Improvement in the management of suspected acute aortic syndrome in the emergency room through a clinical algorithm and study of predictive factors.

BACKGROUND AND OBJECTIVE: Acute aortic syndrome (AAS) is uncommon and difficult to diagnose, with great variability in clinical presentation. To develop a computerized algorithm, or clinical decision support system (CDSS), for managing and requesting imaging in the emergency department, specifically computerized tomography of the aorta (CTA), when there is suspicion of AAS, and to determine the effect of implementing this system. To determine the factors associated with a positive radiological diagnosis that improve the predictive capacity of CTA findings. MATERIALS AND METHODS: After developing and implementing an evidence-based algorithm, we studied suspected cases of AAS. Chi-squared test was used to analyze the association between the variables included in the algorithm and radiological diagnosis, with 3 categories: no relevant findings, positive for AAS, and alternative diagnoses. RESULTS: 130 requests were identified; 19 (14.6%) had AAS and 34 (26.2%) had a different acute pathology. Of the 19 with AAS, 15 had been stratified as high risk and 4 as intermediate risk. The probability of AAS was 3.4 times higher in patients with known aortic aneurysm (P = .021, 95% CI 1.2-9.6) and 5.1 times higher in patients with a new aortic regurgitation murmur (P = .019, 95% CI 1.3-20.1). The probability of having an alternative severe acute pathology was 3.2 times higher in patients with hypotension or shock (P = .02, 95% CI 1.2-8.5). CONCLUSION: The use of a CDSS in the emergency department can help optimize AAS diagnosis. The presence of a known aortic aneurysm and new-onset aortic regurgitation were shown to significantly increase the probability of AAS. Further studies are needed to establish a clinical prediction rule.

Coronary computed tomography in emergencies: The importance of the radiologist's experience.

INTRODUCTION: Incorporating coronary computed tomography angiography (CTA) in the hospital workup for suspected acute coronary syndrome requires appropriate skills for interpreting this imaging test. Radiologists' skills can affect the interobserver agreement in evaluating these studies. OBJECTIVE: To determine the interobserver agreement according to radiologists' experience in the interpretation of coronary CTA studies done in patients who present at the emergency department with acute chest pain and low-to-intermediate probability of acute coronary syndrome. MATERIALS AND METHODS: We studied the interobserver agreement in the urgent evaluation of coronary CTA studies in which CAD-RADS was used to register the findings. We created pairs of observers among a total of 8 assessors (4 attending radiologists and 4 radiology residents). We used the kappa coefficient to estimate the overall concordance and the concordance between subgroups according to their experience. RESULTS: The agreement was substantial between experienced radiologists and residents (k=0.627; 95%CI: 0.436-0.826) as well as between all the pairs of observers (k=0.661; 95%CI: 0.506-0.823) for all the CAD-RADS together. The degree of agreement within the group of experienced radiologists was greater than that within the group of residents in all the analyses. The agreement was excellent for the overall CAD-RADS (k=0.950; 95% CI: 0.896-1) and for CAD-RADS ≥ 4 (k=1); the agreement was lower for CAD-RADS ≥ 3 (k=0.754; 95% CI: 0.246-1.255). The agreement for the residents for these categories was k=0.623, k=0.596, and k=0.473, respectively. CONCLUSION: The agreement among attending radiologists regarding the assessment of urgent coronary CTA studies is excellent. The agreement is lower when residents are paired with attending radiologists. These findings should be taken into consideration when implementing coronary CTA in emergency departments and in the organisation of radiological staff for interpreting and reporting this imaging test.

Recommendations on the use of computed tomography in the stroke code: Consensus document SENR, SERAU, GEECV-SEN, SERAM.

The Spanish Society of Emergency Radiology (SERAU), the Spanish Society of Neuroradiology (SENR), the Spanish Society of Neurology through its Cerebrovascular Diseases Study Group (GEECV-SEN) and the Spanish Society of Medical Radiology (SERAM) have met to draft this consensus document that will review the use of computed tomography in the stroke code patients, focusing on its indications, the technique for its correct acquisition and the possible interpretation mistakes.

Acute abdominal pain in patients with Crohn's disease: what urgent imaging tests should be done? / Dolor abdominal agudo en la enfermedad de Crohn. ¿Qué prueba de imagen urgente se debe hacer?

Crohn's disease is an autoimmune disease that predominantly affects the gastrointestinal tract. Crohn's disease is diagnosed at a young age and runs a chronic course with acute flare-ups. When patients with Crohn's disease present with flare-ups at the emergency department, they are usually managed in a way similar to patients with acute abdomen; there is no consensus about the most appropriate imaging work-up for patients with flare-ups of Crohn's disease. Thus, we decided to review the literature about the imaging tests indicated (whether related to their diagnostic performance or to lower exposure to ionizing radiation) for acute flare-ups in patients with Crohn's disease.

PanGen-Fam: Spanish registry of hereditary pancreatic cancer.

PURPOSE: To describe the organisation of the registry and the preliminary results in terms of characteristics of high-risk pancreatic ductal adenocarcinoma (PDAC) families recruited to date and findings of the screening programme. To compare early onset sporadic cases (⩽50 years), sporadic cases (>50 years) and cases with family history of cancer, for PDAC possible risk factors. METHODS/PATIENTS: Families with hereditary cancer syndromes predisposing to PDAC were recruited from two main sources: Spanish hospitals participating in PanGenEU, a pan-European multicentre case-control study, and their genetic counseling unit. Individuals at high-risk of PDAC were enrolled into a screening programme, consisting of Endoscopic ultrasound, computerised tomography, magnetic resonance imaging. Genetic testing of candidate genes was offered according to each patient's risk. RESULTS: Among 577 consecutive PDAC cases, recruited via PanGenEU, 36 (6%) had ⩾2 first-degree relative with PDAC: Familial pancreatic cancer (FPC). So far PanGen-Fam has recruited 42 high-risk PDAC families; 25 (60%) had FPC. Five index cases with cancer were positive for BRCA2 and one for BRCA1 germline mutations. In the second year of prospective PDAC screening, one neuroendocrine tumour and a high-grade dysplasia lesion suspicious of carcinoma were diagnosed among 41 high-risk individuals. Furthermore EUS detected chronic-pancreatitis-like parenchymal changes in 15 patients. CONCLUDING STATEMENT: The identification and recruitment of PDAC high-risk families into the PanGen-Fam registry provides an opportunity to detect early onset cancer and precursor pancreatic cancer lesions at a potentially curative stage and to increase the knowledge of the natural history of the disease.

Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis.

OBJECTIVE: To assess the diagnostic accuracy of computed tomography (CT) angiography in the evaluation of patients with an episode of acute gastrointestinal haemorrhage. METHODS: Systematic review and meta-analysis to estimate pooled accuracy indices. A bivariate random effects model was adjusted to obtain a summary receiver-operating characteristic (sROC) curve and the corresponding area under the curve (AUC). RESULTS: Twenty-two studies were included and provided data on 672 patients (range of age 5-74) with a mean age of 65 years. The overall sensitivity of CT angiography for detecting active acute GI haemorrhage was 85.2 % (95 % CI 75.5 % to 91.5 %). The overall specificity of CT angiography was 92.1 % (95 % CI 76.7 % to 97.7 %). The likelihood ratios for positive and negative test results were 10.8 (95 % CI 3.4 to 34.4) and 0.16 (95 % CI 0.1 to 0.27) respectively, with an AUC of 0.935 (95 % CI 0.693 to 0.989). The sources of heterogeneity explored had no significant impact on diagnostic performance. CONCLUSIONS: CT shows high diagnostic accuracy and is an excellent diagnostic tool for detection and localising of intestinal bleeding sites. It is highly available, provides fast detection and localisation of the bleeding site, and is minimally invasive. KEY POINTS: • CT angiography is increasingly used for investigating severe gastrointestinal bleeding. • This systematic review and meta-analysis updates previous ones. • In patients with massive gastrointestinal bleeding, CT angiography/MDCT detects bleeding accurately. • CT angiography is useful in locating the bleeding site and determining appropriate treatment.

[Multimodal CT in the diagnostic workup of stroke]. / TC multimodal en el diagnóstico del código ictus.

Stroke results in significant morbidity and mortality. Recent years have seen a revolution in the diagnosis and treatment of stroke, with advances in diagnostic imaging and improvements in early and specific treatment. Multimodal CT (unenhanced CT, perfusion CT, and CT angiography) is widely available, fast, and efficacious, all of which give it a key role in the early diagnosis of stroke and in the selection of patients who will benefit from thrombolytic treatment. Unenhanced CT is useful for ruling out hemorrhage or lesions that simulate stroke and for evaluating the presence of early signs. Perfusion CT enables us to know the presence and extension of infarcted ischemic tissue (irrecoverable) and of penumbra (tissue at risk that is potentially recoverable), thus ensuring more appropriate selection of candidates for treatment. Finally, CT angiography makes it possible to evaluate the intra- and extra-cranial circulation, to know the vascular alteration that originated the stroke, and to guide treatment (intra-arterial or mechanical thrombolysis).

[Radiological management of patients with multiple trauma: history and current practice]. / Manejo radiológico del paciente politraumatizado. Evolución histórica y situación actual.

The radiologist plays a crucial role in the multidisciplinary management of patients with multiple trauma. In the last few decades, technological advances and changes in the healthcare culture have led to changes in the imaging work-up of multiple trauma patients, with emphasis shifting from plain-film radiography to whole-body multidetector CT. This article describes the evolution of the different protocols and the current practice in the management of patients with multiple trauma. As a member of the multidisciplinary team, the radiologist must decide on the best imaging technique and protocol for each situation in function of the technological resources available.

[PET/CT: protocol aspects and legal controversies]. / PET/TC: aspectos de protocolo y controversias legales.

The combination of positron emission tomography (PET) and computed tomography (CT) in a single scanner (PET/CT) allows anatomic and metabolic images to be fused and correlated with a high degree of accuracy; this represents a very important landmark in the history of medicine and especially in the area of diagnostic imaging. Nevertheless, the implementation, startup, and operation of a PET/CT scanner presents particularly interesting challenges, because it involves the integration of two well-established and consolidated techniques (CT and PET, which provide complementary information) that have traditionally been carried out in the context of two different specialties (radiology and nuclear medicine). The rapid diffusion of this new integrated technology raises a series of questions related to the optimal protocols for image acquisition, the supervision of the examinations, image interpretation, and reporting, as well as questions related to the legal competence and responsibility of the specialists involved in a PET/CT study. The objective of this article is to approach these aspects from a constructive perspective and to stimulate the dialog between the specialties of radiology and nuclear medicine, with the aim of maximizing the diagnostic potential of PET/CT and thus of providing better care for patients.

[Nodular alveolar pattern of presentation for amiodarone pulmonary toxicity]. / Patrón alveolar nodular como forma de presentación de la toxicidad pulmonar por amiodarona.

Amiodarone is a triiodinated antiarrhythmic drug that accumulates in alveolar macrophages. Its use is limited by its high rate of associated pulmonary toxicity, estimated at 5-7%. Radiologic findings for pulmonary toxicity caused by amiodarone are unspecific and varied. The most common finding is subpleural reticular-type interstitial thickening, predominately in the bases of the lungs. However, the presence of parenchymal nodules is an uncommon presentation. We report the case of a woman treated with amiodarone that presented multiple nodular lesions at plain-film radiography and high-resolution CT that were compatible with pulmonary toxicity caused by amiodarone at pathologic examination.