Wall suction-assisted image-guided thoracentesis: a safe alternative to evacuated bottles.

AIM: To compare the safety of evacuated bottle-assisted thoracentesis with wall suction-assisted thoracentesis. MATERIALS AND METHODS: An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study of 161 consecutive patients who underwent 191 evacuated bottle-assisted thoracenteses from 1 January 2012 to 30 September 2012, and 188 consecutive patients who underwent 230 wall suction-assisted thoracenteses from 1 January 2013 to 30 September 2013 was conducted. All procedures used imaging guidance. Primary diagnosis, age, gender, total fluid volume removed, and adverse events (AE) up to 30 days post-procedure were recorded and graded using Common Terminology Criteria for Adverse Events 4.0 (CTCAE)2. RESULTS: Overall AE rates were 42.9% (82/191) for the evacuated bottle group and 19.6% (45/230) for the wall suction group (p<0.0001). Grade I AE occurred more commonly in the evacuated bottle group than in the wall suction group, [41.9% (80/191) and 18.3% (42/230)], respectively (p<0.0001). No significant differences were observed in grade 2 [0.5% (1/191) and 0% (0/230), p=0.45] or grade 3 AE [0.5% (1/191) and 1.3% (3/230), p=0.63] between the evacuated bottle and wall suction groups, respectively. No grade 4 or 5 AE occurred. Excluding transient chest pain and cough, there was no statistical difference in overall AE rate between the evacuated bottle and wall suction groups [11% (21/191) and 8.3% (19/230), p=0.4]. CONCLUSION: Image-guided thoracentesis performed with wall suction is safe when compared to evacuated bottles. The use of wall suction, in comparison to evacuated bottles, may decrease the incidence of transient chest pain or cough.

Restoration of morphine-induced alterations in rat submandibular gland function by N-methyl-D-aspartate agonist.

The effects of morphine, 1-aminocyclobutane-cis-1,3-dicarboxylic (ACBD; NMDA agonist) and 3-((R)2-carboxypiperazin-4-yl)-propyl-l-phosphoric acid (CPP; NMDA antagonist) and their concurrent therapy on rat submandibular secretory function were studied. Pure submandibular saliva was collected intraorally by micro polyethylene cannula from anaesthetized rats using pilocarpine as secretagogue. Intraperitoneal injection of morphine (6 mg/kg) induced significant inhibition of salivary flow rate, total protein, calcium, and TGF-beta1 concentrations. Administration of ACBD (10 mg/kg) and CPP (10 mg/kg) alone did not influence secretion of submandibular glands. In combination therapy, coadministration of CPP with morphine did not influence morphine-induced changes in salivary function while ABCD could restore all morphine-induced changes. In combination treatment, ACBD prevented morphine-induced reduction of flow rate, total protein, calcium, and TGF-beta1 and reached control levels. It is concluded that morphine-induced alterations in submandibular gland function are mediated through NMDA receptors.

Protection by Ziziphora clinopoides of acetic acid-induced toxic bowel inflammation through reduction of cellular lipid peroxidation and myeloperoxidase activity.

Inflammatory bowel disease (IBD) is a chronic condition of the intestine with unknown etiology involving multiple immune, genetic and environmental factors. We were interested in examining the effect of a total extract from Ziziphora clinopoides, an Iranian folk herbal medicine, in the prevention and control of experimental mouse IBD. Z. clinopoides was administered (75, 150, 300 mg/kg) through drinking water to mice, which dispensed a toxic dose of acetic acid intrarectally. Prednisolone was used as the standard drug for comparison. Biochemical, macroscopic and microscopic examinations of the colon were performed. Biochemical evaluation of the inflamed colon was carried out using assays of myeloperoxidase (MPO) activity and thiobarbituric acid reacting substances (TBARS) as indicators of free radical activity and cellular lipid peroxidation. Results indicated that the activity of MPO and lipid peroxidation products (TBARS) increased in acetic acid-treated groups, while recovered by pretreatment of animals with Z. clinopoides (75-300 mg/kg) and prednisolone. All doses of Z. clinopoides and prednisolone-treated groups showed significant lower score values of macroscopic and microscopic characters when compared to the acetic acid-treated group. The beneficial effect of Z. clinopoides (300 mg/kg) was comparable to that of prednisolone. It is concluded that Z. clinopoides inhibits acetic acid toxic reactions in the mouse bowel through inhibition of cellular oxidative stress. Proper clinical investigation should be carried out to confirm the same activity in human.

Abdominal cross-sectional imaging for inpatients with abnormal liver function test results: yield and usefulness.

BACKGROUND: Abdominal cross-sectional imaging is often performed to evaluate abnormal liver function test (LFT) results in hospitalized patients. However, few data are available regarding the yield and usefulness of imaging inpatients for the indication of abnormal LFT results, the process of requesting abdominal imaging studies, or the response to their findings. METHODS: We retrospectively reviewed abdominal imaging scans that were obtained during a 27-month period. We matched the imaging studies done with the indication of abnormal LFT results; all scans were requested using computerized physician order entry. Reports were coded for interpretation and associated process step results. To determine the usefulness of the imaging studies, a random sample of patient charts with positively coded imaging studies were reviewed. Imaging examinations were considered useful if they provided new diagnostic information and/or changed subsequent patient care. RESULTS: Of 6494 abdominal imaging studies, 856 were performed for the indication of abnormal LFT results and matched to both image reports and laboratory results. Report coding judged 37% of interpretations as clinically significant, including 27% with "positive" (abnormal results and explain the abnormal LFT results) examinations. Among the positive examinations, the most common diagnoses were biliary obstruction (25%), cholecystitis (21%), malignancy (20%), and cirrhosis (14%). Positively coded reports provided new clinical information in 63% of these studies and changed patient care in 42% of cases. Process measures assessed provision of additional information to and from radiologists (69% and 8%, respectively) and the frequency with which the findings of current abdominal imaging studies were compared with those of prior studies (59%). CONCLUSION: Abdominal cross-sectional imaging studies performed on inpatients with abnormal LFT results had a high diagnostic yield and frequently changed patient care.

Modality interfacing: the impact of a relay station.

We evaluated the effect of a deploying a relay station on demographic discrepancies, image segmentation for routing, quality control (QC), and technologist workflow in a distributed architecture type picture archiving and communication system (PACS) environment. A currently existing PACS environment for computed tomography (CT) was evaluated before and after the implementation of a relay station for demographic error-rate and correct study routing to the workstations. Assessment of the technologists' perceptions with respect to numerous workflow factors was performed with a questionnaire. Statistical analysis was performed using a chi-square test. The demographic error rate for CT examinations was nearly abolished with relay station deployment (14.0% pre-Relay v 0.55% post-Relay, P < .001, chi2). The technologists' perception was favorable, with a substantial majority indicating that a positive impact is made on correcting demographic errors (90%), facilitating QC (67%), and ensuring proper routing (77%). A majority also felt the user interface was intuitive (93.3%) and preferred relay (90%) over film handling but that training should be provided both by didactic sessions and "hands on" time with a trainer. The times to perform tasks were favorable for the relay station (1 to 5 minutes) versus film production and handling (2 to 15 minutes). In conclusion, the relay station prospectively eliminates demographic errors, effectively segments images from the same study routing them to different workstations, and can be seamlessly integrated into the technologists' current workflow. This can be scalable and a lower cost solution as opposed to deploying dedicated PACS QC workstations.

Multidisciplinary gastrointestinal cancer clinic: abdominal radiologist as active participant.

RATIONALE AND OBJECTIVES: Abdominal radiologists actively participated and provided subspecialty radiologic expertise in a multidisciplinary gastrointestinal cancer clinic that served a tertiary referral center. The purpose of this study was to evaluate the feasibility and nonradiologists' opinions of this new approach to radiologic consultation. MATERIALS AND METHODS: One of four subspecialty-trained abdominal radiologists joined physicians from four other subspecialties in staffing weekly 4-hour clinic sessions. Images were reviewed, opinions on test selection and interventional options rendered, and patients met with when interventional options were considered. Radiologists were compensated a fixed sum for each session. A survey of nonradiologists' opinions about the radiologists' active participation was conducted after 15 months (61 clinic sessions). RESULTS: Abdominal radiologists' active participation was feasible and highly regarded by nonradiologist physicians. Specific benefits cited in the survey included improved interpretation, more efficient use of nonradiologist physician time, and improved rapport between radiologists and nonradiologists. Nonradiologist physicians believed that patient care was improved and that the radiologists' participation should continue. CONCLUSION: The active participation of abdominal radiologists in a multidisciplinary gastrointestinal cancer clinic is feasible and highly regarded by nonradiologists.

Correlation of diagnostic imaging and subsequent autopsy findings in patients with pulmonary embolism.

OBJECTIVE: We determined the frequency of correct antemortem diagnosis in patients who underwent lung scintigraphy for suspected pulmonary embolism and for whom the pulmonary embolism was proven at autopsy. MATERIALS AND METHODS: We performed a longitudinal follow-up study of 1210 consecutive patients who underwent scintigraphic imaging for suspected pulmonary embolism. Patients for whom pulmonary embolism was proven at autopsy within 30 days of lung scintigraphy were studied. Diagnostic testing and risk factors were compared in patients with and without an antemortem diagnosis of pulmonary embolism. RESULTS: The antemortem diagnosis was made in four of eight patients with autopsy-proven pulmonary embolism, yielding a sensitivity of 0.5 (95% confidence interval, 0.16-0.84). The diagnosis was made by high-probability lung scintigraphy in two patients, by pulmonary arteriography in one patient, and by lower extremity venous sonography in another patient. The imaging investigation for suspected pulmonary embolism included only lung scintigraphy in four patients in whom the antemortem diagnosis was incorrect: two with low-probability scintigraphy and two with intermediate-probability scintigraphy. Risk factors were similar for patients with and without pulmonary embolism. CONCLUSION: In this cohort study of patients suspected of having pulmonary embolism, the antemortem diagnosis was not made in 50% of patients in whom pulmonary embolism was later proven at autopsy. Underuse of diagnostic testing may have been to blame. We therefore believe that further study is needed to help identify patients with suspected pulmonary embolism who may benefit from additional diagnostic testing after low- or intermediate-probability lung scintigraphy.

Web-based digital radiology teaching file: facilitating case input at time of interpretation.

OBJECTIVE: Our goal was to develop a software system that allows easy and rapid input of digital radiology images and text reports, at the time of interpretation, into an easily searchable electronic teaching file database using the Internet and the World-Wide Web protocols, servers, and browsers. CONCLUSION: Using the Internet, the World-Wide Web, and our software system, we can rapidly input digital radiology images and associated text reports into an easily searchable database accessed by privileged users. This inexpensive and simple method for building a digital teaching file database allows cross-platform access for users who have a Web browser.

Trends in the use of radiology with inpatients: what has changed in a decade?

OBJECTIVE: Our goal was to evaluate trends in the use of radiology with inpatients in the 10-year period of 1984-1993. MATERIALS AND METHODS: We retrospectively reviewed administrative data from a 751-bed, tertiary care hospital between October 1, 1983, and September 30, 1993 (Fiscal years 1984-1993). We coded each study by imaging technique: CT, MR imaging, sonography, nuclear medicine, or conventional studies (plain films and fluoroscopy). Echocardiography, cardiac catheterization, and angioplasty procedures were omitted. The number of admissions per year was adjusted for severity of disease (case-mix-adjusted admission [CMA]). We used relative value units to evaluate workload changes during the study period. We assessed significance of trends using linear regression analysis. RESULTS: The total number of imaging studies per CMA decreased during the study period (p = .0001). This was due to a decrease in the number of conventional studies (p = .0001) and sonograms per CMA (p = .02), despite significant increases in the numbers of CT (p = .005) and MR imaging (p = .0001) studies per CMA. No significant change existed in the number of nuclear medicine studies per CMA (p = .11). The global, professional, and technical relative value units per CMA rose during the latter half of the study. CONCLUSION: The overall number of imaging studies per CMA decreased during the decade, despite a significant rise in the use of CT and MR imaging, suggesting that these new imaging techniques are replacing older ones. To control further increases in overall imaging costs, priority should be placed on understanding the patterns of use for CT and MR imaging techniques and curbing their inappropriate use.

Percutaneous abdominal biopsy: cost-identification analysis.

PURPOSE: To determine the difference in cost to providers of percutaneous abdominal biopsy as the first strategy versus surgical biopsy. MATERIALS AND METHODS: Cost of tissue diagnosis determination with percutaneous biopsy as the first strategy in 439 patients with an abdominal mass was estimated. Costs included direct hospital costs and professional costs of initial and repeat biopsy, follow-up imaging and clinic visits, surgical biopsy (when needed), and treatment of complications. The sum of these costs was compared with the estimated cost had the same patients undergone surgical biopsy instead, with no complications or need for follow-up or repeat biopsy. RESULTS: The total estimated cost of percutaneous biopsy as the first strategy ($543,245) was less than the cost had surgical biopsy been used alone ($1,919,867). The average per patient direct hospital cost of percutaneous biopsy ($800) was lower than that of surgical biopsy ($3,419). The average per patient professional cost of percutaneous biopsy ($438) was also lower than that of surgical biopsy ($955). Savings averaged $3,136 per patient, or $1,376,622 for the study period. CONCLUSION: Substantial health care cost savings may result by using a diagnostic algorithm in which percutaneous biopsy is the first strategy for establishment of a diagnosis in patients suspected of having abdominal malignancy.

Automated evidence-based critiquing of orders for abdominal radiographs: impact on utilization and appropriateness.

OBJECTIVE: Inappropriate utilization of diagnostic testing has been well documented. The purpose of this study was to measure the impact of presenting real time, evidence-based critiques about the appropriateness of abdominal radiograph (KUB) orders on physician decision making. DESIGN: Prospective trial where evidence-based critiques were presented to ordering clinicians in two kinds of situations: (1) a KUB was likely to have a low probability of providing useful information, or (2) an alternative view(s) was more appropriate given the clinical circumstance. There were two phases of the trial: Phase 1 was a 9-week period where evidence-based critiques were presented at the time of ordering a KUB, followed by Phase 2, a 19-week period in which orderers were randomized to receive critiques either amended to include both institutional data regarding the utility of the critiques and stronger messages about the lack of utility of the study, or the same critiques as presented in Phase 1, depending upon indication. Based upon the radiologist's report of their interpretation of the exams, the results of the examinations were scored as positive, equivocal, or negative using structured criteria. RESULTS: 299 KUBs in Phase 1 and 385 KUBs in Phase 2 received at least one critique. Cancellation rates of low yield films were low, and were similar in Phase 1 and 2, 8/258 (3%) vs. 10/283 (4%). Compliance with the recommendation for alternative view(s) was higher: 19/104 (38%) in Phase 1 vs. 96/176 (55%) in Phase 2 (p = 0.006). The results differentiated low-yield from non-low-yield films: 5% of low-yield films vs. 20% of non-low-yield films were positive in Phase 2 (p < 0.0001). Surgical physicians were less likely to cancel (p = 0.07) or to change to the suggested view(s) (p < 0.0001) than medical physicians or nurses. CONCLUSIONS: The intervention identified clinical situations in which KUBs appeared to have a low clinical yield. In response to evidence-based critiques, providers were reluctant to cancel their order, but were more willing to change to different views. To reduce the number of inappropriate radiographic films, stronger incentives or interventions may be required.

Treatment of patients with suspected pulmonary embolism and intermediate-probability lung scans: is diagnostic imaging underused?

OBJECTIVE: We compared patient treatment with imaging strategy in patients with clinically suspected pulmonary embolism (PE) and intermediate-probability lung scans (IPLS). MATERIALS AND METHODS: We retrospectively reviewed the medical records of 214 consecutive patients with clinically suspected PE with IPLS. RESULTS: Treatment (full anticoagulation, filter placement, or both) was given in 66 (31%) of 214 patients. Only 37% of patients were treated on the basis of definitive diagnostic imaging results. Most patients (134 [63%] of 214) were treated without an imaging diagnosis: 30 (14%) of 214 patients were treated for acute PE on clinical grounds, and the diagnosis of PE was not excluded in 104 (49%) of 214 patients. CONCLUSION: Most patients with IPLS are treated without a definitive imaging diagnosis. This lack of diagnosis may result in the overtreatment of patients who do not have acute PE or, more importantly, in the undertreatment of patients who do have acute PE. Further studies are necessary to evaluate the impact of the current management strategies on patient outcome.

Torsion of intraabdominal testicular tumors. A case report.

BACKGROUND: Torsion of an intraabdominal testicular tumor is a rare event. We report a new case and review the literature. METHODS: A review of the literature was carried out in order to identify reported cases of an intraabdominal testicular tumor undergoing torsion of its vascular pedicle. Data on histologic type, common presenting signs and symptoms, radiographic studies, and adjuvant therapy were tabulated. RESULTS: There are 36 reports of an intraabdominal testicular tumor presenting with torsion. The most common histologic types, in descending order, were seminoma, sarcoma, teratoma, embryonal carcinoma, and choriocarcinoma. Common presenting signs and symptoms included pain and/or tenderness, fever, nausea and/or vomiting, and a palpable mass. Most seminoma patients received adjuvant radiation therapy whereas one patient with choriocarcinoma received adjuvant chemotherapy. CONCLUSIONS: Although a rare event, the diagnosis of torsion of an intraabdominal testicular tumor should be considered in any patient presenting with an acute abdomen and a history of cryptorchidism. The presence of a mass may raise the index of suspicion. Preoperative investigation with computed tomography scanning may aid surgical planning.

Inside BrighamRAD: providing radiology teaching cases on the Internet.

The Internet provides opportunities for widely distributing educational materials such as teaching files. Since a teaching file is both a tradition and a requirement in an accredited diagnostic radiology training program, many of the same resources can be committed to designing it for Internet access. The advantages include easier availability for the department residents and fellows, communication to a wider audience, the opportunity for networking and collaboration with other institutions during development, and making information available for more rapidly than traditional publications. Since material available on the Internet represents an alternative means of publication, all cases in an electronic teaching file, as is the case with BrighamRad, should be subject to peer review. A successful computer-based teaching file requires department-wide commitment of trainees and staff as well as additional expertise in multimedia instruction, computer-based graphics and design, image manipulation, programming, and database management. Quality efforts take time and require continual adaptation and support as technology and the laws and customs governing the use of electronically published material evolve. The process should be ongoing, and the departmental commitment must be long term and continuous.

Interactive MR-guided biopsy in an open-configuration MR imaging system.

PURPOSE: To describe new techniques for percutaneous biopsy with use of an open-configuration magnetic resonance (MR) imaging system with integrated frameless stereotaxic guidance tools. MATERIALS AND METHODS: In 28 patients, biopsy was performed in which the image plane was interactively controlled by the position of a hand-held probe attached to the biopsy needle. An icon integrated into the image was used to guide needle advancement in three planes orthogonal to the needle. In vitro measurements of spatial accuracy were also performed. RESULTS: Diagnostic tissue was retrieved in 25 of 28 patients. The system was most accurate near the isocenter with a maximum measured error of 3.1 mm within a sphere of radius 2.5 cm about the isocenter. CONCLUSION: MR-guided biopsy with a frameless stereotaxic technique is safe and accurate. Image feedback is near real time, and the procedure is interactive. These techniques may be used to perform MR-guided biopsies and to place probes for MR-guided therapies.

Asymptomatic functional popliteal artery entrapment: demonstration at MR imaging.

PURPOSE: To determine if functional popliteal entrapment can occur in healthy subjects and to define the mechanism of vascular compression. MATERIALS AND METHODS: The right lower extremities were examined in 13 subjects (nine men 27-34 years of age, mean age 31 years; four women 29-44 years of age, mean age 34 years) with no symptoms of popliteal artery entrapment. Magnetic resonance (MR) and Doppler ultrasound images were obtained while the subjects were at rest and while they performed plantar flexion against resistance. RESULTS: Blood flow during plantar flexion ceased in nine of 13 subjects (69%) and was impaired in three of 13 (23%). MR images showed muscular compression of the popliteal artery at two levels: between the plantaris muscle and the medial head of the gastrocnemius muscle and between the plantaris and popliteus muscles. CONCLUSION: Functional impairment of popliteal arterial flow during plantar flexion occurs in subjects who have no symptoms of popliteal entrapment syndrome.