The complementary nature of peer review and quality assurance data collection.

PURPOSE: To assess the complementary natures of (a) a peer review ( PR peer review )-mandated database for physician review and discrepancy reporting and (b) a voluntary quality assurance ( QA quality assurance ) system for anecdotal reporting. MATERIALS AND METHODS: This study was institutional review board approved and HIPAA compliant; informed consent was waived. Submissions to voluntary QA quality assurance and mandatory PR peer review databases were searched for obstetrics and gynecology-related keywords. Cases were graded independently by two radiologists, with final grades resolved via consensus. Errors were categorized as perceptional, interpretive, communication related, or procedural. Effect of errors was assessed in terms of clinical and radiologic follow-up. RESULTS: There were 185 and 64 cases with issues attributed to 32 and 27 radiologists in QA quality assurance and PR peer review databases, respectively; 23 and nine radiologists, respectively, had cases attributed to only them. Procedure-related entries were submitted almost exclusively through the QA quality assurance database (62 of 64 [97%]). In QA quality assurance and PR peer review databases, respectively, perceptional (47 of 185 [25%] and 27 of 64 [42%]) and interpretative (64 of 185 [34%] and 30 of 64 [47%]) issues constituted most errors. Most entries in both databases (104 of 185 [56%] in QA quality assurance and 49 of 64 [76%] in PR peer review ) were considered minor events: wording in the report, findings already known from patient history or prior imaging or concurrent follow-up imaging, or delay in diagnosing a benign finding. Databases had similar percentages of moderate events (28 of 185 [15%] in QA quality assurance and nine of 64 [14%] in PR peer review ), such as recommending unnecessary follow-up imaging or radiation exposure in pregnancy without knowing the patient was pregnant (nine of 64 [14%] in PR peer review and 28 of 185 [15%] in QA quality assurance ). The PR peer review database had fewer major events (one of 64 [1.6%]) than the QA quality assurance database (32 of 185 [17%]). CONCLUSION: The two quality improvement systems are complementary, with the QA quality assurance database yielding less frequent but more clinically important errors, while the PR peer review database serves to establish benchmarks for error rate in radiologists' performance.

Combined vascular-excretory phase MDCT angiography in the preoperative evaluation of renal donors.

OBJECTIVE: The objective of our study was to test a dose reduction protocol that uses combined vascular-excretory phase scanning achieved by split IV contrast injection and compare it with conventional multiphase MDCT angiography (MDCTA) in evaluating potential renal donors. MATERIALS AND METHODS: This study is a review of MDCTA examinations of 54 potential renal donors scanned on 16- and 64-MDCT. The IV bolus was split: 50 mL was administered 3 minutes before scanning and a second injection of 70-100 mL was administered at a rate of 4-6 mL/s, with CT angiography started by bolus tracking. The second vascular (venous) phase was acquired 20 seconds later. Two readers reviewed the two phases, assessed vascular and parenchymal anatomy and variants or abnormalities, graded the added value of the venous phase on a 5-point scale, and took attenuation measurements in Hounsfield units. The operative notes of 39 subjects were reviewed as the reference standard for anatomic findings and compared with CT reports. RESULTS: All of the relevant anatomy findings, according to the operative notes, were accurately depicted by MDCTA, and all were well recognized on the arterial phase. The arterial phase combined information from the arterial, venous, parenchymal, and excretory phases. The venous phase was inferior to the arterial phase in assessing the renal arteries without additional venous, parenchymal, or excretory phase information. The mean renal artery attenuation was 355 HU in the first phase versus 173 HU in the second phase (p<0.0001). The mean renal vein attenuation was not significantly different between the two phases. The parenchymal system and excretory system were equally well depicted in both vascular phases. CONCLUSION: Split-bolus contrast injection and combined vascular-excretory phase scanning are adequate for studying potential renal donors and result in a marked decrease in multiphase scanning and, thus, in radiation dose.

Tuberculosis: value of lateral chest radiography in pre-employment screening of patients with positive purified protein derivative skin test results.

PURPOSE: To test the hypothesis that lateral radiography adds no clinically relevant information to that acquired with posteroanterior (PA) radiography in individuals with positive purified protein derivative (PPD) skin test results. MATERIALS AND METHODS: As part of routine practice, all 875 adults with positive PPD skin test results at pre-employment examinations performed at a medical center during 2007 underwent PA and lateral chest radiography. In this institutional review board-approved HIPAA-compliant study, the patient informed consent requirement was waived. Two radiologists retrospectively and independently interpreted each radiograph for evidence of abnormalities that were indicative of acute or chronic tuberculosis (TB) infection. First, only the PA radiograph was analyzed. Thereafter, both the PA radiograph and the lateral radiograph were analyzed together to determine if any observed finding was identified on only the lateral radiograph. If a finding was seen on both images, a determination was made as to whether the finding on the lateral radiograph changed the radiologist's decision based on the PA radiograph alone. RESULTS: The PA radiograph revealed abnormalities in all 91 (10.4%) subjects with positive findings at radiography. The lateral radiograph revealed no abnormality in 75 subjects (83.4%). All abnormalities seen on lateral radiographs were also seen on PA radiographs. When abnormalities were seen on both images, the information on the lateral image never caused the radiologist to change the decision he or she made on the basis of the PA image alone. CONCLUSION: In a pre-employment setting, one PA radiograph is sufficient for TB screening of individuals with positive PPD skin test results. Elimination of the acquisition of lateral radiographs would substantially reduce radiation exposure.

Quality initiatives: imaging pregnant patients with suspected pulmonary embolism: what the radiologist needs to know.

Pregnancy is associated with a fivefold increase in the prevalence of venous thromboembolism, and pulmonary embolism is a leading cause of maternal death. However, the diagnosis of pulmonary embolism during pregnancy is challenging because classic clinical symptoms are often absent and physiologic changes during pregnancy can mimic pulmonary embolism. Concerns about exposure of the fetus to ionizing radiation and intravenously administered contrast material, as well as potential medicolegal issues, further complicate the diagnosis. Although diagnostic imaging plays an important role in this setting, there are currently no widely accepted guidelines for radiologists and clinicians to follow. Thus, radiologists should be familiar with the advantages and disadvantages of available imaging modalities, methods for dose reduction, radiation risks, and medicolegal risk management guidelines.

What is the clinical importance of echogenic material in the fetal frontal horns?

OBJECTIVE: The purpose of this study was to evaluate the importance of echogenic material in the fetal frontal horns. METHODS: This was a Health Insurance Portability and Accountability Act-compliant, Institutional Review Board-approved retrospective study. In part 1 of the study, prenatal sonography, prenatal magnetic resonance imaging (MRI), and birth outcomes of 17 fetuses (mean gestational age, 19 weeks; range, 15-34 weeks) with prospective echogenic material in the frontal horns were assessed. In part 2, 400 consecutive sonographic fetal surveys (mean gestational age, 19 weeks; range, 15-38 weeks) were reviewed to determine the incidence. In part 3, 2 independent reviewers assessed the appearance of the frontal horns in 40 fetuses (20 with suspected intraventricular hemorrhage from parts 1 and 2 and 20 who were interpreted to have normal findings in part 2). RESULTS: Part 1 of the study showed that suspected hemorrhage was unilateral in 13 fetuses and bilateral in 4. Additional findings by sonography were grade 4 intraventricular hemorrhage (n = 2), ventriculomegaly (n = 2), and porencephaly (n = 1). An additional finding by MRI was porencephaly in 1 fetus. In part 2, echogenic material in the frontal horns was identified in 3 of 400 fetuses (0.8%). In part 3, hemorrhage was probably or definitely present in 11 of the 20 fetuses with abnormalities; material looked like a cyst in 6; and normal choroid was in an abnormal position in 2 and a normal position 1. Of 19 fetuses with abnormalities, 14 had a posteriorly symmetric choroid; 9 had material of different echogenicity compared with the choroid; and 17 had an expanded frontal horn. Birth outcomes were abnormal in 7, including platelet abnormalities (n = 2), hemorrhage on imaging or pathologic examination (n = 2), extraventricular hemorrhage (n = 3), and ventriculomegaly (n = 3). CONCLUSIONS: The incidence of echogenic material in the frontal horns is less than 1%. This does not represent the normal location of the choroid plexus and may represent hemorrhage, which may resolve without sequelae or result in ventriculomegaly and porencephaly.

Routine use of modified CT Enterography in patients with acute abdominal pain.

PURPOSE: To evaluate routine use of CT Enterography (CTE) in patients presenting with non-traumatic acute abdominal pain with respect to patient tolerance, imaging of intestinal detail along with conventional abdominal evaluation. MATERIALS AND METHODS: Modified CTE was performed in 165 consecutive patients with acute abdominal pain: ingestion, as tolerated, of 900-1200 ml of 2% barium suspension + 5 ml of Gastrografin over 45 min; 150 ml of iv contrast given in two boluses (50 and 100 ml) 3 min apart (split bolus injection protocol). Axial, coronal and sagittal reformats were reviewed by two radiologists and graded on a 5-point scale (5 best) in regard to GI tract luminal opacification and distension and abdominal organ and vascular enhancement. RESULTS: In 81 patients the cause of abdominal pain was identified (intestinal in 54 and extraintestinal in 27). Oral contrast reached cecum in 76% of the patients and the small bowel was well distended and opacified (medians=4). Mucosa detail was good (median=3) and there was significant (p<0.0001) correlation between bowel opacification and distension for both jejunum and ileum. A combined nephrographic and excretory phase was achieved (medians 4 and 5, respectively), while the great vessels were well opacified, allowing for vascular evaluation (median=5). The rest of the abdominal structures were well visualized. CONCLUSION: Modified CTE is well tolerated by patients with acute non-traumatic abdominal pain, and can be used routinely as a non-invasive examination informative of bowel, vessel and organ pathology in Emergency Department patients.

Linfangioma quístico abdominal / Cystic lymphangiomas

Los linfangiomas quísticos abdominales son tumores benignos multiloculados poco frecuentes (2 por ciento-8 por ciento de los linfangiomas),de crecimiento lento y derivados de los vasos linfáticos. Se presentan con más frecuencia en la infancia, y la gran mayoría son diagnosticados en niños menores de cinco años. Las manifestaciones clínicas son variable aunque la distensión abdominal es el signo más frecuente. En el artículo se presenta caso de una paciente de dos años con linfangioma quístico abdominal