors that may interfere with the preparation of radiopharmaceuticals and the quality control tests that can be used to ensure the quality of the agents.

Keywords: Radiopharmaceuticals. Generators. Technetium-99m. Quality controls.

The use of high-dose rate brachytherapy for cancer treatment is increasing and the number of patients treated in Brazil is high, considering the number of existing equipments. However, the small number of equipments is a limiting factor that bring on a lot of pressure on the working routine. For this reason, a reevaluation of emergency procedures is not carried out in most centers. This paper describes the most frequent emergency situations and suggests a code of practice when errors do not allow the return of the radiation source to the shield and result in undesirable radiation exposure to the patient and staff in remote centers for brachytherapy. We suggest training, additional caution measures and quality control in order to minimize undesirable doses.

Keywords: HDR. Brachytherapy. Remote afterloading. Radiology emergency. Quality control. Code of practice.

Objetivo: A principal utilidade da tomografia por emissão de pósitrons com 18-fluordeoxiglicose (FDG-PET) está no estadiamento do câncer de pulmão. Porém, ela também pode ser utilizada para diferenciar lesões pulmonares indeterminadas, mas seu impacto na ressecção cirúrgica de lesões benignas é desconhecido. O objetivo deste estudo foi comparar a prevalência de lesões benignas em toracotomias feitas por suspeição de câncer de pulmão, antes e após a introdução do FDG-PET, em um centro de referência de cirurgia torácica. Materiais e Métodos: Os autores analisaram, prospectivamente, uma base de dados cirúrgicos de todos os pacientes consecutivos submetidos a toracotomia por câncer de pulmão suspeito ou comprovado e compararam a prevalência de lesões benignas em dois grupos ao longo de dois anos consecutivos, respectivamente antes (grupo I) e depois (grupo II) da introdução da FDG-PET. Resultados: Ressecção cirúrgica foi feita em 1.233 pacientes durante o período do estudo. A prevalência de lesões benignas na cirurgia nos grupos I e II foi similar (44/626 e 41/607, ambas correspondendo a 7%), e também no grupo II, entre aqueles submetidos a FDG-PET e os restantes (21/301 e 20/306 respectivamente, ambos correspondendo a 7%). No grupo II, dos 21 pacientes com lesões benignas submetidos a FDG-PET, 19 tiveram um estudo falso-positivo (valor médio padrão de captação 5.3 [faixa 2.6–12.7]). Desses, respectivamente 13 e 4 pacientes tiveram broncoscopia não diagnóstica e biópsia transtorácica percutânea de pulmão antes da toracotomia. Não houve diferença na proporção de lesões benignas diferentes ressecadas entre o grupo I e aqueles submetidos a FDG-PET no grupo II. Conclusão: A introdução da FDG-PET não alterou a proporção de pacientes submetidos a toracotomia por lesões benignas, principalmente devido à avidez pelo isótopo de algumas lesões não malignas. Tais resultados falsos-positivos devem ser considerados nos casos em que se contempla a possibilidade de ressecção cirúrgica em pacientes com câncer de pulmão não confirmado.

Keywords: Tomografia por emissão de pósitrons; Tomografia computadorizada; Pulmão – lesões benignas ou congênitas; Câncer de pulmão – diagnóstico e estadiamento; Câncer de pulmão – cirurgia.

Objetivo: Avaliar a percepção de médicos residentes em radiologia de 4º ano sobre as melhores modalidades de imagem na investigação de neoplasias e trauma. Materiais e Métodos: Vinte e sete médicos residentes de 4º ano de quatro programas de residência em radiologia americanos participaram do estudo. Aos participantes foi perguntado sobre a melhor modalidade de imagem para se avaliar o cérebro e a coluna vertebral, pulmões, abdome e o sistema musculoesquelético. As modalidades de imagem disponíveis foram: RM, TC, ultrassonografia, PET e radiografia simples. Todos os achados foram comparados com os Critérios de Adequação de Exames de Imagem e Radioterapia do ACR. Resultados: A RM foi escolhida como melhor modalidade de imagem para se avaliar neoplasias encefálicas, espinhais, abdominais e musculoesqueléticas por 96,3%, 100%, 70,4% e 63% dos residentes, respectivamente. A TC foi escolhida por 88,9% dos residentes para avaliar neoplasias pulmonares. A modalidade de imagem ótima para se avaliar trauma foi a TC para lesões encefálicas (100%), espinhais (92,6%), pulmonares (96,3%), abdominais (92,6%) e grandes lesões traumáticas musculoesqueléticas (74,1%); a RM foi escolhida para lesões esportivas (96,3%). Observou-se concordância com os critérios de adequação do ACR. Conclusão: Houve concordância entre a percepção dos residentes sobre as melhores modalidades de imagem para avaliação de neoplasias e trauma e os critérios de adequação do ACR.

Keywords: Formação de residentes; Educação médica; Modalidades de imagem.

OBJECTIVE: To evaluate the quality of primary and secondary displays of conventional radiography systems based on luminance measurements. The level of ambient lighting within the rooms was also measured. MATERIALS AND METHODS: Luminance measurements were performed with an Unfors Xi Light Detector in 23 primary and 22 secondary displays (six of them utilized in emergency departments) at five different institutions, and according to the method described on the American Association of Physicists in Medicine (AAPM) TG18 report. The level of ambient lighting was measured with Delta Ohm HD 9221 lux meter. RESULTS: In general, both the primary and secondary the displays were compliant with the AAPM guidelines. As regards ambient lighting, the primary workstation rooms were slightly above the recommended levels. As far as The Royal College of Radiologists (RCR) recommendations are concerned, the number of compliant displays corresponded to a minority, with no significant difference, though. CONCLUSION: Although most of the displays could not meet the strict RCR guidelines, in general, the results were satisfactory. The level of agreement between primary and secondary displays should be as high as possible in order to guarantee the image quality. Considering the key role played by diagnostic imaging systems, medical imaging displays must be regularly evaluated to assure that the quality of the imaging system is maintained.

Keywords: Quality control; Luminance; Illuminance.

OBJETIVO: Este estudo teve por finalidade avaliar a perfusão miocárdica de pacientes com diabetes mellitus tipo 1 (DM1) e tipo 2 (DM2) assintomáticos, sem diagnóstico prévio de doença arterial coronariana (DAC) ou acidente vascular cerebral. MATERIAIS E MÉTODOS: Cinquenta e nove pacientes consecutivos (16 DM1, 43 DM2) foram submetidos a cintilografia de perfusão miocárdica com sestamibi-^99mTc (CPM). Foram avaliados quanto ao índice de massa corpórea, controle metabólico do diabetes, dislipidemia, terapia para o diabetes, hipertensão arterial sistêmica, nefropatia, retinopatia, neuropatia periférica, tabagismo e história familiar de DAC. RESULTADOS: CPM foi anormal em 25,4%: 12 (20,3%) com alterações de perfusão e 3 com disfunção ventricular esquerda isolada. Os mais fortes preditores de perfusão miocárdica anormal foram: idade igual ou maior a 60 anos (p = 0,017, odds ratio [OR] = 6,0), neuropatia periférica (p = 0,028, OR = 6,1), nefropatia (p = 0,031, OR = 5,6) e ECG de esforço positivo para isquemia (p = 0,049, OR = 4,08). CONCLUSÃO: A isquemia miocárdica silenciosa ocorre em mais de um em cada cinco diabéticos assintomáticos. Os mais fortes preditores de isquemia foram: idade avançada, neuropatia periférica, nefropatia, retinopatia e ECG de esforço positivo para isquemia.

Keywords: Diabetes mellitus; Cintilografia de perfusão miocárdica; Isquemia miocárdica silenciosa; Doença arterial coronariana.

OBJETIVO: Avaliar a completude das fissuras, resposta radiológica ao tratamento e análise quantitativa por TC (AQTC) em população de pacientes com enfisema grave submetidos ao implante de valvas endobrônquicas (VEB). MATERIAIS E MÉTODOS: Foram estudados exames de TC multidetectores de 29 pacientes, realizados com protocolo de baixo dose, cortes finos, sem contraste. Dois radiologistas revisaram, retrospectivamente, os exames em consenso. A completude das fissuras foi estimada em escala de 5% e a resposta radiológica (atelectasia/perda volumétrica do lobo alvo) foi avaliada. AQTC foi realizada nos exames pré e pós-tratamento utilizando programa completamente automático. RESULTADOS: Resposta radiológica positiva foi vista em 16/29 pacientes. Os 13 pacientes sem resposta à TC apresentavam fissuras incompletas e completude média das fissuras obliquas de 72,8%, contra 88,3% no outro grupo. Os resultados mais significativos da AQTC mostraram redução do volume pulmonar (VP) total (média de 542 ml), VP tratado (700 ml) e volume de enfisema (331,4 ml) no grupo com resposta positiva, que também apresentou melhora nos testes funcionais. CONCLUSÃO: O benefício das VEB é maior em pacientes com fissuras completas e que desenvolvem atelectasia lobar. Nos pacientes sem resposta radiológica encontramos maior prevalência de fissuras incompletas e grau de incompletude das fissuras. Nossa AQTC automática detectou as alterações pós-tratamento, principalmente considerado a análise do pulmão tratado.

Keywords: Enfisema; Terapia de colapso pulmonar; Tomografia computadorizada.

OBJETIVO: Avaliar os padrões tomográficos relacionados aos agentes etiológicos da pneumonia em pacientes durante o primeiro ano após transplante renal. MATERIAIS E MÉTODOS: Foram analisados dados de prontuários de 956 pacientes submetidos a transplante renal, no período de 2013 a 2018, em um centro transplantador renal do nordeste do Brasil. Nos pacientes que desenvolveram pneumonia, os agentes etiológicos foram classificados em bactérias piogênicas, micobactérias, fungos, vírus e pneumonia polimicrobiana, enquanto os padrões tomográficos foram classificados em consolidação, broncopneumonia, pneumonia intersticial e nódulos e massas. Para verificar associação estatística entre micro-organismos e padrões tomográficos, foi utilizado o teste exato de Fisher, com p < 0,001. RESULTADOS: Foram encontrados 101 casos de pneumonia, dos quais 60 (59,4%) tiveram agente etiológico identificado, sendo as bactérias piogênicas as mais frequentes, detectadas em 22 (36,7%) dos casos. Entre os pacientes com agente causal identificado, o padrão tomográfico predominante foi o de nódulos e massas, identificado em 25 (41,7%) casos. Foi observada associação entre bactérias piogênicas e o padrão de consolidação, fungos com nódulos e massas, bem como entre agentes virais e padrão intersticial. CONCLUSÃO: Foi demonstrada associação estatística entre micro-organismos causadores de pneumonia e padrões tomográficos, informação que pode contribuir para o planejamento da terapia de pacientes transplantados renais.

Keywords: Pneumonia; Transplante de rim; Tomografia computadorizada.