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Deowall Chattar-Cora, MD

• Department of Orthopedic Surgery
• Division of Plastic and Reconstructive Surgery
• University of Texas Health Science Center at San Antonio
• San Antonio, Texas
• Plastic and Reconstructive Surgery of Puerto Rico
• San Juan, Puerto Rico

The artists of the period were quick to fgure blindness and deafness as complex metaphors in their work erectile dysfunction treatment in kerala order viagra capsules 100 mg free shipping, in ways which have been insufciently recognized erectile dysfunction medication for diabetes viagra capsules 100 mg with visa. In the eighteenth century erectile dysfunction treatment nasal spray buy viagra capsules 100 mg, the sensualist philosophy of the Enlightenment continued this relativ ist concept of the body erectile dysfunction treatment sydney viagra capsules 100 mg without a prescription, but gave it a moral connotation elite custom erectile dysfunction pump purchase viagra capsules without a prescription. Sensualism held that the mind was formed Blindness and Art 381 directly from sensory experience and that those with difering senses had diferent minds erectile dysfunction treatment following radical prostatectomy buy viagra capsules cheap online. He frst mused on the morality of the blind, which he found wanting: I suspect them of inhumanity. What diference would there be for a blind man between a man who urinates and a man who, without complaining, was spilling blood All our virtues depend upon our manner of sensing, and the degree to which things afect us! How that of a deaf man would difer again from that of the blind, and how a being which had one sense more than us would fnd our morality imperfect, to say the least. Indeed, he went on to refect on ways in which the lack of sight could even be an advantage. He ar gued that the blind have a tactile memory in the same way that the sighted have a visual memory. The sensation of a mouth on the hand of a blind man and the drawing of it amounted to the same thing, as both were secondary representations of the original. I would reply, Madame, that they are those which are proper to a sense, to touch for example, and which are metaphorical at the same time to another sense, like sight; there was thus a double light for those who spoke to him, the true and direct light of the expression, and the refected light of the metaphor. The true blindness was not that of the visu ally impaired but of those who believed they could see like the artist but could not. For actors to accurately represent the widest range of emotions, it was essential that they themselves have no emotions. Actors constantly observed their work in order to make it appear natural and unforced. Acting was to be no one in order to be everyone, just as it is the blind spot which permits seeing. Belisarius was a Roman general who, afer many successes, lost the confdence of the 382 Nicholas Mirzoeff Emperor Justinian and was blinded by him. Belisariusblindness thus comes to have a metaphorical meaning, suggestive of his indiferent not merely to his fate but to the potential spectator. Fried in efect proposes that the picture itself postulates a certain blind ness in that it is constructed without the needs of a spectator in mind. Fried discerns a central distinction between such absorption, which is praised, and vulgar theatricality, which is to be condemned. He argues that David constructed an im age which refused theatricality, and instead opted to create a pictorial space in which the characters are wholly absorbed and unaware of the possibility of spectatorship. Such analyses run counter to the notion of the paradox, developed above, and indeed Fried noted that the late publication of the Paradox renders it less relevant for eighteenth-century art history. However, this argument cannot apply to the central example of the Belisarius, which was exhibited in the Salon of 1781. The painter leaves his can vas, just as the actor who speaks to the audience [parterre] steps down from the stage. Diderot was not afraid that the actor might communicate with the audience in general but that he might speak to the parterre, the popular audience standing in front of the stage. This group was never envisaged in the eighteenth century as being equivalent to the entire audience, as Fried translates it, but were disparaged as a rowdy, disruptive group of pleasure seekers. In the eighteenth century the parterre were able to disrupt plays to such an extent that one new production by the Comedie Francaise had to be cut from fve acts to only one and a half. It was a cliche of eighteenth-century French aesthetics that, while the public could form accurate judgments of artistic works, the parterre and its socially mixed clientele could not be equated with that public. In the frst version of the painting, it is slightly obscured by Belisariusstaf, but it is prominent in the later copy now in the Louvre. In itself, it requires a beholder, for only a spectator of the image would be in a position to read it. Furthermore, only an outside beholder would need such an inscription for all the fgures painted by David are only too aware of the identity of the general. It would be stretching credulity to suggest that the wandering, blind general carved the sign himself to attract alms. The inscription is an interpellation by David which addresses the outside spectator and calls attention to the politi cal message of the painting. In English political satire, Belisarius had been a symbol of government ingratitude and incompetence since 1710, when a pamphlet compared the then disgraced Duke of Marlborough to the Roman general. Her presence allows the soldier to drop back and recognize his former leader from a safe distance, but more importantly it gives a gendered dynamic to the painting. They are miles beyond us in sen sibility; there is no sort of comparison between their passion and ours. The unknown woman who acts out of pity for the fallen general is the counterpoint to the masculine sensibility of the soldier. But that moment must be contained and controlled in conscious refection, the masculine quality which women are held to lack. Only the spectator outside, whether it was the artist observing himself, the Salon spectator or the critic, could fully appreciate and meditate upon these diferent reactions and insights. Blindness in ancien regime art, then, called attention to the relativism and vulnerability of human sensory perception, and the paradoxical nature of artistic creation. The blind were not used as meta phors beyond the specifc limitations of their condition, but constituted an important point of reference for sensualist philosophy, as it strove to understand understanding itself. However, not long afer these words were written, philosophy took a turn away from sensualism to the more abstracted pursuit of epistemology, and medicine became inseparable from morality. In the second half of the eighteenth century, medical science began to rely on a distinction between the normal states of the body and its pathology, that is, its diseases and abnormalities. Disease, abnormality and immorality became linked in a powerful trinity which is still in force today. Georges Canguilhem has analyzed the spread of a distinction between the normal and the pathological from the frst appearance of the terms in the mid-eighteenth century to their widespread acceptance in the nineteenth century: In the course of the nineteenth century, the real identity of normal and pathological vital phenomena, apparently so diferent, and given opposing values by human experience, became a kind of scientif cally guaranteed dogma, whose extension into the realms of philosophy and psychology appeared to be dictated by the authority biologists and physicians granted it. Blindness was at once categorized as a pathological state of the body, in distinction to the normal 384 Nicholas Mirzoeff condition of sight. During the French Revolution the state appropriated the wealth of the Quinze Vingts, the charitable hospital for the blind in Paris, due to the tradition that patients said prayers for the Church and the King. Moreover, those blind persons who had formerly been in the nobility or clergy received a higher pension than others and there were suspicions of immoral conduct in the hospital. In place of royal charity, the Revolution hoped to construct a national, moral and egalitarian system of assistance for the blind, which did not entail any change in the medical care of the blind. Although there was a seemingly absolute distinction between the pathological blind and the normal sighted, it was soon blurred by further classifcation among the ranks of the pathological. As the nineteenth century progressed, it became clear that, despite the physical limitations of blindness, it was regarded as less morally debilitating than other sensory loss. The blind and deaf pupils of the state were initially housed together during the French Revolution, until political discord among their educators forced a separation in 1793. At this time, both the deaf and the blind were seen as pre-civilized beings who required the assistance of the state to render them human. As discussions of the old chestnut regarding the preferability of blindness or deafness continued, the issue was decisively resolved (by those who could see and hear) in favour of blindness. For the loss of hearing was held to entail the loss of voice and hence of thought. When the blind read Braille, they converted the dots into the pure medium of sound, which more than com pensated for its non-alphabetic character, whereas the deaf used sign language, and thought without sound. In 1840, Braille was considered arbitrary and deaf sign language had won a certain acceptance, but by 1890 it was Braille that had become acceptable and the deaf were considered pre-civilized. Nothing essential had changed in the nature of sign language and Braille in the intervening ffy years. Medico-psychology thus considered the loss of sight to be far less grievous a blow than deafness. The rise of this perceived morality of blindness from the nineteenth to the early twentieth century can also be traced in the cultural representation of blindness. Insight could only be gained because the critics were in the grip of this peculiar blindness: their language could grope toward a certain degree of insight only because their method remained oblivious to the perception of this insight. In the pur suit of clarity, insight and self-expression, successive modernist artists have deployed blindness as a key fgure for their work.

In contrast to the psychiatric survivor movement impotence 36 discount viagra capsules 100mg line, her primary focus is on this lack of access erectile dysfunction pills free trial cheap 100mg viagra capsules with amex, rather than the efects of involuntary treatment erectile dysfunction in the age of viagra buy 100mg viagra capsules with amex. Disability is something imposed on top of our impairments new erectile dysfunction drugs 2011 purchase viagra capsules cheap online, by the way we are unnecessarily isolated and excluded from full participa tion in society erectile dysfunction doctors phoenix purchase viagra capsules 100mg without prescription. What the social model may sacrifce erectile dysfunction causes heart safe viagra capsules 100mg, however, is a way of thinking in political terms about the sufering that some impairments cause. Critiquing the medical model does not necessarily preclude recognition of chronic and terminal illnesses as disabling forms of impairment. However, in practice this critique ofen functions to diferentiate people with disabilities from those who are ill. Indeed, disability studiesemphasis upon observable manifestations of impairments makes it dif fcult to know how to begin thinking about a condition like depression, which is primarily a subjective experience. While impairments ranging from cerebral palsy to blindness, spinal cord injury, or autism do not always cause sufering in and of themselves, it makes little sense for a person to say she is clinically depressed but does not sufer. A lack of social validation or understanding, although a persistent facet of her experience, seems to recede into the background of the intense and prolonged sufering in which her depression immerses her. Troughout Willow Weep for Me, Danquah describes this sufering in vivid and ofen metaphorical language, which contrasts with her matter-of-fact reports of lost friends and career opportunities. Moreover, analyses that privilege disability over impairment defect attention from the political nature of impairment itself. In junior high, she is raped by a recent high school graduate she has a crush on (120). When she confdes in her stepfather about the incident, he rapes her, too; the sexual abuse continues throughout her adolescence (124). As a young adult, un diagnosed postpartum depression coupled with physical abuse by the father of her child contribute to an episode of serious depression. Terefore, Willow Weep for Me might at frst seem to accord with the argu ments of some disability scholars who, deconstructing the impairment-disability binary, claim that impairment is a discursive production. To elucidate this process, it will be helpful to refect upon the epistemic shif that Foucault and other historians have documented in late eighteenth and early nineteenth-century medicine. With the rise of clinical medicine in the nineteenth century, the physical examination and the dissection of corpses supplanted patientsstories as the privileged modes of generating medical knowledge. Whereas the careful observation of bodily changes, the dissection of cadavers, and eventually the emerging science of bacteriology enabled nineteenth-century physicians to defne diseases like tuberculosis as distinct clinical entities, the same cannot be said of depression. Indeed, the project of solidifying depression as a bona fde medical condition is grounded in the expectation that it will one day be possible to identify specifc biological markers of the disorder and thus to demonstrate that depression is an organic disease of the brain. Instead of simply reporting a pain or displaying a rash, a fever, or a tremor, the depressed patient is most ofen subjectivized as such through the production of a narrative. Tremain does not explore the possibility, however, that the production of specifc impairment categories might have multiple, competing efects, including, paradoxically, the contestation of the assumptions on which these categories are based. By showing how the convergence of racism, sexual violence, and poverty literally made her ill, Danquah insists upon the validity of depression as a diagnostic category while at the same time contesting hegemonic accounts of its etiology. Yet Danquah nonetheless accepts the category of mental illness and makes it integral to her self-conception. Tremain accurately observes that the institutionalization of reverse discourses as identity politics movements poses signifcant dangers. Paradoxically, while the notion that Black women are uniquely equipped to endure hardship has historically served as a justifcation for their oppression, it may also have enabled their survival. Refusing any denial of her pain, Danquah unfinchingly describes the shame and self-loathing that are both symptoms and sources of her depression. This conclusion may seem at odds with one of the central messages of the disability rights move ment.

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During the deepest part of win ter erectile dysfunction doctors fort worth discount viagra capsules 100 mg without a prescription, Gunthorp adds hay and a corn-and-soybean feed to their diet erectile dysfunction treatment injection cost viagra capsules 100mg with amex. Not only does Gunthorp vastly reduce the cost of hog production compared to farmers raising hogs intensively in confinement but he also adds value and employs special strategies to market his pork statistics on erectile dysfunction purchase 100 mg viagra capsules overnight delivery. I know because I have from it erectile dysfunction medication south africa order discount viagra capsules line, I started spreading the word that this keted in pieces best erectile dysfunction doctor purchase viagra capsules paypal, with the tenderloins erectile dysfunction doctors in cincinnati buy viagra capsules from india, ribs a partially slatted building that sits empty was something else I was offering in addition and bacon easy to sell. In fact, Gunthorp takes advantage of the crowds at Gunthorp estimates whole-hog purchases Gunthorp only gives shots to his breeding the market to promote his burgeoning cater account for one-third of his sales each year. His hogs just knock down the corn once he lets them in his fields, where they eat stalk and all. Department of Agriculture or politi Greg and Lei Gunthorp my time is taken up now with marketing, or cians to improve the markets. Every five weeks, they Gunthorp believes his ability to increase his receive another 5,000 chicks, which they start Transition Advice income is unlimited. He really had a strong belief that conventional fertilizers and chemicals were harming the soil and the life that was in the soil. That means that the farm is self-sufficient in controlling pests and in producing what is needed for the nutrition of the soil. We believe that our farm management and our tillage practices, along with our rotations, will control the weeds and the pests, and provide fertility for us. The senior Johnson converted the farm to an organic operation in 1976 when Charlie was just getting out of high school. Alfalfa controls weeds and fixes nitrogen, while its deep taproots loosen the soil to improve tilth. They then broadcast rye in the fall for a green manure cover crop between the sec ond and third year. The fourth-year crop of either corn or wheat is followed by another year of soybeans. Only the crop of oats is harvested that year, with the alfalfa left to come through the following year, when the rotation begins again. So a third of For the last few years, the Johnsons have sold organic soybeans for between $8 and $14. They have tried rotational grazing on land Economics and Profitability In addition to the cropland, 90 acres are list that is too wet and too rocky for crops. The While their crop yields are comparable to ed in the federal water bank program. That cattle are divided into about six or seven dif other operations, and may even lag up to 15 usually is a ratio of one acre of water with one ferent units of 20 to 30 head each. Johnson says they receive tures are divided into paddocks, so the cattle maintain profits. Organic soybeans are their a small payment from the federal government will be on 10 to 15 acres for a couple of main moneymaker. They are just done on our own, not as part of any pro On their 350 acres of soybeans, for example, beginning to sell more of their products gram. We are able to take a crop of hay off in they make one trip to rotary hoe, followed by cooperatively through the National Farmers the fall of the year when the other crops are three cultivations. That wetlands management has made better take advantage of informational resources, habitat for wildlife. Like their father before them, the Johnsons able work experience for their futures. Edward, Nebraska Summary of Operation n 90 to 100 stocker cattle and flocks of chickens n Organic grains, popcorn, soybeans for tofu, barley for birdseed and forage turnips Problems Addressed Demanding labor requirements. Just preparing the field required up to four tractor passes, with another two to three for cultivation. The laborious work kept Glen Larson busy from sunup to sundown for much of the season. Background Larson decided to strive for maximum returns rather than maximum yields, and adjusted his operation accordingly. He diversified by planting a greater variety of crops, became certified organic and began a cattle stocker operation in a unique grazing system. Over the next decade and a half, he would try new ventures, focusing both on their outcome in the marketplace and their place in his rotation. A major change came when Larson began raising pasture and forage crops for grazing rather than har vesting grain and feeding it to confined livestock. Larson double-dips wherever possible, selling organ ic grain in the marketplace but also sending his cattle into the crop fields to graze grain stubble in con ditions carefully controlled to maintain a steady diet. Typically, he plants and the National Organic Directory from turnips provide as much nutrition as high small grains in the spring, then harvests the California Alliance with Family Farmers quality alfalfa. Key to their diet are the for times more value per acre, Larson decided across the landscape. With their larger land base, Larson compared to 6 to 8 percent figures their standards of living are about equal. Larson continues to nurture a hobby that Larson constantly reassess helps keep the operation in the black: retro es his rotation, choosing fitting farm equipment for his unique needs. He has modi soybeans for the tofu market fied planters, cultivators and harvest equip as well as popcorn. A former schoolteacher, Anita Nelson realized that many children do not know where their food comes from. Don took over the family farm, first purchased by his father in 1920, when he was 18. Anita opened Thunder Valley Inn Bed and Breakfast in 1988 when her two daughters, Kari and Sigrid, were still in high school. They acquired the property, formerly a horse ranch and riding stable, shortly before opening the inn. The animals are housed in a combination of a stanchion barn and a free-stall barn. The couple built a new milking parlor complete with a handicapped-accessible viewing room. In some winters, they let the alfalfa grow as a cover crop, then plow and plant a cash crop into it in the spring. They haul manure from the barns and spread it twice a year on the crop fields, supplement ing very occasionally with commercial fertil izer when soil tests dictate. The Nelsons have tried to minimize pesti cide use, depending instead on their rota tions to break up insect cycles. The dinners are the garden for them part time, in exchange a limited amount of land and we have to designed to inform the guests about their for a share of the produce. A regular tainment and education about the rural workers perform farm chores, such as gath entertainer tells stories and plays the accor heritage of the United States, food produc ering eggs from their flock of 50 layers or dion.

Radiographic assessment mainly relies in the evaluation of the bowel gas pattern and in the detection of extraluminal gas erectile dysfunction gel treatment discount viagra capsules 100mg otc. Furthermore erectile dysfunction best medication cheap viagra capsules 100 mg free shipping, sonography may also detect portal venous gas and pneumoperitoneum erectile dysfunction prescription medications order viagra capsules 100mg line, the latter indicative of bowel perforation erectile dysfunction endovascular treatment discount 100mg viagra capsules with visa. For example erectile dysfunction lawsuits buy cheap viagra capsules line, sonography may allow diagnosis of bowel necrosis before perforation occurs and pneumoperitoneum becomes evident on abdominal radiographs thus facilitating early intervention erectile dysfunction doctor michigan purchase viagra capsules with a mastercard. This creates up to 1260 virtual cameras each with a resolution higher than 10 microns1. For the animal studies, pre term piglets (N=11) were delivered via C-section 2 weeks before reaching full term. A search of the radiology database revealed 2180 pediatric patients who underwent imaging for suspected appendicitis, 1,982 (90. All imaging reports were reviewed and classified as positive, negative or indeterminate/equivocal for appendicitis, and correlated with surgical and pathology reports. Samples were scored as positive, negative, or equivocal for appendicitis, or non-visualized appendix. However, the percentage of nondiagnostic scans was higher for noncontrast exams (with: 26. To test the role of contrast in improving certainty of interpretation, nondiagnostic without contrast scans were re-read with addition of contrast sequences. We propose a scanning algorithm whereby an exam is initialized as a noncontrast study and reviewed by a radiologist for diagnostic quality prior to contrast administration, if necessary. With this approach, fewer children will receive intravenous contrast without deterioration in overall diagnostic quality. In general, these techniques are based on either strain or shear wave imaging, and they can easily be performed in children. To correct for T2* decay, six nominally in and out-of-phase echoes were obtained. Microvascular flow was categorized into four grades: grade 0, no detectable intratesticular flow; grade 1, one or two focal areas of flow; grade 2, one linear or more than two focal areas of flow; and grade 3, more than one linear flow. Statistical analysis was performed to compare the differences between undescended and normal testes. These parameters were also significant in multivariate analysis (area under the curve, 0. Based on these parameters, machine learning techniques (support vector machines) were used to identify critical cases based on different T1/2 thresholds that would be clinically relevant at 20, 30 and 40 min. A best-fit model was derived for each threshold using optimal morphological parameters to categorize the renal units and receiver operating characteristic curve analysis was performed. Image clips of bladder, ureters and kidneys were obtained during bladder filling and voiding. Patients voided around the catheter and transperineal urethral images were obtained. Urethral images were obtained in 40/48 patients, with urethral anatomy well shown in all 40 (21M, 19F). Renovascular hypertension accounts for between 5-10% of cases of pediatric hypertension and presents clinically with significantly elevated blood pressure, usually refractory to multiple medications. Renovascular hypertension is also associated with a variety of genetic syndromes, including neurofibromatosis type 1 and Williams syndrome. In patients with clinically suspected renovascular hypertension, imaging is employed to confirm the diagnosis, to characterize the renovascular abnormality and to guide surgical or endovascular therapy. Ultrasound with Doppler is the most frequently used initial imaging test, but has historically been thought to be unreliable due to suboptimal sensitivity and specificity. Catheter based digital subtraction agiography remains the gold standard imaging test because of its superior temporal and spatial resolution, allowing for excellent visualization of both extra-renal (aorta, main renal artery) and intra-renal vascular lesions. It is important for the diagnostic radiologist to understand the differences between pediatric and adult renovascular hypertension, and to understand the strengths and weaknesses of the different imaging modalities available, in order to help guide the treatment of these patients. Both Canada and the United States have designed curriculum that address these essential learning modules. These two educational models will be compared, contrasted, and discussed in detail. In addition, the practicing techologist must be given an opportunity to learn this new technology and to safely and effectively operate it to deliver the necessary information so that the patient can reap the benefit of this technology. This path can be challenging but if undertaken in a planned fashion, and using lessons from the field to mitigate hurdles, on the job training can produce very competent, dual licensed and credentialed individuals. The attendee will learn to classify the distribution of disease according to the craniocaudal, axial distribution and distribution relative to the secondary pulmonary lobule. They will understand how to describe radiologic abnormalities as air-space opacities, including ground glass and consolidation, nodular opacities, linear opacities and areas of decreased attenuation. This knowledge will enable the attendee to apply a pattern based approach to differential diagnosis of acute parenchymal opacities in their clinical practice. This will enable a more focused differential diagnosis that can be used to direct further evaluation and management. By analyzing the distribution of disease, characterizing the most pronounced radiologic abnormalities and incorporating the presence of ancillary findings, it is possible for the radiologist to offer a limited differential diagnosis to direct further evaluation or management. This talk will illustrate the common diseases that present with acute dyspnea and provide practical tips on the approach to diffuse parenchymal abnormalities detected on imaging. This presentation will illustrate the anatomy, proper positioning, and malpositions of the more common tubes and lines with illustrations and examples. It is imperative to adopt an aggressive approach to getting specific microbiologic diagnosis. Imaging signs must be applied with caution and it is important to consider non-infectious etiologies. The radiologist must take on the role of an image guided clinician and combine clinical, serological and microbiological data with imaging features in making a diagnosis. Traditional graduate medical education curricula have often left young radiologists ill equipped to address complex issues related to practice management, health policy and economics. Given the many leadership opportunities available for practicing radiologists, additional education and training in these areas should enhance their effectiveness as clinical and non-clinical leaders to positively impact healthcare systems through appropriate use and integration of medical imaging. This course is intended to introduce such educational opportunities at the resident, fellow, and practicing radiologist level and share the early experience of several academic and private medical centers in these pursuits. Calcified plaque is the "sclerosis" of atherosclerosis and thus is an established imaging biomarker of coronary artery disease. Importantly, it provides an accurate assessment of the presence or absence of a myocardial perfusion abnormality, yields incremental prognostic information, and contributes to therapeutic decision making. Maximizing resections more safely can improve the accuracy diagnosis, optimized treatment algorithms, and most importantly, decrease the incidence of devasting postoperative deficits associated with injury to functional brain networks. At the same time, the technique is among the available, easy to acquire, and easily translatable to clinical practice. This, in turn, can impact surgical decision making, guide intraoperative assessments, and improve post-operative outcomes. To summarize the current understanding of iodinated contrast media nephrotoxicity. To outline meaningful radiation metrics including organ dosages and the overall radiation absorbed to estimate patient risk. While best practices are evolving and sometimes incomplete, many do exist, yet there is marked departmental variation from one organization to another. This will require evaluation of current practices and comparison to nationally driven guidelines, with subsequent compliance to guidelines where they exist. Patients who have repeated reactions in this setting tend to have reactions of similar severity. Studies performed with control groups suggest that there is minimal to no increased risk of contrast induced renal failure in patients who receive iodinated contrast material; however, the control groups likely included patients at increased risk of acute kidney injury. Some errors treating contrast reactions relate to failure to administer epinephrine or using the wrong dose / wrong route. The second issue is how to transform the radiation incident on the patient into the organ doses received which are essential to understanding (any) patient risks. The final consideration is to understand the radiological significance of the radiation absorbed by the patient, and to estimate (any) radiological risks, as well as the corresponding uncertainties. Causes of inaccurate measurements will be reviewed along with strategies as to how to improve measurement accuracy. Fine needle aspiration has been the method of choice for diagnosing suspicious lesions with a sensitivity of 54%-90% and specificity of 60-96% for detection of malignant lesions. Several studies have been performed evaluating strain and shear wave elastography to characterize thyroid nodules. These studies suggest that ultrasound elastography may improve sensitivity and specificity of characterizing thyroid lesions over B-mode imaging alone. There is a learning curve for performing adequate thyroid ultrasound elastography. Both cystic lesions and calcified lesions are difficult to evaluate with elastography. There is some overlap of stiffness values between benign and malignant thyroid nodules and elastography should not eliminate biopsy of suspicious lesions based on B-mode imaging. This presentation will discuss the differences between strain and shear wave elastography, discuss technique and pitfalls in performing the examination, review the literature, and discuss published guidelines. Kidney stiffness changes can be affected by mechanical factors such as external pressure induced by the probe and intrarenal characteristics such as tissue anisotropy, which is high in renal medulla, vascularization, which is high within the cortex, and hydronephrosis. During progression of such renal parenchymal diseases, cellular density may increase, mainly during acute inflammatory phases, and the interstitial matrix may be invaded by fibrosis. All components of these tissue changes may induce an increase of renal elasticity which is not specifically related to fibrosis. Tubular, glomerular, interstitial and vascular changes may also be responsible for an increase of stiffness. This is why, further studies are now necessary before to understand the real impact of elastography measurement in clinical nephrology. Considering characterization of renal tumors with elastography, clinical experience is still limited. Preliminary results show that benign tumors seem to have lower values of elasticity than malignant ones, but, here too, more experience is also necessary. Most cases are a consequence of chronic viral disease (Hepatitis B and C) with alcoholic lever disease an important ethiological factor. The degree of liver fibrosis, and the presence of established cirrhosis confer differnet mamangement stratergies, with imaging playing an important role in the non-invasive assessment of patents with chronic liver disease. Fibrosis grading traditionally performed using the Metavir or Ishak scoring system is essentially a hiistological grading system. Ultimately the possibility to avoid a liver biopsy is the aim, if a non-invasive technique can stage the grade of fibrosis, establishing correct patient management. Liver ultrasound elastography is a developing technique that offers this possibility, with varying methods of aassessment ranging form strain methods and shear wave methods. These techniques will be explained, the status of the current standing of the techniques will be summarised, and the level of technology offered by differnet machines will be reviewed. An overall summary of the current status and the implications for clinical practice will be discussed. Issues that will be discussed include controversies in the extent of thyroid surgery and the appropriate use of radioiodine ablation in patients with thyroid cancer which is controversial in low risk and intermediate risk patients. The incidence of thyroid cancer in the United States has almost tripled since the early 1970s with unchanged mortality principally due to overdiagnosis. The extent of surgery performed for thyroid cancer is controversial especially in small cancers but only patients with complete thyroidectomy are candidates for radioiodine ablation. Recently lower doses of I-131 have been shown to be effective for radioiodine ablation of remnant thyroid tissue after thyroidectomy. High risk patients will benefit from radioiodine ablation with decreased recurrence and improved mortality. Radioiodine ablation in low risk patients is very controversial and has not been shown to improve mortality. The use of radium-223 is increasing worldwide, and new applications are being evaluated. The objectives of this presentation are: 1) Review the chemistry and mechanism of action of Ra-223. While numerous types of embolotherapies are employed by interventional radiologists for treatment of cancer, Y90 therapy is unique in its multimodality and multi-procedural nature. Not only does this treatment effect rely on deposited ionizing radiation therapy, but scintigraphic imaging is also an integral component of treatment. The differences between the two types are subtle, but there are differences in administration and manufacturer-recommended dosimetric calculation. Y90 therapy is comprised of several steps and is frequently subclassified into a "planning" phase and "treatment" phase. In the planning phase, detailed angiographic imaging is performed to delineate arterial anatomy, determine tumoral distributions, and redistribute vascular flow if indicated. Scintigraphic imaging is an integral component of this planning phase, in order to help identify angiographically occult arterial anomalies, confirm appropriate infusion site, and to quantify the hepatopulmonary shunt fraction. From this information, as well as other factors, the appropriate treatment doses can be determined. In the treatment phase(s), the Y90 dose is administered to the appropriate portions of the liver with subsequent scintigraphic imaging for confirmation. Growing data supports the use of models to capture complex anatomy including congenital heart disease requiring surgery.

References

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