Diagnostic Imaging Utilization in the Emergency Department: Recent Trends in Volume and Radiology Work Relative Value Units.

PURPOSE: The aim of this study was to quantify and characterize the recent trend in emergency department (ED) imaging volumes and radiology work relative value units (wRVUs) at level I and level III trauma centers. METHODS: Total annual diagnostic radiology imaging volumes and wRVUs were obtained from level I and level III trauma centers from January 2014 to December 2021. Imaging volumes were analyzed by modality type, examination code, and location. Total annual patient ED encounters (EDEs), annual weighted Emergency Severity Index, and patient admissions from the ED were obtained. Data were analyzed using annual imaging volume or wRVUs per EDE, and percentage change was calculated. RESULTS: At the level I trauma center, imaging volumes per EDE increased for chest radiography (5.5%), CT (35.5%), and MRI (56.3%) and decreased for ultrasound (-5.9%) from 2014 to 2021. Imaging volumes per EDE increased for ultrasound (10.4%), CT (74.6%), and MRI (2.0%) and decreased for chest radiography (-4.4%) at the level III trauma center over the same 8-year period. Total wRVUs per EDE increased at both the level I (34.9%) and level III (76.6%) trauma centers over the study period. CONCLUSIONS: ED imaging utilization increased over the 8-year study period at both level I and level III trauma centers, with an increase in total wRVUs per EDE. There was a disproportionate increased utilization of advanced imaging, such as CT, over time. ED utilization trends suggest that there will be a continued increase in demand for advanced imaging interpretation, including at lower acuity hospitals, so radiology departments should prepare for this increased work demand.

COVID-19 Vaccine Mandates: Impact on Radiology Department Operations and Mitigation Strategies.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) vaccine mandates are being implemented in health systems across the United States, and the impact on the radiology department workforce and operations becuase of vaccine hesitancy among health care workers is currently unknown. This article discusses the potential impact of the COVID-19 vaccine mandate on a large multicenter radiology department as well as strategies to mitigate those effects. METHODS: Weekly vaccine compliance data were obtained for employees across the entire health system from August 17, 2021, through September 13, 2021, and radiology department-specific data were extracted. Vaccine compliance data was mapped to specific radiology job titles and the five different hospital locations. RESULTS: A total of 6% of radiology department employees were not fully vaccine compliant by the initial deadline of September 10, 2021. MR technologists and radiology technology assistants had the highest initial rates of noncompliance of 37% and 38%, respectively. Vaccine noncompliance rates by the mandate deadline ranged from 0.5% to 7.0% at the five hospital sites. Only one hospital required a decrease in imaging hours of operation because of the vaccine mandate. CONCLUSION: Despite initial concerns about the impact of vaccine mandate noncompliance on departmental operations, there was ultimately little effect because of improved vaccine compliance after the mandate. Understanding individual employee and locoregional differences in vaccine compliance can help leaders proactively develop mitigation strategies to manage this new challenge during the COVID-19 pandemic.

Radiologic Manifestations of Pulmonary Vein Ablation Complications: A Pictorial Review.

In patients with atrial fibrillation refractory to drug therapy and cardioversion, pulmonary vein ablation is an alternative treatment that eradicates arrhythmogenic activity originating in the muscles of the pulmonary veins. While this procedure has a low incidence of significant complications, iatrogenic injuries are possible. Through multimodality pictorial examples utilizing computed tomography, nuclear medicine, fluoroscopy, and chest radiographs, the complications associated with pulmonary vein ablation will be reviewed. Examples of pulmonary vein stenosis, right phrenic nerve injury with associated diaphragmatic paralysis, atrioesophageal fistula, and pericardioesophageal fistula will be illustrated.

Extraosseous multiple myeloma: imaging spectrum in the abdomen and pelvis.

Multiple myeloma represents a subset of plasma cell dyscrasias characterized by the proliferation of plasma cells typically in the bone marrow, representing approximately 1% of all cancers and 15% of hematologic malignancies. Often multiple myeloma is limited to the skeletal system; however, a small percentage (<5%) of patients will develop extraosseous manifestations. We review the current WHO classification of plasma cell dyscrasias and use multimodality imaging including US, CT, MRI, and PET-CT to illustrate the spectrum of extraosseous multiple myeloma in the abdomen and pelvis. Because extraosseous multiple myeloma is associated with a poorer prognosis and decreased survival, it is important for the radiologist to become familiar with a variety of extraosseous manifestations in the abdomen and pelvis, especially in a patient with a known diagnosis of multiple myeloma and the development of an abdominal or pelvic mass.

Patients avoided important care during the early weeks of the coronavirus pandemic: diverticulitis patients were more likely to present with an abscess on CT.

PURPOSE: To evaluate the frequency with which patients with an urgent health concern, specifically diverticulitis, avoided appropriate medical care during the early weeks of the coronavirus pandemic of 2020 and to study the consequences of the resultant delay in care, the incidence of an associated abscess. METHODS: This study was institutional review board approved. Reports for CT studies with findings of newly diagnosed diverticulitis within Henry Ford Health System during the early weeks of the coronavirus pandemic of 2020 were reviewed and compared with the same time period in 2019. Total cases of diverticulitis on CT were compared, as well as the prevalence of an associated abscess. A chi-squared analysis was performed to determine the statistical significance of the percentage of patients presenting with an abscess in each year. RESULTS: During the early weeks of the coronavirus pandemic, 120 patients were identified with CT findings of newly diagnosed diverticulitis with 11.7% of those patients (14 patients) presenting with an associated abscess. During the same time period in 2019, many more CT studies with newly diagnosed diverticulitis were obtained (339), and, compared to 2020, less than half the percentage of those patients had an associated abscess (4.4% or 15 patients). CONCLUSION: Patients with urgent health concerns avoided appropriate and necessary care during the early weeks of the coronavirus pandemic. While non-COVID-19 emergency visits were diminished, patients who did present with diverticulitis were more likely to present with greater disease severity as manifested by an associated abscess. Patients must be encouraged to seek care when appropriate and need reassurance that hospitals and their emergency departments are safe to visit. Furthermore, emergency physicians and radiologists in particular should be vigilant during times when emergency volumes are low, such as a future surge in coronavirus patients, other pandemics, snow storms, and holidays as the patients who do present for care are more likely to present at later stages and with serious complications.

Appendiceal endosalpingiosis: clinical presentation and imaging appearance of a rare condition of the appendix.

Endosalpingiosis rarely affects the appendix but can be mistaken for acute appendicitis or appendiceal tumors. The medical literature regarding appendiceal endosalpingiosis is sparse; consisting of only four case reports which are primarily focused on the histopathology but provide little radiologic correlation. Endosalpingiosis is a rare condition characterized by the presence of benign fallopian tubal-like glandular epithelium derived from Mullerian ducts, usually affecting the serosal surfaces of the pelvis and peritoneum. It is histologically differentiated from endometriosis as endosalpingiosis lacks endometrial stroma. Endosalpingiosis tends to affect older women and has been associated with ovarian serous tumors of low malignant potential. After a retrospective review of a pathology database, we present pathologically proven cases of appendiceal endosalpingiosis with correlative imaging. We discuss the clinical presentation, illustrate the CT and MRI appearance, histologic characteristics, and review the current medical literature of appendiceal endosalpingiosis.

Intestinal transplants: review of normal imaging appearance and complications.

Intestinal transplant (IT) is one of the least common forms of organ transplant but is increasing both in volume of cases and number of centers performing intestinal transplants, with the busiest centers in North America and Europe. IT can be performed in isolation or as part of a multivisceral transplant (MVT). Intestinal failure either in the form of short gut syndrome or functional bowel problems is the primary indication for IT. The normal post-surgical anatomy can be variable due to both recipient anatomy in regard to amount of residual bowel and status of native vasculature as well as whether the transplant is isolated or part of a multivisceral transplant. Complications of isolated IT and IT as part of an MVT include complications shared with other types of organ transplants such as infection, rejection, post-transplant lymphoproliferative disorder and graft versus host disease. Mechanical bowel complications of the graft include bowel obstruction, stricture, leak, perforation and enterocutaneous fistula. Lastly, vascular complications of both the venous and arterial anastomoses including stricture and pseudoaneurysm occur.

Mucinous appendiceal neoplasms: pathologic classification, clinical implications, imaging spectrum and mimics.

Mucinous appendiceal neoplasms are uncommon, but important to recognize with imaging due to malignant potential. Peritoneal seeding and pseudomyxoma peritonei can occur with both frankly malignant as well as low-grade appendiceal neoplasms. Prospective imaging identification of potential appendiceal neoplasm is paramount to clinical/surgical management. When a mucinous appendiceal neoplasm is suspected, a right hemicolectomy with lymph node dissection is the preferred surgical management. Unfortunately, accurate preoperative diagnosis can be challenging due to a wide range of clinical presentations and overlapping imaging appearances of appendiceal neoplasms with benign entities. Using the 2010 World Health Organization (WHO) pathologic classification as a framework, we provide a comprehensive multi-modality pictorial essay detailing the broad array of imaging findings of mucinous appendiceal neoplasms and common imaging mimics.

Multidetector CT imaging of bariatric surgical complications: a pictorial review.

The prevalence of obesity is increasing, along with the number of bariatric surgical procedures performed to treat obesity. Laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic gastric banding (GB) comprise the vast majority of procedures with SG now the dominant procedure in the USA. Although multidetector computed tomography (MDCT) is not always the examination of choice for a particular suspected complication, many of these patients present with non-specific abdominal symptoms and undergo MDCT evaluation as an initial diagnostic test. This pictorial essay will review and discuss the normal post-surgical bariatric appearance on MDCT, and the appearance of common and uncommon complications associated with the common bariatric procedures on MDCT with correlative imaging. SG complications include leak/abscess, hemorrhage, splenic injury, and portomesenteric thrombosis. RYGB complications include leak/abscess, gastrogastric fistula, small bowel obstruction, internal hernia, and intussusception. Although GB is waning in popularity, radiologists continue to see the legacy of these patients and complications include gastric prolapse, band erosion, and port/tubing mechanical failures. Awareness of the characteristic findings of bariatric complications on MDCT is critical, allowing for earlier recognition and prompt intervention.

Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes.

PURPOSE: Cesarean scar ectopic pregnancy (CSEP) is considered to be quite rare, but the frequency is increasing given the increasing number of cesarean sections being performed, along with increased detection due to widespread use of early endovaginal sonography. The normal sonographic and magnetic resonance findings of this phenomenon will be discussed, including the appearance of complications associated with abnormal placentation, such as the placenta accreta spectrum. Cases of CSEP at our institution will be illustrated, along with clinical presentations and treatment outcomes. METHODS: The study included women who were diagnosed with a CSEP in the first trimester, which was confirmed by ultrasound. The clinical presentations, imaging findings, and treatment outcomes of these pregnancies were recorded. RESULTS: In our series, treatment ranged from no intervention with fetal demise on short-term follow-up ultrasound to viable near-term deliveries requiring cesarean section, urgent blood products, and emergent surgery. The majority of our cases 75% (15 of 20) underwent successful early first trimester termination by a combination of systemic methotrexate administration, ultrasound-guided injection of embryocidal agents, and/or surgery. CONCLUSION: Early imaging recognition and diagnosis of CSEP is critically important to minimize maternal complications, maintain treatment options, and potentially preserve future fertility.

CSF shunt complications: what the abdominal imager needs to know.

Cerebrospinal fluid (CSF) shunting has been a mainstay in the treatment of hydrocephalus for many decades. With a reported 33,000 shunt placement procedures performed in the US annually, and a lifetime revision rate approaching 50%, abdominal radiologists must be familiar with the typical imaging appearance of an array of shunt complications. Complications related to the peritoneal portion of the shunt have been reported in up to 25% of patients. We present a comprehensive pictorial essay including computed tomography, conventional radiography, ultrasound, and nuclear medicine examples illustrating abdominal complications related to CSF shunting and a review of the current literature. The purpose of this pictorial essay is to provide multimodality imaging examples of CSF shunt complications and familiarize the abdominal imager with the spectrum of findings.

Hysterosalpingography: an imaging Atlas with cross-sectional correlation.

Hysterosalpingography (HSG) provides a unique combination of both fallopian tube and uterine cavity evaluation. A comprehensive understanding of both HSG and correlative cross-sectional imaging findings are essential radiologic skills. This article will review the spectrum of technical artifacts, anatomic variants, congenital uterine anomalies, uterine and tubal pathology, and postsurgical findings as they appear on HSG. Additionally, correlation with MR and ultrasound images is provided. This review article serves as a reference for residents new to HSG as well as staff who perform and interpret HSG infrequently.

Stump appendicitis: surgical background, CT appearance, and imaging mimics.

Stump appendicitis, also known as remnant appendicitis, is an uncommon entity with little radiologic literature. It is the result of unintentional incomplete appendectomy with subsequent inflammatory changes in the appendiceal remnant. A retrospective review of the radiology and pathology archives at our institution over an 8-year period yielded six surgically/pathologically confirmed cases. Imaging findings at presentation were evaluated, including appendiceal stump length, appendiceal stump diameter, presence or absence of surrounding stranding in the periappendiceal fat, and presence or absence of complication (perforation or abscess). The CT findings of the six cases had an average surgical specimen appendiceal stump length of 3.5 cm (range 2.0-5 cm) and an average appendiceal diameter of 12.3 mm (range 10-16 mm). All six cases demonstrated the presence of periappendiceal inflammatory fat stranding on the CT scan. Range of imaging presentation is reviewed with pictorial examples as well as examples of potential false-positive cases (mimics) including Crohn's disease, residual surgical drain tract, and epiploic appendagitis. Familiarity with stump appendicitis as well as its imaging mimics may lead to earlier diagnosis and treatment and prevent unnecessary complications.