Diagnostic imaging requisition quality when using an electronic medical record: a before-after study.

Diagnostic imaging requisition (DIR) content is legally constrained for care quality and patient safety concerns. A French national indicator, based on administrative and clinical data, has been introduced to monitor nationwide the conformity of such documents (CDIR). The purpose of this study was to assess the effect on CDIR of the deployment of the ORBIS™ electronic medical record at the Tenon hospital (Paris, France). A before-after study has been carried out. A significant increase of CDIR, from 37.0% (n=676) to 49.1% (n=800), was observed (p < 10⁻5). Conformity of administrative criteria improved, but there was no statistical difference of clinical criteria conformity, despite the improvement of clinical history documentation (100%). Up to five different paper-based requisition forms were used by clinical departments in the before period. In the after period, only 27.1% of requisitions were ORBIS-edited with a CDIR of 66.8% (n=217). In both periods, CDIR was correlated to the level of standardization of the forms.

Impact of MDCT angiography on the management of patients with hemoptysis.

OBJECTIVE: The aim of this study was to evaluate the ability of MDCT angiography to modify early results in patients undergoing endovascular embolization for hemoptysis. MATERIALS AND METHODS: A comparative study was performed of two consecutive cohorts with 200 patients each who were treated by endovascular embolization for severe hemoptysis; one cohort underwent MDCT angiography and the other did not, but patients underwent further exploration with global aortography. We compared the two groups for patients' age and sex and for the volume, cause, and mechanisms of hemoptysis. Evaluation included the number of sessions needed to control the hemoptysis, the primary failure of bronchial artery embolization, the recurrence of hemoptysis, pulmonary artery vasoocclusion, urgent surgical resection, and death by massive hemoptysis during hospitalization. Failure was defined as the absence of embolization during the first session. Recurrence was defined as rebleeding despite technically successful bronchial artery embolization. RESULTS: Differences between the groups were statistically significant for patient age (p < 0.05), endovascular treatment failure among patients older than 70 years (p < 0.05), pulmonary artery vasoocclusion in comparison with diagnostic pulmonary artery angiography (p < 0.0001), and urgent surgical resection (p = 0.034). CONCLUSION: The impact of MDCT angiography was significant in reducing the rate of vascular catheterization failure in patients older than 70 years, increasing the number of pulmonary artery vasoocclusions, and reducing the number of urgent surgical resection.

Systemic arterial embolization in patients with hemoptysis: initial experience with ethylene vinyl alcohol copolymer in 15 cases.

OBJECTIVE: The purpose of this study was a preliminary evaluation of the use of ethylene vinyl alcohol copolymer to treat patients with hemoptysis of systemic arterial origin. MATERIALS AND METHODS: We reviewed the cases of 15 consecutively registered patients (10 men, five women; mean age, 53.7 years) who underwent endovascular administration of ethylene vinyl alcohol copolymer in the management of hemoptysis. The indications, immediate control of hemoptysis, and clinical tolerability were analyzed. RESULTS: The indications for embolization were mainly early recurrence of hemoptysis with reperfusion of systemic arteries in seven cases; unstable microcatheter in two cases; large ectopic bronchial artery in two cases; and, in one case each, bronchial arterial bleeding through a small anastomotic network, aneurysm of the left internal thoracic artery in a patient with invasive aspergillosis, a potentially risky connection between the bronchial and right coronary arteries, and occlusion of a systemic artery due to Pryce type 1 intralobar lung sequestration. Hemoptysis was controlled in all but one case and did not recur in the other 14 cases. The injection procedure was well tolerated. CONCLUSION: Ethylene vinyl alcohol copolymer embolization for hemoptysis of systemic arterial origin is feasible. The agent seems beneficial in the care of patients with recurrent hemoptysis after previous bronchial arterial embolization, patients who would be at high risk during embolization with microparticles, and patients who need embolization of large systemic arteries through small-caliber anastomoses.

Dynamic contrast-enhanced MR imaging to assess physiologic variations of myometrial perfusion.

PURPOSE: To prospectively evaluate the ability of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to assess physiological microvascular states in normal myometrium. MATERIALS AND METHODS: Eighty-five women (62 women of reproductive age, 23 postmenopausal) undergoing DCE-MRI of the pelvis were included. Microvascular parameters for the inner and outer myometrium were analysed using a pharmacokinetic model. These parameters were tissue blood flow (F), blood volume fraction (V(b)), permeability-surface area product (PS), interstitial volume fraction (V(e)) and lag time (Dt). RESULTS: In the women of reproductive age, the inner myometrium displayed higher F and PS, lower V(b) and V(e), and longer Dt than the outer myometrium (p = 0.02, p = 0.01, p = 0.005, p = 0.03 and p = 0.01, respectively). The inner myometrium presented microvascular variations during the menstrual cycle with a pre-ovulatory peak followed by a fall reaching a nadir of F and V(b) about 4 days after ovulation. Compared with women of reproductive age, in the postmenopausal state, F and V(b) decreased in the outer myometrium, while PS, V(e) and Dt increased (p < 0.0001, p = 0.001, p = 0.001, p = 0.03 and p = 0.0004, respectively). CONCLUSION: DCE-MRI is a non-invasive technique that can measure variations of myometrial microcirculation, and thereby be potentially useful to help characterize the role and states of the myometrium in assisted reproductive therapy.

Contribution of diffusion-weighted MR imaging for predicting benignity of complex adnexal masses.

The purpose of this study was to prospectively assess the contribution of diffusion-weighted MR imaging (DWI) for characterizing complex adnexal masses. Seventy-seven women (22-87 years old) with complex adnexal masses (30 benign and 47 malignant) underwent MR imaging including DWI before surgery. Conventional morphological MR imaging criteria were recorded in addition to b(1,000) signal intensity and apparent diffusion coefficient (ADC) measurements of cystic and solid components. Positive likelihood ratios (PLR) were calculated for predicting benignity and malignancy. The most significant criteria for predicting benignity were low b(1,000) signal intensity within the solid component (PLR = 10.9), low T2 signal intensity within the solid component (PLR = 5.7), absence of solid portion (PLR = 3.1), absence of ascites or peritoneal implants (PLR = 2.3) and absence of papillary projections (PLR = 2.3). ADC measurements did not contribute to differentiating benign from malignant adnexal masses. All masses that displayed simultaneously low signal intensity within the solid component on T2-weighted and on b(1,000) diffusion-weighted images were benign. Alternatively, the presence of a solid component with intermediate T2 signal and high b(1,000) signal intensity was associated with a PLR of 4.5 for a malignant adnexal tumour. DWI signal intensity is an accurate tool for predicting benignity of complex adnexal masses.

Dynamic contrast-enhanced MR imaging of ovarian neoplasms: current status and future perspectives.

MR imaging is useful for characterizing ovarian tumors. Dynamic contrast-enhanced MR imaging is a promising new technique useful for characterizing perfusion and angiogenesis of ovarian masses. This article describes the dynamic contrast-enhanced MR imaging technique examines the current and future applications of this technique in patients with ovarian tumors.

Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography.

BACKGROUND: Hemoptysis of pulmonary arterial origin is a diagnostic challenge in patients admitted to a respiratory ICU (RICU) for treatment of hemoptysis. Its early accurate recognition and treatment reduce morbidity and prevent mortality. Multidetector row CT angiography (MDCTA) is an accurate method for imaging the systemic vascular network. Our aim was to assess the MDCTA signs and role in managing hemoptysis of pulmonary arterial origin. METHODS: We performed a retrospective clinical and radiologic analysis of all consecutive patients who were referred for severe hemoptysis to our RICU and were treated by endovascular means between January 2004 and December 2006. We reviewed all of those cases with hemoptysis of pulmonary arterial origin. RESULTS: Of 272 patients who were referred for severe hemoptysis to the RICU, 189 patients were treated by endovascular means. Thirteen patients (nine men, four women; mean age, 45 years) had hemoptysis of pulmonary arterial origin. Signs of pulmonary arterial hemoptysis seen on MDCTA were of the following three types: pseudoaneurysm (n = 5); aneurysm of the pulmonary artery (n = 3); or the presence of a pulmonary artery in the inner wall of a cavity (n = 5). Hypertrophy of the bronchial arteries seen on MDCTA associated with any of these signs predicted the necessity to treat both the bronchial and pulmonary arteries. Pulmonary artery vasoocclusion was performed as a first treatment in eight patients with such an association (n = 1) or without such an association (n = 7) along with bronchial artery embolization. The remaining five patients were treated with systemic artery embolization, followed by surgery (n = 1), pulmonary artery vasoocclusion (n = 3), and death from massive hemoptysis (n = 1). CONCLUSIONS: MDCTA performed prior to endovascular treatment allows the correct identification and early appropriate management of severe hemoptysis of pulmonary arterial origin.

Hemoptysis complicating Scimitar Syndrome: from diagnosis to treatment.

We report the case of a 24-year-old patient with known scimitar syndrome presenting with hemoptysis. Multidetector CT angiography showed the scimitar vein draining the right lung to the inferior vena cava associated with right lower lobe bronchopulmonary sequestration. The presence of hemoptysis associated with scimitar syndrome is likely secondary to an anomalous systemic arterial blood supply. We treated this patient successfully with transcatheter occlusion of the anomalous feeding arterial vessels.

Value of dynamic enhanced magnetic resonance imaging for distinguishing between ovarian fibroma and subserous uterine leiomyoma.

PURPOSE: The purpose of this study was to assess the accuracy of magnetic resonance imaging (MRI), particularly, dynamic MRI, in distinguishing ovarian fibromas from subserous uterine leiomyomas. MATERIAL AND METHODS: Fifteen ovarian fibromas and 15 subserous uterine leiomyomas were retrospectively reviewed. All MR examinations included dynamic contrast-enhanced (DCE) sequences. Morphological criteria (size, T1 and T2 signals, ovarian tissue, associated uterine leiomyoma, and pelvic fluid), arterial vessels, time-intensity curves (maximal enhancement and signal intensity at 30, 60, and 90 seconds), and signal intensity on delayed T1-weighted images were compared between the 2 groups. RESULTS: No significant difference in morphological criteria was noted between the 2 types of masses. Visualization of arterial vessels was more frequent in uterine leiomyomas than in ovarian fibromas (P= 0.002). The DCE MR enhancement rate was higher for uterine leiomyomas than for ovarian fibromas in terms of both maximal enhancement (P < 0.001) and enhancement rate at 30 (P = 0.009), 60 (P = 0.007), and 90 seconds (P = 0.0009). On delayed T1 postcontrast sequence, no statistical difference exists between signal intensity of ovarian fibromas and uterine leiomyomas. CONCLUSION: Our findings suggest that DCE MRI can distinguish ovarian fibromas from uterine leiomyomas and should be used if sonography fails to show the origin of a pelvic mass.

Role of MDCT in identification of the bleeding site and the vessels causing hemoptysis.

OBJECTIVE: MDCT has improved the management of hemoptysis by providing more precise depiction of bronchial and nonbronchial systemic arteries than conventional CT. The purpose of this article is to review the role of MDCT in the identification of the bleeding site and the vessels causing hemoptysis. CONCLUSION: Identification of the origin of the involved systemic arteries (bronchial and nonbronchial) or involved pulmonary artery on MDCT enables the interventional radiologist to treat them, especially in elderly patients with a tortuous aorta and atheroma.

[The TELIF network of Paris-area public hospitals (AP-HP)]. / Le réseau TELIF à l'Assistance Publique--Hôpitaux de Paris.

After a feasibility study, the TELIF network (neurosurgical emergencies in the Paris region) was created in November 1994. The goal was to reduce the number of patient transfers among the different hospitals, by teletransmission of computed tomography images between computers located in the emergency departments of general hospitals and the neurosurgery department. The initial goal has been reached, with a 70 % reduction in the number of patient transfers. The network is also being used with success for teleinterpretation of standard radiographs in gerontology. Today the network's technology is obsolete, and it will now be integrated into the new medical record system, using web-based technology for secure and confidential teletransmission.

[Intramedullary lipomatous ependymoma: case report]. / Ependymome lipomateux intramédullaire.

A 51 year-old man was admitted to our hospital with poor general health and neurological disturbances with paresthesia, dysuria and defecation disorder. Neuroimaging showed a syringomyelia cyst from C1 to conus medullaris, together with a intramedullar tumoral mass in T6-T7. Histological examination of the surgical specimen led to the diagnosis of lipomatous ependymoma.

[Harmonizing indications for emergency radiological examinations for adults]. / Harmoniser les indications des examens radiologiques dans les situations cliniques urgentes de l'adulte.

INTRODUCTION: The "Collégiale des radiologistes" of the Paris public hospital system (Assistance Publique-Hôpitaux de Paris, AP-HP) has participated since 1998 in a collaborative quality improvement program for the 49 radiology departments. They work together with the AP-HP college of emergency physicians on one part of this program, which focuses on emergency radiologic work-ups. Analysis of the dysfunctions in this sector underlined the lack of agreement between clinicians and radiologists on the examinations required. OBJECTIVE: The aim of this project was to establish operational and consensual guidelines for physicians, radiologists and emergency teams for the use of diagnostic radiology in emergency situations in adults. METHOD: The working group of radiologists and emergency physicians drafted this document, largely from documentary sources. A large panel of physicians validated the draft during successive review sessions, and the two colleges then approved them. RESULTS: The guidelines are presented in 3 columns: clinical situations, quality aims (type of imaging, time within which the examination should be performed) and comments. The clinical situations were regrouped by anatomical area or system: head, neck, thorax, heart, gynecology, abdomen, urinary, non-traumatic bone and spine disorders, multiple trauma, and isolated trauma of the spine and limbs and of the head, trunk, abdomen, and pelvis. CONCLUSION: These guidelines based on consensus within the institution make it possible to harmonize the requests for and practices of radiologic examinations in emergency situations. Their implementation is an integral part of the ongoing development of operating agreements between the radiology and emergency departments.

LINAC radiosurgery for brain metastasis of renal cell carcinoma.

The purpose of the study was to evaluate the efficacy and toxicity of stereotactic radiotherapy in the treatment of the brain metastasis of renal cell carcinoma. From 1994 to 2001, 28 patients presenting with 65 metastases of renal cell cancer were treated by radiosurgery. Median age was 55 years (35-75), and median Karnofski performance status ranges between 50 and 100. Seven patients had received whole brain radiotherapy (WBRT) before radiosurgery. Twelve patients were treated by radiosurgery for 1 metastasis, 5 patients for two metastases and 6 for three, and 5 for more than three metastases. One procedure was performed in 22 patients and, 2 or 3 procedures for 6 patients. Median metastasis diameter was 19 mm (5-55 mm). Median metastasis volume was 1.28 cc (0.02-28 cc). Irradiation was delivered by linear accelerator. Median minimal dose (on the 70% isodose) was 14.7 Gy (10.8 Gy, 19.5 Gy), median maximal dose (at the isocenter) 20.5 Gy (14.3 Gy, 39.6 Gy). Median follow-up was 14 months (1-33). Two metastases progressed (3%), 2 and 12 months after radiosurgery. Overall, crude local control rate was 97% and 3-, 6- and 12-month local control rates were 98% +/- 2%, 98% +/- 2%, and 93% +/- 5%, respectively. In univariate analysis, no prognostic factor of local control was retrieved. Median brain disease-free survival was 25 months after RS. the 3-, 6- and 12-month distant brain control rates were 91% +/- 4%, 91% +/- 4%, and 70% +/- 12%, respectively. Median survival duration was 11 months. The 3-, 6-, 12- and 24-month overall survival rates were 82% +/- 7%, 67% +/- 9%, 48% +/- 10%, and 33% +/- 10%, respectively. According to univariate analysis, only site of metastasis was overall survival prognostic factor. Radiosurgery for brain metastasis of renal cell carcinoma is an effective and accurate treatment. The use of radiosurgery alone is an appropriate management strategy for many patients with brain metastasis of renal cell carcinoma. Radiosurgery is efficient even after development of new metastasis appearing after WBRT.

Proximal great vessels of aortic arch: comparison of three-dimensional gadolinium-enhanced MR angiography and digital subtraction angiography.

PURPOSE: To prospectively compare dynamic three-dimensional (3D) gadolinium-enhanced magnetic resonance (MR) angiography and digital subtraction angiography (DSA) for the detection of ostial stenosis of the craniocervical vessels. MATERIALS AND METHODS: Thirty-three patients with carotid stenosis of more than 50% at sonography prospectively underwent both MR angiography and DSA. The overall quality of each DSA and MR angiographic study was analyzed. For each craniocervical vessel (brachiocephalic, common carotid, subclavian, and vertebral arteries) (n = 231), ostial stenosis was graded as follows: normal, mild (<50%), moderate to severe (>50%), or occlusion. MR angiographic and DSA results were compared by means of the Spearman rank correlation coefficient (Rs). RESULTS: The overall diagnostic quality of MR angiography was excellent or adequate. Three studies were inadequate because of a poor signal-to-noise ratio (13 of 231 arteries) or a coverage error (five of 231 arteries). Findings at MR angiography and DSA agreed on the degree of stenosis (Rs = 0.82, P <.001). No cases of stenosis of more than 50% were missed at MR angiography. However, some discrepancies were noted between vertebral arteries and the other craniocervical vessels. The sensitivity and specificity for stenosis of more than 50% in other craniocervical vessels were 100% and 98%, respectively. The sensitivity and specificity for stenosis of more than 50% in the vertebral arteries were 100% and 85%, respectively. Findings at MR angiography tended to result in overestimation of the degree of ostial stenosis, especially in vertebral arteries (10 [15%] of 66 arteries). CONCLUSION: MR angiography is useful to rule out ostial stenosis of the craniocervical vessels. MR angiography is an adequate diagnostic tool for ostial stenosis, except in the vertebral artery.

Three irradiation treatment options including radiosurgery for brain metastases from primary lung cancer.

PURPOSE: To determine local control and survival rates in 92 patients with 145 brain metastases treated with three options of radiotherapy including stereotactic radiosurgery (SR). METHODS: Between July 1994 and August 2002, 92 consecutive patients with 145 metastases were treated with a SR, 34 with initially SR alone, 22 initially with an association of whole-brain radiotherapy (WBRT) and 36 with SR alone for recurrent new brain metastasis after WBRT. At time of treatment, extracranial disease was controlled in 46 (50%) and uncontrolled in 46 (50%). Pathologies were adenocarcinoma in 54 cases (59%), squamous cell carcinoma in 14 cases (15%), small cell carcinoma in 10 cases (11%) and miscellaneous in 14 cases (15%). All patients underwent only one treatment fraction for 1 or 2 metastases in 73 cases (83%) and for more than 2 metastases for the others. RESULTS: The characteristics of patients and metastases in the group treated initially with SR alone and in the group treated initially with WBRT+SR were comparable. Median follow-up was 29 months (18-36). Overall, the median and the 1- and 2-year rates of overall survival were, respectively, 9 months, 37 and 20%. A controlled extracranial disease, a high Karnofsky index and a low number of metastasis were independent prognostic factor of overall survival, respectively, HR 0.53 (95% CI 0.31-0.90, P=0.01), HR 0.95 (95% CI 0.92-0.97, P=0.0002), and HR 0.48 (95% CI 0.25-0.90, P=0.02). Thirteen metastases were not controlled (9%). Six-month and 1-year local control rate were, respectively, 93 and 86%. High delivered dose was an independent prognostic factor of local control, HR 0.41 (95% CI 0.18-0.95, P=0.03). A controlled extracranial disease was favourable independent prognostic factor of brain free-disease free survival, HR 0.47 (95% CI 0.2-0.98, P=0.04). Although there was a trend of a better local control, overall and brain disease free survivals rates in the WBRT+SR group compared to SR alone one, the difference were not statistically different. CONCLUSION: Local control and survival rates are acceptable for a palliative treatment for the three option of treatment. In this series, the number of patients is not enough great to conclude to the necessity of the association of WBRT to SR. Re-irradiation is a safe treatment after new metastases appeared in previously irradiated area.

Radiosurgery for brain metastasis: impact of CTV on local control.

PURPOSE: The purpose of the present analysis was to assess whether adding a 1 mm margin to the gross tumour volume (GTV) improves the control rate of brain metastasis treated with radiosurgery (RS). PATIENTS AND METHODS: All the patients had one or two brain metastases, 30 mm or less in diameter, and only one isocentre was used for RS. There were 23 females and 38 males. The median age was 54 years (34-76). The median Karnofsky performance status was 80 (60-100). At the time of RS, 23 patients had no evidence of extracranial disease and 38 had a progressive systemic disease. Thirty-eight patients were treated up-front with only RS. Twenty-three patients were treated for relapse or progression more than 2 months after whole brain radiotherapy. From January 1994 to July 1995, clinical target volume (CTV) was equal to GTV without any margin (33 metastases). From August 1995 to August 2000, CTV was defined as GTV plus a 1 mm margin (45 metastases). A dose of 20Gy was prescribed to the isocentre and 14Gy at the margin of CTV. RESULTS: The median follow-up was 10.5 months (1-45). The mean minimum dose delivered to GTV was 14.6Gy in the group without a margin and 16.8Gy in the group with a 1 mm margin (P<0.0001). The response of 11 metastases was never assessed because patients died before the first follow-up. Ten metastases recurred, eight in the group treated without a margin and two in the group treated with a 1 mm margin (P=0.01). Two-year local control rates were 50.7+/-12.7% and 89.7+/-7.4% (P=0.008), respectively. Univariate analysis showed that the treatment group (P=0.008) and the tumour volume (P=0.009) were prognostic factors for local control. In multivariate analysis, only the treatment group with a 1 mm margin was an independent prognostic factor for local control (P=0.04, RR: 5.8, 95% CI [1.08-31.13]). There were no significant differences, either in overall survival rate or in early and late side effects, between the two groups. CONCLUSION: Adding a 1 mm margin to the GTV in patients treated with RS significantly improves the probability of metastasis control without increasing the side effects.

Foot, hand, face and eye representation in the human striatum.

The present study aimed at determining the three-dimensional organization of striatal activation during foot, hand, face and eye movements. Seven right-handed, healthy volunteers were studied at 1.5 T using blood oxygen level dependent (BOLD) contrast. The tasks consisted of self-paced flexion/extension of the right and left fingers and right toes, contraction of the lips and saccadic eye movements. For foot, hand and face movements, striatal activation was mainly found in the putamen with a somatotopical organization, the foot area being dorsal, the face area more ventral and medial, the hand area in between. Overlap between somatotopic territories was present, more prominent for hand-face than for foot-face or foot-hand areas. In the putamen, the activated areas of the ipsi- and contralateral hand areas were not identical, suggesting a partial segregation of the ipsi- and contralateral striatal sensorimotor projections. For saccadic eye movements, bilateral activation was observed at the junction between the body and the head of the caudate nucleus and in the right putamen. These data present evidence for a somatotopic organization of the human striatum which corresponds with the topography of corticostriatal projections described in the non-human primates.