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The American Heart Association recommends therapeutic hypothermia for comatose patients with return of spontaneous circulation after out-of-hospital ventricular fibrillation cardiac arrest. While there is a growing body of evidence for the general efficacy of therapeutic hypothermia, the individualized benefit of therapy is not currently predictable. Ninety-one consecutive patients, from April 2011 to July 2014, were treated at the University of Kentucky Medical Center with the therapeutic hypothermia protocol. Medical records were reviewed retrospectively. Data, such as preexisting comorbidities, cardiac arrest characteristics, and hospital course, were used to compose a multivariate logistic regression with mortality serving as the primary endpoint. The overall in-hospital mortality was 64% (n= 58) in this group. The arrest was considered cardiac etiology in 84% (n= 76) of patients, of which 49% (n= 45) were classed as ventricular fibrillation and 9% (n= 8) as ventricular tachycardia. The presence of a shockable rhythm, as well as shorter duration of cardiac arrest, was associated with increased survival, whereas time to target temperature was not. The presence of a preexisting neurologic disease was associated with a 10-fold increase in estimated odds of mortality. Age, serum lactate, ionized calcium, arterial pH, estimated glomerular filtration rate, and APACHE score were all predictors of mortality. Cardiac arrest is a devastating condition with a high mortality rate. Given the limited resources of the resuscitation community, the ability to predict survivors based on routinely obtained measures upon admission would be of tremendous value. In this study, we show a series of admission parameters that demonstrate predictive ability in identifying patients more likely to survive with therapeutic hypothermia.

Breast cancer is the second most common cancer in women in the United States after skin cancer. Mammography remains the mainstay of cancer screening, but breast MRI has a role in screening of women at high risk of breast cancer (e.g., BRCAmutation). In women who are identified with breast cancer at diagnostic mammography and subsequent breast biopsy, breast MRI also has a role in the evaluation of the extent of disease. Typically, abnormal findings on breast MRI can be grouped into two categories—mass enhancement and non-mass enhancement (NME). Most breast imagers are comfortable with assessing radiologic-pathologic correlation in the setting of biopsy of a mass on breast MRI, but non-mass enhancement can create more uncertainty as to whether cancer is present because hormonally influenced breast tissue can appear as non-mass enhancement on breast MRI. After studying this CME activity, the diagnostic radiologist will be able to discuss the appearance of non-mass enhancement on breast MRI, principles of MRI-guided breast biopsy of non-mass enhancement, common diagnoses accounting for non-mass enhancement, and approaches to assessing radiologic-pathologic concordance of non-mass enhancement with MRI-guided breast biopsy.

Invasive pulmonary aspergillosis (IPA) is increasingly being recognized as an important infection in critically ill patients who do not have the classic risk factors of immunodeficiency. Background pulmonary disease such as chronic obstructive pulmonary disease and the administration of corticosteroids, even in the short term, may be the most important risk factors in this population. The diagnosis of IPA is extremely difficult in critically ill patients because standard guidelines for the diagnosis of IPA had been developed for immunocompromised patients and have not been validated in immunocompetent critically ill patients. A new algorithm for the diagnosis of IPA has been validated in critically ill patients, which may be useful, but is not without limitations. A high index of suspicion is therefore required. The detection of IPA on the basis of serum galactomannan antigen and the β-d-glucan assay is of little value in non-neutropenic critically ill patients. However, the lateral-flow device test may be a useful diagnostic test in critically ill patients for the diagnosis of IPA. Voriconazole remains the first-line treatment of suspected IPA and should be administered even without confirmed histologic diagnosis, which is usually not possible in critically ill patients due to the overall status of such patients.

Amyloidosis is a heterogeneous group of disorders of protein folding and shape with associated deposition of protein fragments in body tissues. Amyloidosis has an incidence of about 1 in 100,000 patients annually in the United States. Most patients are women, diagnosed between 50 and 70 years of age. Certain chronic diseases such as rheumatoid arthritis and multiple myeloma often coexist with amyloidosis, whereas other predisposing factors may be familial (genetic) or acquired, as in patients with chronic renal failure on long-duration hemodialysis. As a consequence of protein fragment deposition, organ dysfunction and failure may ensue. Throughout this process, imaging examinations may offer clues that point to a diagnosis of amyloidosis. With this CME activity, the radiologist will be able to recognize some of the potential imaging findings that may be associated with amyloidosis, thus leading to a higher level of suspicion when a patient presents with organ dysfunction because of amyloidosis.

Superior vena cava syndrome (SVCS) consists of a constel-lation of symptoms that result from some degree of obstruction of the superior vena cava (SVC). The SVC is formed by the union of the left and right brachiocephalic veins and ends with the continuation into the right atrium of the heart. The SVC's function of returning blood from the upper half of the body, and its location anterior to the trachea at the right margin of the sternum, helps explain the typical signs and symptoms of the superior vena cava syndrome. The patient with superior vena cava syndrome might complain of head-ache, dysphagia, hoarseness, or shortness of breath. Blockage of the SVC can lead to clinical signs such as upper body edema, plethora, jugular vein distension, and appearance of prominent collateral veins.

Introduction: This was a retrospective observational study of imaging used to evaluate and treat 13 U-2 pilots with neurological decom-pression sickness (DCS). Magnetic resonance imaging (MRI) and com-puted tomography (CT) provided data for screening, diagnosis, and determinations of fitness to fly after recovery. While small series and case reports described the role of imaging in diving DCS, none addressed radiology's role in aviation DCS. Methods: We performed a literature review of altitude DCS radiology studies. We then reviewed radiology images at our institution on U-2 pilots with neurological DCS between January 2002 and August 2010. We retrospectively analyzed MRI data for white matter hyper-intensities (WMHs), defined as hyperintense lesions ≥3 mm on T2 and FLAIR. All studies occurred after hyperbaric oxygen (HBO) treatment. Results: There were 17 pilots who reported 20 neuro-logical DCS incidents. Of these 17 pilots, 13 underwent imaging. Two (15%) demonstrated acute subcortical lesions on MRI, seven (54%) had asymptomatic WMHs, and six (46%) were normal. The clinical signifi-cance of the lesions is unknown. Consistent with diving DCS, imaging played no role in acute diagnosis. However, imaging was vital for deter-mining fitness for return to flying. Additionally, CT identified a poten-tially predisposing sinus condition in one pilot which may enable return to flying after treatment. Conclusions: Modern imaging has unique find-ings for altitude DCS patients. The high incidence of WMHs in this series is a matter of ongoing research to determine potential clinical conse-quences. Emerging techniques such as functional MRI may play impor-tant roles in future aeromedical decisions. [ABSTRACT FROM AUTHOR]

Cocaine is the second most abused illicit drug in the United States with 2.4 million users in 2006 (Cannabisis the leading offender). Cocaine is also the most common recreational drug resulting in emergency department visits. According to the Drug Abuse Warning Network, a public health surveillance system, there were 2.1 million drug-abuse-related emergency department visits in the United States in 2008, and more than 400,000 of these visits directly involved cocaine use. Based on the 2010 National Survey on Drug Use and Health report, the 18- to 25-year-old population accounted for nearly 45 of illicit drug use during 2010, with those aged 26 to 34 years accounting for an additional 30. These statistics are important because cocaine use can result in acute and chronic pathology involving almost every body organ system and often more than a single organ system at a time. Commonly involved organ systems include the central nervous, cardiovascular, pulmonary, gastrointestinal, and musculoskeletal. The most dramatic complication of cocaine use is sudden death, which can occur after a single-use episode. After completing this CME activity, the radiologist will be able to recognize the emergency department presentations that may be associated with cocaine use, thus leading to a higher level of suspicion of cocaine abuse when a young, relatively healthy patient presents to the emergency department.

The topic of genitourinary diverticulosis will be presented in 2 sequential issues: Part I (Volume 35, No. 12) and part II (Volume 35, No. 13). Part I will cover diverticulosis of the female and male urinary tracts, and part II will cover diverticulosis of the female reproductive system.

Part I of this 2-part series on genitourinary diverticulosis discussed diverticula of the urinary tract in women and men, and was presented previously in Volume 35, Number 12, 2012. This issue, Part II, will cover diverticula of the female reproductive system.

The sacroiliac (SI) joint is unlike most other joints in the body in that it often demonstrates early manifestations of arthropathy before other joints. The SI joint is composed of hyaline and fibrocartilage on both sides of the joint; typically, sacroiliitis will affect the iliac side of the joint first where the cartilage is the thinnest, and then progress to the sacral side.1In addition, synovial inflammation typically occurs first at the anterior-inferior aspect of the SI joint. The posterior-superior aspect of the SI articulation is a syndesmosis without cartilage, synovium, or a joint capsule.

Fat necrosis is a noncancerous inflammatory condition thought to involve a vascular insult to adipose cells.1This condition is most often encountered in the breast, abdomen, and extremities with a potential risk factor being obesity. The cause for fat necrosis in most cases is unknown, but common potential causes include blunt trauma, surgery, and radiotherapy. In cases of whole-breast irradiation, up to 30 of patients may develop fat necrosis, and up to 8 of patients present with clinical symptoms related to fat necrosis. Fat necrosis can progress, remain the same, or resolve. Fat necrosis can mimic breast cancer, both clinically and on imaging, especially in progressive cases associated with breast deformity.2–7

We report a case of a 61-year-old Filipino-American male who developed pulmonary tuberculosis after travel to the Philippines. His history, presentation, imaging findings, and clinical course are presented as well as a discussion of the interesting imaging features in his case. Our case highlights the importance of having a high index of suspicion for tuberculosis in the setting of "bronchiectatic air bronchograms" as well as the value of computed tomography (CT) imaging in pulmonary tuberculosis.

Objective: To assess the effects on lipid and lipoprotein levels of a combination therapy of matrix patch and oral sequential dydrogesterone.

This was a multicentre prospectively randomized double-blind parallel cornparison of clovoxamine (n= 37) and diazepam (n= 35) in 72 patients suffering from anxiety neurosis, in general practice. Patients were seen weekly. Treatment was for 4 weeks (50 mg clovoxamine b.d. or 5 mg diazepam b.d.) rising according to response to a maximum of 300 mg clovoxamine or 30 mg diazepam daily. Drug was tapered off in week 5 and patients were seen again in week 6 after they had been off drug for at least a week. A treatment period of 4 weeks was selected in line with WHO guidelines for the testing of anxiolytic drugs. Although more patients dropped out due to intolerance on clovoxamine (24) compared with diazepam (11), analysis of completed patients showed that clovoxamine was equally effective with significant improvement in both groups at week 4 (p< 001) compared with baseline Morbid Anxiety Inventory scores and Hamilton Anxiety Scale scores. Diazepam patients had a more rapid response which levelled off, whereas those on clovoxamine continued to improve after 2 weeks. At 6 weeks after taper off the improvement on clovoxamine was sustained whereas on diazepam there was evidence of deterioration after stopping the drug. Clovoxamine appears to have potential as an alternative treatment to diazepam for anxiety in general practice.

SUMMARYThis study examined the psychomotor and antidepressant effects of fluvoxamine in a depressed, GP patient population, compared to those of mianserin. It was a single centre, double‐blind, six‐week study, preceded by a one‐week pre‐treatment placebo washout, in 59 patients suffering from major depressive episode (DSM III) and scoring over 24 on MADRS. The starting dose was 100 mg fluvoxamine or 60 mg mianserin daily for one week, rising to 300 mg fluvoxamine or 180 mg mianserin. Both treatment groups showed significant improvement overtime with no differences between drugs in terms of efficacy. Fluvoxamine and mianserin were both shown to be effective in the treatment of depressive illness. Some psychomotor impairment in the first few days and weight gain over a longer period could affect compliance with mianserin. Fluvoxamine does not reduce psychomotor performance or cause weight gain.

SummaryA double-blind study was carried out in 62 hospital out-patients suffering from mild to moderate depression to investigate the efficacy and tolerance of fluvoxamine given as a single daily dose or in divided doses. Patients were allocated at random to receive 100 mg fluvoxamine either as a single daytime dose, a single nighttime dose or as 50 mg twice daily over a period of 6 weeks after a 1 week wash-out period on placebo. Patients were assessed using the Hamilton and Montgomery Asberg depression rating scales and the Clinical Global Impression scale before and during treatment. All three dosage regimens produced significant improvement and no significant difference was found in antidepressive effect between the groups. However, patients receiving a single night-time dose experienced fewer side-effects leading to drop-out before the end of the study than in the other two groups.

Vascular abnormalities of the breast include a wide spectrum of arterial and venous disorders, as well as benign and malignant vascular masses. Multimodality imaging is often necessary to accurately diagnose several of these uncommon conditions, and pathologic correlation can be important for accurate diagnosis of vascular masses. After a review of the vascular anatomy of the breast, the authors discuss the imaging appearance of several native arterial disorders (atherosclerosis and aneurysm) and venous disorders (superior vena cava syndrome, congestive heart failure, thrombophlebitis, and varix). Benign vascular tumors (hemangioma, lymphangioma, and angiolipoma) and malignant vascular tumors (angiosarcoma and hemangiopericytoma) that may be encountered in the breast are also reviewed. In addition, pitfalls in the correct interpretation of vascular breast lesions (devascularization of masses and pathologic mimics) are reviewed. Understanding and assessing normal and pathologic breast vasculature will permit more accurate diagnosis and treatment planning and allow breast imagers to have a more active role in breast care.