The prognostic value of quantitating and localizing F-18 FDG uptake in cardiac sarcoidosis.

BACKGROUND: There is no identified level of FDG uptake in cardiac sarcoidosis (CS) associated with increased risk of arrhythmias, conduction disease, heart failure, or death. We aim to utilize standardized uptake value (SUV) quantitation and localization to identify patients at increased risk of cardiac events. METHODS AND RESULTS: F18-FDG PET/CT with MPI was used in CS diagnosis (N = 67). Mean and max SUV were measured and grouped as basal, mid, and apical disease. Post-scan ventricular tachycardia, AICD placement, complete heart block, pacemaker placement, atrial fibrillation, heart failure, and cardiac-related hospital admissions were recorded (mean follow up 2.98 ± 2 years). Poisson regression analysis revealed that max SUV, mean SUV, as well as mean basal SUV, and LVEF were significantly associated with total cardiac events. Max SUV odds ratio (OR) = 1.068 (95% CI 1.024-1.114, P = 0.002), mean SUV OR = 1.059 (95% CI 1.008-1.113, P = 0.023), mean SUV OR = 1.061 (95% CI 1.012-1.112, P = 0.014), scan LVEF OR = 0.731 (95% CI 0.664-0.805, P < 0.001). CONCLUSIONS: SUV at time of CS diagnosis has significant associations with future cardiac events. Patients with higher SUV, particularly in basal segments, are at increased risk of events. Further studies are needed to identify treatment methods utilizing risk stratification of CS.

A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis.

BACKGROUND: Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy. METHODS: We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports. RESULTS: Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively). CONCLUSION: Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might replace the need for computed tomography imaging in a majority of patients. LEVEL OF EVIDENCE: Diagnostic Test, Level III.

Comparative efficacy of Prolene and Prolene-Vicryl composite mesh for experimental ventral hernia repair in dogs.

In this study, efficacy of two hernia mesh implants viz. conventional Prolene and a novel Prolene-Vicryl composite mesh was assessed for experimental ventral hernia repair in dogs. Twelve healthy mongrel dogs were selected and randomly divided into three groups, A, Band C (n=4). In all groups, an experimental laparotomy was performed; thereafter, the posterior rectus sheath and peritoneum were sutured together, while, a 5 × 5 cm defect was created in the rectus muscle belly and anterior rectus sheath. For sublay hernioplasty, the hernia mesh (Prolene: group A; Prolene-Vicryl composite mesh: group B), was implanted over the posterior rectus sheath. In group C (control), mesh was not implanted; instead the laparotomy incision was closed after a herniorrhaphy. Post-operative pain, mesh shrinkage and adhesion formation were assessed as short term complications. Post-operatively, pain at surgical site was significantly less (P<0.001) in group B (composite mesh); mesh shrinkage was also significantly less in group B (21.42%, P<0.05) than in group A (Prolene mesh shrinkage: 58.18%). Group B (composite mesh) also depicted less than 25% adhesions (Mean ± SE: 0.75 ± 0.50 scores, P≤0.013) when assessed on the basis of a Quantitative Modified Diamond scale; a Qualitative Adhesion Tenacity scale also depicted either no adhesions (n=2), or, only flimsy adhesions (n=2) in group B (composite mesh), in contrast to group A (Prolene), which manifested greater adhesion formation and presence of dense adhesions requiring blunt dissection. Conclusively, the Prolene-Vicryl composite mesh proved superior to the Prolene mesh regarding lesser mesh contraction, fewer adhesions and no short-term follow-up complications.

The Role of Report Comparison, Analysis, and Discrepancy Categorization in Resident Education.

OBJECTIVE: The purpose of this study was to show the value of automated radiology report comparison and analysis in resident education by providing qualitative and quantitative feedback on the discrepancies between preliminary and finalized reports. MATERIALS AND METHODS: Anonymous surveys on dictation practices and the process of reviewing reports were completed by consenting radiology residents and faculty. All 277 reports obtained across all modalities during the 4-week study were retrieved from the dictation server in both their preliminary and finalized states, for a total of 544 reports. Disparities between these reports were automatically compared side by side and were categorized according to clinical relevance, report quality, or report structure. The frequency of report corrections was compared between junior (postgraduate years [PGYs] 2 and 3) and senior (PGYs 4 and 5) residents. Residents were surveyed regarding the usefulness of the feedback. RESULTS: Eighty-six reports (31%) were verified as unchanged, with no statistically significant difference noted between junior and senior residents (33.2% and 25.9%, respectively; p = 0.03). Of the 370 discrepancies noted in the 191 edited reports, 81 (21.9%) were discrepancies in clinically relevant findings; 106 (28.6%) were discrepancies in report quality; and 183 (49.5%) were discrepancies in report structure, syntax, or both. Although senior residents had a lower rate of discrepancies in the clinical relevance category than did junior residents (12.8% and 26.5%; p = 0.004), they had a higher rate of discrepancies in the report quality category (58.4% and 44.9%; p = 0.02). Surveys of both residents and faculty showed strong support for the project. CONCLUSION: Categorization of corrections was deemed useful by residents and can be helpful in assessing elements of reporting accuracy for individual feedback. Quantitative report comparison and analysis show promise in tailoring resident education at the programmatic level as cumulative data are gathered and trends are analyzed.

The floating cardiac fat pad-sign of occult pneumothorax.

Pneumothoraces are a possible sequela of chest trauma with potential morbidity and mortality if not recognized and treated promptly. A portable supine chest radiograph is frequently the first radiologic study performed in the setting of trauma. While large pneumothoraces can be readily recognized on these radiographs, smaller pneumothoraces are missed in up to 15 % of trauma patients. There are many radiographic signs of occult pneumothoraces, and we are presenting a new radiographic sign of occult pneumothorax. The floating cardiac fat pad sign occurs when pleural air collects anteriorly and superiorly in the most non-dependent portion of the chest lifting the pericardial fat pad off the diaphragm. Lung markings are still seen surrounding the pericardial fat pad due to the inflated lower lobe of the lung resting dependently. Rapid and accurate identification of pneumothoraces is critical but often difficult on chest radiographs. Although there are many existing radiographic signs for identification of pneumothorax, prospective identification of small pneumothoraces is still relatively poor. Here, we describe an additional sign which aides in the detection of pneumothoraces, the floating cardiac fat pad. When present, this should prompt further evaluation with chest CT or upright chest radiograph.

Completion CT of Chest, Abdomen, and Pelvis after Acute Head and Cervical Spine Trauma: Incidence of Acute Traumatic Findings in the Setting of Low-Velocity Trauma.

PURPOSE: To determine the frequency of acute traumatic findings in computed tomographic (CT) chest abdomen pelvis (CAP) examinations in patients with acute traumatic head and/or cervical spine injury and no evidence suggesting bodily injury. MATERIALS AND METHODS: After institutional review board approval with a waiver of informed consent was obtained, a HIPAA-compliant retrospective study was performed. A review of the electronic medical records and dictated reports identified patients who met the following criteria: CT-documented acute head and/or cervical spine trauma, CT CAP performed at least 20 minutes after initial brain and/or cervical spine CT, and no evidence of bodily injury at physical examination or on initial plain radiographs. The types of head and/or cervical injury, as well as mechanisms of injury in these patients, were analyzed. The frequency of acute traumatic injury in the CT CAP examinations was also determined, and 95% confidence intervals were calculated. RESULTS: There were 115 patients who met the study criteria (average age, 67.3 years). Sixty-three (54.8%) patients were male. The average injury severity score was 9.3. No patients who met the criteria for this study were found to have an acute traumatic injury to the chest, abdomen, or pelvis. These 115 CT CAP examinations comprised 7.5% (115 of 1530) of all CT CAP examinations performed in the emergency department over the 15-month study period. CONCLUSION: CT CAP examinations rarely if ever reveal acute traumatic injury in patients who have experienced low-velocity trauma and have acute head and/or cervical spine trauma in the absence of evidence of bodily injury.

Reshaping the emergency radiology call experience after the merger of two programs: the Yale experience.

In the summer of 2013, 16 radiology residents from the Hospital of Saint Raphael (HSR) joined the 38 residents of Yale-New Haven Hospital (YNHH) to become a single 54-resident program. This posed a significant challenge given the number of residents and very different call structures of the two institutions. After evaluating the emergency radiology volume at both hospitals, it was determined that implementing YNHH's traditional call system at HSR would increase call by approximately 25 %. In order to negate this increase, the SRC rotation was created at HSR. This Monday-Friday rotation covered by R3s starts at 1 p.m. with afternoon conference. Residents then read cases on a subspecialty service from 2-5 p.m. and then cover the entire hospital until 10 p.m. with a single attending. Because of this rotation, call did not increase for the YNHH residents and third year residents were provided with increased responsibility. For programs not undergoing a merger, call rotations can also be extremely beneficial. These rotations allow third year residents to have more "call-free" weeks prior to the ABR core exam. Also, patient care can be improved, as the shift length for on-call residents is reduced, which has been shown to improve accuracy.

Impact of a dedicated emergency surgical unit on early laparoscopic cholecystectomy for acute cholecystitis.

INTRODUCTION: Emergency general surgery (EGS) accounts for 50% of the surgical workload, and yet outcomes are variable and poorly recorded. The management of acute cholecystitis (AC) at a dedicated emergency surgical unit (ESU) was assessed as a performance target for EGS. METHODS: The outcomes for AC admissions were compared one year before and after inception of the ESU. The impact on cost and compliance with national guidance recommending early laparoscopic cholecystectomy (ELC) within seven days of diagnosis was assessed. RESULTS: The overall ELC rate increased from 26% for the 126 patients admitted in the pre-ESU period to 45% for the 152 patients admitted in the post-ESU period (p=0.001). With those unsuitable for ELC excluded, the ELC rate increased from 34% to 82% (p<0.001). The proportion of patients precluded from ELC for avoidable reasons, particularly owing to 'surgeon preference/skill', was reduced from 69% to 18% (p<0.001). The mean total length of stay (LOS) and postoperative LOS fell by 1.7 days (from 8.3 to 6.6 days, p=0.040) and 2 days (from 5.6 to 3.6 days, p=0.020) respectively. The higher ELC rate and the reduction in LOS produced additional tariff income (£111,930) and estimated savings in bed day (£90,440) and readmission (£27,252) costs. CONCLUSIONS: A dedicated ESU incorporating national recommendations for EGS improves alignment of best practice with best evidence and can also result in financial rewards for a busy district general hospital.

Implementation of a novel emergency surgical unit significantly improves the management of gallstone pancreatitis.

INTRODUCTION: Emergency surgery is changing rapidly with a greater workload, early subspecialisation and centralisation of emergency care. We describe the impact of a novel emergency surgical unit (ESU) on the definitive management of patients with gallstone pancreatitis (GSP). METHODS: A comparative audit was undertaken for all admissions with GSP before and after the introduction of the ESU over a six-month period. The impact on compliance with British Society of Gastroenterology (BSG) guidelines was assessed. RESULTS: Thirty-five patients were treated for GSP between December 2013 and May 2014, after the introduction of the ESU. This was twice the nationally reported average for a UK trust over a six-month period. All patients received definitive management for their GSP and 100% of all suitable patients received treatment during the index admission or within two weeks of discharge. This was a significantly greater proportion than that prior to the introduction of the ESU (57%, p=0.0001) as well as the recently reported national average (34%). The mean length of total inpatient stay was reduced significantly after the ESU was introduced from 13.7 ± 4.7 days to 7.8 ± 2.1 days (p=0.03). The mean length of postoperative stay also fell significantly from 6.7 ± 2.6 days to 1.8 ± 0.8 days (p=0.001). CONCLUSIONS: A dedicated ESU following national recommendations for emergency surgery care by way of using dedicated emergency surgeons and a streamlined protocol for common presentations has been shown by audit of current practice to significantly improve the management of patients presenting to a busy district general hospital with GSP.

Frequency of impaired glucose tolerance and diabetes mellitus in subjects with fasting blood glucose below 6.1 mmol/L (110 mg/dL).

The diagnosis of diabetes mellitus by the available criteria is controversial and relies heavily on fasting glucose results. This cross-sectional study in 2010-2011 aimed to measure the frequency of impaired glucose tolerance and diabetes mellitus in 127 subjects having fasting blood glucose < 7.0 mmol/L and to measure the agreement between different standard diagnostic criteria. Subjects presenting to a laboratory for analysis of fasting blood glucose for excluding diabetes mellitus underwent a 2-hour 75 g oral glucose challenge. A total of 40.6% of subjects with fasting blood glucose from 5.6-6.0 mmol/L had abnormal glucose regulation on the basis ofthe gold standard glucose challenge. Agreement between American Diabetes Association and World Health Organization diagnostic criteria was only fair (kappa = 0.32). Abnormalities of glucose metabolism including impaired glucose tolerance and diabetes mellitus can exist at fasting blood glucose results < 6.1 mmol/L (110 mg/dL).

Frequency of impaired glucose tolerance and diabetes mellitus in subjects with fasting blood glucose below 6.1 mmol/L [110 mg/dL]

The diagnosis of diabetes mellitus by the available criteria is controversial and relies heavily on fasting glucose results. This cross-sectional study in 2010-2011 aimed to measure the frequency of impaired glucose tolerance and diabetes mellitus in 127 subjects having fasting blood glucose < 7.0 mmol/L and to measure the agreement between different standard diagnostic criteria. Subjects presenting to a laboratory for analysis of fasting blood glucose for excluding diabetes meilitus underwent a 2-hour 75 g oral glucose challenge. A total of 40.6% of subjects with fasting blood glucose from 5.6-6.0 mmol/L had abnormal glucose regulation on the basis of the gold standard glucose challenge. Agreement between American Diabetes Association and World Health Organization diagnostic criteria was only fair (kappa =: 0.32). Abnormalities of glucose metabolism including impaired glucose

Impact of adaptive statistical iterative reconstruction on radiation dose in evaluation of trauma patients.

BACKGROUND: A recent study showed that computed tomographic (CT) scans contributed 93% of radiation exposure of 177 patients admitted to our Level I trauma center. Adaptive statistical iterative reconstruction (ASIR) is an algorithm that reduces the noise level in reconstructed images and therefore allows the use of less ionizing radiation during CT scans without significantly affecting image quality. ASIR was instituted on all CT scans performed on trauma patients in June 2009. Our objective was to determine if implementation of ASIR reduced radiation dose without compromising patient outcomes. METHODS: We identified 300 patients activating the trauma system before and after the implementation of ASIR imaging. After applying inclusion criteria, 245 charts were reviewed. Baseline demographics, presenting characteristics, number of delayed diagnoses, and missed injuries were recorded. The postexamination volume CT dose index (CTDIvol) and dose-length product (DLP) reported by the scanner for CT scans of the chest, abdomen, and pelvis and CT scans of the brain and cervical spine were recorded. Subjective image quality was compared between the two groups. RESULTS: For CT scans of the chest, abdomen, and pelvis, the mean CTDIvol (17.1 mGy vs. 14.2 mGy; p < 0.001) and DLP (1,165 mGy·cm vs. 1,004 mGy·cm; p < 0.001) was lower for studies performed with ASIR. For CT scans of the brain and cervical spine, the mean CTDIvol (61.7 mGy vs. 49.6 mGy; p < 0.001) and DLP (1,327 mGy·cm vs. 1,067 mGy·cm; p < 0.001) was lower for studies performed with ASIR. There was no subjective difference in image quality between ASIR and non-ASIR scans. All CT scans were deemed of good or excellent image quality. There were no delayed diagnoses or missed injuries related to CT scanning identified in either group. CONCLUSION: Implementation of ASIR imaging for CT scans performed on trauma patients led to a nearly 20% reduction in ionizing radiation without compromising outcomes or image quality. LEVEL OF EVIDENCE: Therapeutic study, level IV.

SP-D polymorphisms and the risk of COPD.

INTRODUCTION: There are limited data linking serum levels of surfactant protein D, its genetic polymorphisms to the risk of Chronic Obstructive Pulmonary Disease (COPD). OBJECTIVES: We sought to investigate these relationships using a case control study design. METHODS: Post bronchodilator values of FEV1/FVC < 0.7 were used to diagnose COPD patients (n=115). Controls were healthy subjects with normal spirometry (n=106) Single nucleotide polymorphisms (rs721917, rs2243639, rs3088308) were genotyped using polymerase chain reaction (PCR) and restriction analysis. Serum SP-D levels were measured using a specific immunoassay. RESULTS: Allele 'A' at rs3088308 (p < 0.00, B= -0.41) and 'C' allele at rs721917 (p=0.03; B= -0.30) were associated with reduced serum SP-D levels. Genotype 'T/T' at rs721917 was significantly associated with risk of COPD (p=0.01). Patients with repeat exacerbations had significantly higher serum SP-D even after adjusting for genetic factors. CONCLUSIONS: We report for the first time that rs3088308 is an important factor influencing systemic SP-D levels and confirm the previous association of rs721917 to the risk of COPD and serum SP-D levels.

Plerixafor for PBSC mobilisation in myeloma patients with advanced renal failure: safety and efficacy data in a series of 21 patients from Europe and the USA.

We describe 20 patients with myeloma and 1 with primary amyloidosis from 15 centres, all with advanced renal failure, most of whom had PBSC mobilised using plerixafor following previous failed mobilisation by conventional means (plerixafor used up-front for 4 patients). For 15 patients, the plerixafor dose was reduced to 0.16 mg/kg/day, with a subsequent dose increase in one case to 0.24 mg/kg/day. The remaining six patients received a standard plerixafor dosage at 0.24 mg/kg/day. Scheduling of plerixafor and apheresis around dialysis was generally straightforward. Following plerixafor administration, all patients underwent apheresis. A median CD34+ cell dose of 4.6 × 10(6) per kg was achieved after 1 (n=7), 2 (n=10), 3 (n=3) or 4 (n=1) aphereses. Only one patient failed to achieve a sufficient cell dose for transplant: she subsequently underwent delayed re-mobilisation using G-CSF with plerixafor 0.24 mg/kg/day, resulting in a CD34+ cell dose of 2.12 × 10(6)/kg. Sixteen patients experienced no plerixafor toxicities; five had mild-to-moderate gastrointestinal symptoms that did not prevent apheresis. Fifteen patients have progressed to autologous transplant, of whom 12 remain alive without disease progression. Two patients recovered endogenous renal function post autograft, and a third underwent successful renal transplantation. Plerixafor is highly effective in mobilising PBSC in this difficult patient group.

Role of HCT-comorbidity index, age and disease status at transplantation in predicting survival and non-relapse mortality in patients with myelodysplasia and leukemia undergoing reduced-intensity-conditioning hemopoeitic progenitor cell transplantation.

Reduced-intensity-conditioning (RIC) regimens have allowed older patients to have allogeneic hemopoietic progenitor cell transplantation (HCT). This retrospective study was done to assess the impact of the HCT-comorbidity index (HCT-CI) in addition to other pre-transplant factors on the outcome of RIC transplants. In all 121 such patients were transplanted between 2002 and 2008 at two centers using fludarabine, melphalan and alumtuzumab conditioning. The OS and non-relapse mortality (NRM) were 56% and 30% at 2 years, respectively. The NRM of patients with HCT-CI ≥ 3 was not significantly different from the NRM of those with HCT-CI 0-2 (P value 0.24). Age and disease status at transplantation were significant factors affecting OS (P value 0.07 and 0.008, respectively), with no impact on NRM (P value 0.14 and 0.24, respectively). Although HCT-CI on its own did not independently predict NRM or survival, taken together with age and disease status at transplantation, it can be utilized to further delineate RIC allograft recipients into groups with different outcomes. Patients with none or one of these three adverse factors (age ≥ 60 years, leukemia in second CR or PR/high-risk myelodysplasia (MDS) and HCT-CI ≥ 3) had a 2-year NRM and survival of 18% and 80%, respectively, which was significantly better than those of patients with two or more of these adverse factors with 2-year NRM and survival of 46% (P value 0.03) and 40% (P value 0.02), respectively. None of the patients with all three adverse factors (age ≥ 60 years, leukemia in second CR or PR/high-risk MDS and HCT-CI ≥ 3) had survived for 2 years (median survival 12 months). This information can be used to guide patient selection for RIC transplants and to appropriately counsel patients of the risks and benefits of this treatment.

Introducing medical students to radiology as paid emergency department triage assistants.

PURPOSE: The aim of this report is to provide a detailed description of a program employing medical students to assist with triaging off-hour diagnostic imaging studies at a major academic medical center. METHODS: Current and former participants of the Medical student Emergency Department (ED) Radiology Triage Program were interviewed regarding the inception, development, and impact of this program. Student participation and triage activities were compiled and tabulated from scheduling records and triage assistant call logs. RESULTS: Opportunities for medical students to obtain an intensive, well-organized experience in radiology are often absent or occur relatively late during medical school, which can be problematic for developing basic imaging literacy and for making timely, well-informed decisions regarding radiology as a career path. The authors describe a program that provides students with a rigorous, hands-on experience in radiology relatively early in their training by employing medical students to assist the emergency department radiology staff with managing off-hour radiology workflow. Students work with the off-hour emergency department radiologists and staff members answering phone calls and help to facilitate the ordering and protocoling of studies and the dissemination of results to clinicians. CONCLUSIONS: The employment of medical student triage assistants provides in-depth exposure to clinical radiology relatively early in medical school, while providing an effective system to help streamline the off-hour workflow for attending radiologists, residents, technicians, and support staff members.

Gold nanoparticle based microbial detection and identification.

Microorganisms belong to one of the biggest threats to humanity. Rapid detection and identification of microbes in environmental, food and clinical samples is required for safety purposes as well as diagnosis of infectious diseases. Conventional techniques for microbial detection, though reliable and gold standard, are time consuming, expensive and unsuitable for field situations. Advent of novel techniques involving Nanotechnology has been promising for the development of rapid and low cost strategies for rapid detection and identification of microbes with higher sensitivity. Gold nanoparticles find a significant place in medicine, material sciences as well as diagnostics for their unique optical and physiochemical properties. This review focuses at recent advancements in the development of gold nanoparticle based assays for microbial detection and identification.