08/19/2015 General Overview of Radiology

12:30 – 13:30 Principles and Perspectives

YL6: 01.22.01 R Koa-Sales

OUTLINE ASMPH Radiology Track

I. Orientation to YL6 VI. Magnetic Resonance YL5 – Normal Radiographic Anatomy
Radiology Imaging (MRI) YL6 – Pathology: Imaging Patterns
II. Overview of A. Principles and YL7 – Pathology – Specific Findings
Radiopathologic Technique YL8 to YL9 – Patterns, Specific Findings, Differential
Imaging B. Interpretation Diagnosis
III. Conventional C. Advantages of MRI
Radiography: Plain X- D. Disadvantages of Textbooks
ray MRI Paul and Juhl’s Essentials of Radiologic Imaging
A. Principles and E. Advantages of CT Brant and Helm’s Fundamental of Diagnostic Radiology
Technique over MRI Diagnostic Imaging – Ultrasound (Amirsys)
B. Interpretation VII. Nuclear Radiology Diagnostic Imaging – Breast (Berg and Birdwell)
C. Indications A. Principles and
The Hands-on Guide to Imaging (David Howlett and
IV. Ultrasonography Technique
Brian Ayers)
A. Principles and B. Interpretation
Technique C. Advantages of
Evaluation
B. Interpretation Nuclear Imaging
C. Advantages of D. Disadvantages of Quizzes
Grade booster
ultrasound Nuclear Imaging
D. Disadvantages of VIII. Terminologies Written exam
ultrasound A. Radiography ~10 to 15 questions on the module exams (except
V. Computed Tomography B. Ultrasonography endocrine module)
(CT) C. CT Scan Practical/Oral Exam – OSCE
A. Principles and D. MRI At the end of the school year
Technique From simple positioning or placing of the plates to
B. Interpretation Review Questions proper reading/ interpretations
C. Advantages of CT Freedom Space Comprehensive exam for Radiology
D. Disadvantages of References At the end of the school year
CT
Concerns/ Problems
This trans can be divided into two parts: Approach Dr. Reza Koa Sales
Part 1 – I. Orientation to YL6 Radiology TMC Radiology Department
Part 2 – II onwards – Overview of Radiopathologic Imaging Reading Room (ground floor)
th
(lecture proper) Breast Center (6 Floor)
Mondays to Fridays, and some Saturdays
I. ORIENTATION TO YL6 RADIOLOGY
II. OVERVIEW OF RADIOPATHOLOGIC
Course Description IMAGING
Radiologic principles
May be useful for the MLE General Objectives
Very helpful in YL8 and YL9
We are lucky that we discuss radiology. Other
schools don’t.
Different imaging techniques Specific Objectives
Diagnostic imaging of common diseases Recognize normal
Patterns of radiographic findings
Enumerate modalities
The goal is to help YOU integrate your knowledge of basic
sciences with clinical diagnosis. Familiarize terminologies
(Dr. Sales’ Presentation)

Radiology Lectures Imaging Techniques

Overview
Radiation harm and benefit
Contrast media
Cardiac Imaging
Pulmonary
Gastrointestinal
Hepatobiliary
Genitourinary III. CONVENTIONAL RADIOGRAPHY:
Reproductive PLAIN X-RAY
Nervous system
Musculoskeletal Note: there are other methods of conventional
radiography aside from plain x-ray (mammography,
fluoroscopy)

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 higher density
A. PRINCIPLES AND TECHNIQUE lower density
lowest density
How is a radiograph produced? white
1. X-ray tube generates a beam of x-ray from an external
source 5 Basic Densities
2. X-ray beam is transmitted through the body (some of the 1. Air: least attenuating, most lucent, least dense material
radiation are absorbed, scattered, or pass through) (BLACK)
Note that pregnant women (near X-ray) can absorb 2. Fat
scattered rays and may cause mutations on the baby. 3. Soft tissues
3. X-rays that pass through are recorded in a detector of 4. Bone
the x-rays, producing the image (radiograph) 5. Metal: most attenuating, most dense (WHITE)
Film Note: Fluids and blood appear as white
Digital – One may alter the contrast and can zoom the
image for better viewing

Figure 3. Basic X-ray Densities. Least dense substances (air)

appear black. Densest substances (metal) appear white. Body
tissues appear as varying shades of gray depending on thickness
and density, (Image taken from 2018 Trans)

C. INDICATIONS

Figure 1. X-ray image production “Indications”

(Image taken from 2018 Trans)

Plain X-ray Chest X-ray

Most common lungs (aerated) heart
(not enlarged)

Chronic cough

Figure 4. Chest x-ray with a coin dislodged in the esophagus

Figure 2. Anatomy of the human heart (Image taken from 2018 Trans)
(Image taken from 2018 Trans)

B. INTERPRETATION

Different degrees of attenuation of the x-rays produce the

radiograph.
“Attenuate” – to reduce the force, effect, or value of
In x-rays, attenuating the beam depends on the
absorption, scattering, and transmission of the signal
through the body.
Tissues have different capacities to attenuate the signal.
White – most attenuating
Varying shades of gray – tissues of varying density
Black – least attenuating

REMEMBER: denser the tissue more x-rays

are attenuated

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 Figure 5. Abnormal chest x-ray. Large Pleural effusion (diaphragm
cannot be seen due to the pleural effusion)
(Image taken from 2018 Trans) Figure 7. Abnormal Abdominal X-ray: Ingested Nail (A) Ingested
Nail, (B) Fecal Material (Image taken from 2018 Trans)

KUB (Kidney, Ureter, Bladder) X-ray

Indications: renal calcifications
Staghorn calculi must have a stone occupying your
pelvis and at least one calyx

Figure 6. Chest x-ray (Female)

(Image taken from 2018 Trans)

Abdominal X-ray
Indications Figure 8. Abnormal calcification of calyces (Staghorn Calculi).
Ingestion of foreign bodies (Image taken from 2018 Trans)

Pelvic X-ray
Indications: obstetrics, fractures, other “behavior-related
incidents”

Figure 6. Normal Abdominal X-ray: Normal Soft Tissues à (A) Liver,

(B) Spleen, (C) Right Kidney, (D) Left Kidney, (E) Feces, (F) Normal
Bowel Gas. Both the stomach and colon appear black due to air
inside. The stomach lies in the left upper quadrant, and soft tissues Figure 9. Pelvic Radiograph. Foreign material left inside the body.
are not visible. (Image taken from 2018 Trans)

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Arm, Hand, Knee, Limbs X-ray
Indications: fracture; swelling; trauma; pain.
Only arm x-ray is shown.

Figure 11
(Image taken from 2018 Trans)

How is an ultrasound image produced?

Figure 10. Fracture of ulnar shaft with dislocation of the radial head
at the elbow. (Image taken from 2018 Trans)

IV. ULTRASONOGRAPHY

A. PRINCIPLES AND TECHNIQUE Bright highly reflective

Also known as sonography or sonogram Dark passes freely through

(ultrasonography, ultrasound are the same)
Uses high-frequency sound waves emitted from a probe
Radiation is NOT used in this imaging modality B. INTERPRETATION
Image created depends on reflecting and absorbing
properties of tissue. Ultrasound Images
Sound waves propagate through fluid and soft tissues Fat white
Sound transmission is blocked or scattered by Calcifications white
calcifications and air Fluid dark
Ultrasound is not recommended for imaging of the
lungs due to presence of air opposite
stones
kidneys gallbladder
Gastric ulcer: Should we request an ultrasound?
No, the gastric lumen is naturally filled with air – not
ideal for ultrasound.
Typical Appearance of Normal Tissue
Different organs/areas that can be subjected to
2 Skin: echogenic hyperechoic
ultrasound
Abdomen (Peritoneal cavity and retroperitoneal cavity) 3,4
Fat
Liver
Bile ducts
Gallbladder Muscle
Spleen (hypoechoic)
Pancreas
Adrenal glands
Kidneys
Uterus Fluid
Ovaries and adnexa
Testes and scrotum
Prostate
Bladder Tendons
Pleural space
Lung parenchyma Nerves
Thyroid
Parathyroid Bones
Neonatal brain

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 Cannot penetrate through bone
Tumor in bone marrow cannot be visualized
Limited body habitus – poor visualization of deep
structures in the obese because the sound waves can
only reach a certain depth.

V. COMPUTED TOMOGRAPHY (CT)

A. PRINCIPLES AND TECHNIQUE

Uses multiple, simultaneous x-rays to generate cross-

sectional images
Multiple x-ray beams in the gantry (part of CT Scan -
the rotating ring which the person passes through) are
simultaneously transmitted through the patient
In figure
Figure 12. Gallstone ultrasound
(Image taken from 2018 Trans) CT makes use of higher radiation as compared to X-ray
It shows better delineation of structures and allows for
better imaging compared to x-rays
Doppler Ultrasound Indications include trauma, stroke, massive bleeding
and brain hemorrhage
Dense structures in the body block the transmission of x-
Do not use Doppler ultrasound for the first trimester. High
rays
frequency sound may affect the baby negatively.
Vascular application Bone
patterns
venous angioma
not invasive not as expensive

velocity of moving objects

stenosis

Figure 13. Doppler ultrasound waveform of flow velocities in the

middle (Image taken from 2018 Trans)

C. ADVANTAGES OF ULTRASOUND
Figure 14. Parts of the CT Scan. The gantry is the rotating x-ray
No ionizing radiation source. (Image taken from: http://www.cogneuro-lab.org/)
Portable; can image in any plane (Depending where you
place the probe)
Real-time – good for mobile structures and guiding
drainage or biopsy procedures
Useful in obstetrics, children and vascular evaluation
It is not advisable to subject babies to CT scan despite
the advantages

D. DISADVANTAGES OF ULTRASOUND

Operator-dependent
Hard for the non-physician operator if he doesn’t know
what he is looking for
The technique is depended on the skills of the operator
Cannot image air-containing structures (ex. Stomach,
bowels)

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 Hounsfield CT density scale

Figure 15. Thorax region – part of the heart, pulmonary arteries

(A) Heart, (B) Pulmonary Arteries, (C) Lung
(Image taken from 2018 Trans)

B. INTERPRETATION C. ADVANTAGES OF CT

CT Scan Image Good contrast between tissues

Displayed on gray scale More sensitive to differences in density than plain films
Dense structures: metal and bone – white Now we can see different planes, not just axial cut
Less dense: various shades of gray Can now show 3D images
Least dense: lungs – black Not degraded by bowel gas (Ultrasound is the only one
that is degraded by bowel sounds)
Table 1. Objects of different densities and appearance on CT Scan It takes 15-30 minutes for the procedure, relatively shorter
Density Object Color than MRI
Dense Metal White
Structures Bone D. DISADVANTAGES OF CT
Less Dense Soft Tissues Varying shades of
gray High-dose procedure (= 100 – 500 CXR)
Least Dense Lungs Black Recent barium studies obscure images of the abdomen
(Air, Fat) and pelvis
Artifact caused by high-density metal in teeth and joint
Image orientation replacement may limit the diagnostic accuracy of neck
Look at the patient from below (always remember this!) and pelvic examination
Right side of the patient is on the left of image CT scans emit more radiation than plain X-rays, which is
Hounsfield unit (HU): CT numbers are assigned to each why we don’t warrant them on children
pixel in the image Younger tissues are more susceptible to radiation, which
is the reason why radiologists don’t allow young women to
Hounsfield Scale have a mammography
Important for radiologists, because it helps you identify
what the lesion is.
Air:
Fat:
Water: 0 HU
Soft tissue:
Bone:
For instance, you have a mass and you are not sure
whether it is a calcification or soft tissue. If you get a value
of +78 HU, you will now be certain that it is soft tissue.
5
Hounsfield scale relevance in diagnostics
During a CT acquisition, the scanner records the relative
radiodensities of the object in the scanner's Field of View
(FOV); however the radiodensities differ for each scan, Figure 16. Cerebral CT, axial reconstruction. 1, Superior frontal
depending on the acquisition and reconstruction parameters. gyrus. 2, Lateral ventricle. 3, Caudate nucleus. The spaces are filled
Thus, these density values cannot be compared among with CSF, so they should appear dark
reconstructions. To correct for this, un-calibrated data can be (Image taken from 2018 Trans)
quantified according to the Hounsfield scale, which is a
standard density scale measured in Hounsfield Units (HU)
where air is estimated at -1000 HU, water at 0 HU and bone
tissue at +1000 HU. Once the data is calibrated to the HU
scale, the density values recorded in a CT image can be
objectively compared to other HU calibrated images.

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 Note: T1 and T2 studies will be further and better discussed
in the upcoming lecture. Just to give an overview, the
following are presented. “FYI only.”

Bright on T1
Fat
Blood (methemoglobin)
Proteinaceous material
Melanin
Gadolinium (MR contrast agent)
Dark on T2
Calcium
Gas
Chronic hemorrhage (hemosiderin)
Mature fibrous tissue

Figure 17. Brain structures – brain mass. The image is abnormal

because there is a large mass impinging the lateral ventricle,
pushing them to the contralateral side.
(Image taken from 2018 Trans)

VI. MAGNETIC RESONANCE IMAGING (MRI)

A. PRINCIPLES AND TECHNIQUE

Produces images by means of magnetic fields and radio

waves
Radiowaves excite the protons to align with the magnetic
field. After some time, the excited state returns to the
Figure 19. Axial MRI – T1 (left) vs. T2 (right)
normal state and this releases signals which are then (Image taken from 2018 Trans)
captured by the machine.
Tissues are differentiated by characteristic T1 and T2 C. ADVANTAGES OF MRI
relaxation times
There are 2 types of MRI:
Outstanding soft tissue contrast
Open-type
Better in soft tissue detail compared to CT scan
Lower resolution compared to the closed-type
Multiplanar imaging capability
Closed-type
Coronal and sagittal cuts
issues of claustrophobia ensue
NOTE: CT Scan can only produce axial cuts. It is
through software rendering that CT becomes
multiplanar.
Better anatomic detail
No ionizing radiation
Even pregnant women can be treated to this imaging
modality
Use of contrast media is not essential to visualize vascular
structure
Can give additional functional information (aside from
anatomic info) depending on present machine technology

D. DISADVANTAGES OF MRI

Limited in demonstrating dense bone detail or

Figure 18. Basic principle of MRI calcifications
(Image taken from 2018 Trans)
Unable to visualize cortical bone
Long imaging times
Long waiting times lasting 30 minutes – 1 hour
Limited availability in some areas
Expensive
The average price in the Philippines is Php 10,000 to
Php 20,000
Problems with claustrophobia
Figure 19. Closed MRI vs Open MRI
May become a serious problem because there are
(Image taken from http://www.amerimedimaging.com/)
some patients who do not proceed with the procedure
even if they have already paid because of
B. INTERPRETATIONS
claustrophobia
Contraindicated in patients with metallic implants
Fat – bright on T1 and less bright on T2
Water – dark on T1 and bright on T2
E. ADVANTAGES OF CT OVER MRI
Mnemonic: “WWII” – water appears white on T2

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 Superior to MRI for evaluating calcified or ossified Cold Spots
abnormalities of the musculoskeletal system Areas of less intensity
Less expensive Smaller concentration of accumulated radiotracers
Faster study Some disease processes lead to exclusion of
No problems with claustrophobia radiotracers.
Indicates relatively lower physiological function, chemical
VII. NUCLEAR IMAGING and/or metabolic activity

A. PRINCIPLES AND TECHNIQUES

Basic Principle
Detection of the biodistribution of radiotracers that
have been administered to the patient (injected,
swallowed, or inhaled)
Provides physiologic and functional information on the
presence or absence of disease
The body is the one emitting radiation

Note: Nuclear imaging was discussed very lightly. It is better

just to have a background on for future references.

Types
6
Bone scan or bone scintigraphy Figure 20. Comparison of CT, PET, and PET/CT Scan.
Shows areas of increased or decreased bone turnover (Image taken from 2018 Trans)
(metabolism)
Used to detect bone tumor, spread of cancer to the B. ADVANTAGES OF NUCLEAR IMAGING
bones
Used to detect bone infection like osteomyelitis Provides functional information such as rates of
Used to evaluate metabolic disorders (e.g. metabolism or levels of various other chemical activity
osteomalacia, osteoporosis) Give true functional and physiological detail depending
SPECT = single photon emission computed on how much of the tracer is absorbed
tomography Less expensive than exploratory surgery
Type of nuclear imaging test that shows how blood May detect the early onset of disease before it is evident
flows to tissues and organs on the other imaging tests such as CT or MRI
The tracer stays in your blood stream rather than being
absorbed by surrounding tissues, thereby limiting the C. DISADVANTAGES OF NUCLEAR IMAGING
images to areas where blood flows
Cheaper and more readily available than higher Poor anatomic resolution, depicting physiologic
resolution PET scans processes within the body, instead of showing anatomy
PET = positron emission tomography and structure
Measures important body functions, such as blood High dose (= 50 to 200 CXR)
flow, oxygen use, and sugar (glucose) metabolism, to Limited by availability of radionucleotides
help doctors evaluate how well organs and tissues Patient needs to lie relatively still for long periods
are functioning Time-consuming
PET-CT Long waiting time. It takes days before the material starts
Combined PET/CT scans provide images that pinpoint emitting radiation
the anatomic location of abnormal metabolic PET-CT is very expensive. It could cost Php120,000
activity within the body You combine imaging of PET scan and CT scan
CT scan is superimposed on the PET study. Makes it
easy to identify specifically the location of the VIII. TERMINOLOGIES
abnormality
7,8 Terms used to describe lesions: usually refers to the
INTERPRETATIONS :
signal of a pathologic process relative to surrounding
Nuclear Imaging is an imaging procedure as a means of
tissues
diagnosing certain medical conditions in a non-invasive
(except for intravenous injections) way with the use of
radioactive materials (radiopharmaceuticals/radiotracers) A. RADIOGRAPHY
which are injected, swallowed or inhaled by the patient. (OPAQUE/DENSE/LUCENT)
Unlike other imaging techniques which are centered on
anatomy, this focuses on physiological process of the Opaque/dense/hazy – white
body. Lucent – dark or less dense
The term dark is not usually used in x-rays
Hot Spots
Areas of greater intensity
Focal increase accumulation of large amounts of
radiotracers
High levels of physiological function, chemical and/or
metabolic activity

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 Figure 21. Opaque vs. Lucent
Left: lodged coin appears opaque/dense on X-ray.
Right: X-ray of head in the lateral view, lucent density indicates
metastasis. (Image taken from 2018 Trans)

B. ULTRASONOGRAPHY (ECHO)

Anechoic – no internal echoes black Figure 24. Ultrasound of thyroid with hypoechoic nodule
Hyperechoic/echogenic – bright echoes white (Image taken from 2018 Trans)
Hypoechoic – dark echoes gray to black
C. CT SCAN (DENSITY)

Isodense – same as surrounding structures

Hyperdense – bright
space-occupying lesion
Hypodense – dark
infarct

Figure 22. Breast ultrasound showing anechoic cyst

(Image taken from 2018 Trans)

Figure 25. CT scan, axial section of upper abdomen (liver, spleen),

isodense parts (Image taken from 2018 Trans)

Figure 23. Gallbladder ultrasound showing hyperechoic

gallstones (Image taken from 2018 Trans)

Figure 26. CT scan of abdomen, contrast study, hypodense

(arrows) (Image taken from 2018 Trans)

D. MRI (INTENSITY)

Hyperintense – bright/white
Hypointense – dark signal
Isointense – same as brain parenchyma

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Figure 27. Magnetic resonance imaging of spine, T1W (a), T2W (b),
and STIR (c) images. There is a well - defined lobulated
intramedullary mass expanding the dorsal spinal cord. The cranial
cystic component (M) is hypointense on T1W and hyperintense on
T2W and STIR images. The caudal component (arrows) is
hyperintense on T1W, T2 W images and shows suppression on
STIR images consistent with fat (Image taken from 2018 Trans)

E. NUCLEAR IMAGING (HOT/COLD SPOTS)

Areas of greater intensity, or hot spots - indicate where

large amounts of the radiotracer have accumulated and Figure 26. Monitoring responses to pelvic recurrence and liver
where there is a high level of chemical or metabolic metastases. Three PET/CT scans were obtained in a 55-year-old
activity woman five months after rectal cancer resection. A: PET/CT
Dark color demonstrated a locoregional recurrence and liver metastasis foci
Less intense areas, or cold spots - indicate a smaller (arrows) before salvage treatment; B: PET/CT showed obvious
decreasing of intense activity after two cycles of chemotherapy
concentration of radiotracer and less chemical activity
(arrows); C: After six cycles of chemotherapy, PETCT imaging
Light color follow-up revealed good control of pelvic recurrence and liver
metastases (arrows). (Image taken from 2018 Trans)

REVIEW QUESTIONS

1. Jojo was involved in a motorcycle accident. He hit his

head on the pavement but fortunately he was wearing
a helmet. He was immediately rushed to the ER. What
imaging technique can be used to check if Jojo
sustained any head injury?
a. X-Ray
b. Ultrasound
c. CT scan
d. MRI
2. Jaja was sleeping when she incidentally swallowed a
coin as she moved through her sleep. The
independent lady rushed herself to the ER. Which of
the following describes her MRI:
a. Hypointense
b. Isointense
c. Hyperintense
d. MRI is not the appropriate radiographic technique
Figure 28. A nuclear medicine whole-body bone scan. The nuclear 3. Jeje feels something weird in her chest. Upon
medicine whole-body bone scan is generally used in evaluations of consultation, he was "boomed panes" by the news
various bone-related pathology, such as for bone pain, stress that he might have fluid in his chest! Because of his
fracture, nonmalignant bone lesions, bone infections, or the spread riches, he decided to undergo all four imaging
of cancer to the bone. (Image taken from 2018 Trans) modalities. What will the fluid look like in Xray,
Ultrasound, CT and MRI (T1 and T2)
a. Opaque – anechoic – hypodense – hypointense –
hyperintense
b. Lucent – anechoic –isodense – hypointense and
hyperintense
c. Opaque – hypoechoic – hypodense –hypointense and
hyperintense
d. Lucent – hypoechoic – isodense – hypointense and
hyperintense
4. All of the following are true EXCEPT
a. CT scan can provide transverse section images
b. MRI can provide functional information of radiographed
organ
c. Ultrasound degrades bowel sound
d. Doppler ultrasound is ideal visualization for fetus
during first trimester

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5. All of the following are advantages of CT scan over
MRI EXCEPT
a. CT procedure costs less
b. It is superior to MRI in imaging soft tissue
c. CT scan takes a shorter time
d. Patients will not have any claustrophopic issues in
machine

Answers: c, d, a, d, b

FREEDOM SPACE

“You are gonna be our doctors in the future”

-Dra. Reza

What is doc’s favorite movie?

ANS: 50 Shades of Grey
- Parang radiology movie lang!

“Gusto ko yung napa-punish ako.”

-Gayo, 2015 Acquaintance Party

REFERENCES

1. 2018 trans
2. Brant W, Helms C. Fundamentals Of Diagnostic
Radiology. Philadelphia: Lippincott, Williams &
Wilkins; 2007.
3. Siegel M. Pediatric Sonography. Philadelphia: Lippincott
Williams & Wilkins; 2002.
4. Website:Euerle B. Soft Tissue
Ultrasound. Sonoguidecom. 2015. Available at:
http://www.sonoguide.com/soft_tissue.html.
Accessed August 20, 2015.

5. Broder J. Diagnostic Imaging For The Emergency

Physician. Philadelphia, PA: Elsevier/Saunders;
2011.
6. Website: Updated by: Jatin M. Vyas a. Bone scan:
MedlinePlus Medical Encyclopedia. MedlinePlus.
2015. Available at:
https://www.nlm.nih.gov/medlineplus/ency/article/003
833.htm. Accessed August 21, 2015.
7. Website: (ACR) R. Nuclear Medicine,
General. Radiologyinfoorg. 2015. Available at:
http://www.radiologyinfo.org/en/info.cfm?pg=gennucl
ear. Accessed August 19, 2015.
8. Website: Patientinfo.myesr.org. Patient-Info. 2015.
Available at: http://patientinfo.myesr.org. Accessed
August 19, 2015.

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