Are We Speaking the Same Language? Communicating Diagnostic Probability in the Radiology Report.

OBJECTIVE. The purpose of this study was to evaluate the level of agreement in diagnostic probability for selected phrases among radiologists and emergency medicine (EM) physicians. MATERIALS AND METHODS. A survey was distributed to the radiologists and EM physicians at our academic institution. Respondents selected the degree of diagnostic probability they believe was conveyed by 18 commonly used phrases chosen from studies in the radiology literature. Potential responses for the degree of diagnostic probability were < 10%, ≈ 25%, ≈ 50%, ≈ 75%, and > 90%. RESULTS. Seventy-eight percent (28/36) of EM residents and 56% (14/25) of EM attending physicians (combined fellows and attending physicians) completed the survey; 83% (15/18) of radiology residents and 81% (17/21) of radiology attending physicians completed the survey. There was a high degree of shared understanding for most phrases between the departments except for the phrase "compatible with," which was associated with a higher degree of diagnostic probability by radiologists than by EM physicians (p = .02). Although no term was significantly more specific than any other within the ≈ 50% category or below, "most likely" and "diagnostic of" were significantly more specific than other terms in the ≈ 75% and > 90% categories, respectively. CONCLUSION. The results of this study show a high degree of shared understanding between radiologists and EM physicians for most of the phrases (17/18) in the survey. The only phrase that showed a significant difference was "compatible with." These results can be used to generate diagnostic probability groups with suggested phrases that can be used when creating radiology reports, thereby improving communication with the emergency department.

Pediatric Semicircular Canal Dehiscence: Radiographic and Histologic Prevalence, With Clinical Correlation.

OBJECTIVES: To determine the prevalence of radiographic and histologic superior semicircular canal dehiscence (SSCD) and posterior semicircular canal dehiscence (PSCD) and associated changes in temporal bone thickness in children aged 0 to 7 years. STUDY DESIGN: Retrospective chart review and histopathologic review of cadaveric bone specimens. SETTING: Two tertiary referral centers. PATIENTS: Children younger than 7 years who underwent high-resolution computed tomography scan including the temporal bones between 1998 and 2013 and temporal bones harvested from children younger than 7 years. INTERVENTION(S): Two hundred twenty-eight computed tomography studies and 58 temporal bone specimens were reviewed. Available patient demographics were tabulated. MAIN OUTCOME MEASURE(S): Prevalence of SSCD and PSCD and bone thickness over semicircular canals, with comparison across age groups. Clinical data were extracted for patients with radiographic dehiscence. RESULTS: Prevalence by ear of SSCD was 11.9%, 4.9%, 2.8%, and 0% and of PSCD was 16.7%, 2.4%, 1.4%, and 0% in children aged less than 6 months, 6 to 11 months, 12 to 35 months, and 3 to 7 years, respectively. SSCD was statistically more common before 1 year of age and PSCD before 6 months of age. Bone thickness overlying both the SSC and the PSC increased with age. Radiographic PSC bone was significantly thicker than SSC bone in patients older than 12 months. No dehiscences were found in the histologic specimens. CONCLUSION: Radiographic dehiscence of the canals is common in the first 6 months of life, with thin bone seen histologically. Prevalence decreases with increasing age as the bone overlying the canals increases in thickness.

Pulmonary embolism at follow-up outpatient CT pulmonary angiography: implications on patient risk stratification.

The purpose of this study was to determine the prevalence of pulmonary embolism in outpatients who return to care with clinical suspicion of pulmonary embolism and are evaluated by computed tomography pulmonary angiogram (CTPA) after an initial CTPA was negative for pulmonary embolism within the preceding 12 months. Following institutional review board approval, we performed a retrospective review of all CTPAs performed at our institution from June 2006 through June 2009. One hundred and seventy-two outpatients [102 women; mean age 56.7±18.8 (SD)] with an initial CTPA that was negative for pulmonary embolism and a subsequent CTPA within 12 months of their initial study were included in our analysis. Each patient's CTPA was assessed for evidence of pulmonary embolism and their electronic medical records (EMR) reviewed for the presence of risk factors associated with venous thromboembolism (VTE). Fisher exact test (two-tailed) analysis was used to assess whether thromboembolic risk factors had an effect on developing pulmonary embolism after an initial negative CTPA. CTPAs were negative for pulmonary embolism in 165 (96%) of 172 outpatients who returned to care within 12 months after an initial negative CTPA. Eighty-five (49.4%) of 172 patients had no identified thromboembolic risk factors. In the group with no risk factors none (0%) of 85 patients (P=0.028) had pulmonary embolism at the time of repeat CTPA. This may help appropriately triage patients evaluated for pulmonary embolism and reduce the number of unnecessary CTPAs.

Lemierre syndrome: from pharyngitis to fulminant sepsis.

We report a case of a previously healthy 33-year-old male who presented to his primary care physician with nausea, vomiting, diarrhoea and fever. One week prior to presentation the patient reported a history of sore throat which he presumed to be a viral infection and sought no medical attention. Upon hospital presentation, the patient was admitted and rapidly progressed to sepsis and respiratory failure. Goal directed therapy was initiated and the patient was intubated. Further clinical work up included blood cultures revealing Fusobacterium varium bacteraemia, and CT and ultrasound imaging demonstrated thrombosis of the internal jugular vein and septic pulmonary emboli. A diagnosis of Lemierre syndrome was made, and antibiotics as well as anticoagulation therapy were initiated. The patient's clinical condition improved with treatment, and he was discharged home on hospital day 12 with completion of an uneventful 4-week course of outpatient antibiotic and anticoagulation therapy.

Suppression of hypothalamic pro-opiomelanocortin (POMC) gene expression by daily melatonin supplementation in aging rats.

Both plasma melatonin levels and hypothalamic arcuate nucleus pro-opiomelanocortin (POMC) (biosynthetic precursor to the endogenous opioid ss-endorphin and other opiomelanocortins) mRNA content decrease with aging. To test whether the decline in melatonin is responsible for the decline in POMC mRNA, we investigated the effects of daily melatonin treatment on hypothalamic POMC mRNA content in middle-aged and older Sprague-Dawley rats. Daily nocturnal melatonin treatment (50 microg kg bw(-1) night(-1), in the night-time drinking water) for 7 months, starting at 13 months of age, did not significantly alter female arcuate nucleus POMC mRNA content determined at the end of the light period (i.e., before nightly melatonin administration), but suppressed (24%, P < 0.05) POMC mRNA content at the end of the dark period (i.e., following melatonin administration). Likewise, nocturnal administration of 50 or 500 microg melatonin kg bw(-1) night(-1) to male rats for 7 months suppressed (31 or 28%, respectively; P < 0.05) POMC mRNA content at the middle of the dark period at 20 months of age. Finally, 10 wk administration of 30 microg melatonin kg bw(-1) day(-1) suppressed (31%, P < 0.01) POMC mRNA content in middle-aged male rats killed at the end of the dark period. Melatonin treatments did not significantly alter estradiol or testosterone levels. Thus, moderate-dosage nocturnal melatonin supplementation suppressed nocturnal hypothalamic POMC gene expression in both middle-aged males and females, suggesting that melatonin supplementation during aging decreases, rather than increases, forebrain opiomelanocortinergic activity. These POMC responses were apparently not dependent on gonadal steroid responses and did not become refractory to melatonin treatment maintained until old age.

Chronic daily ethanol and withdrawal: 3. Forebrain pro-opiomelanocortin gene expression and implications for dependence, relapse, and deprivation effect.

BACKGROUND: Although forebrain pro-opiomelanocortin (POMC)-producing neurons seem to mediate or modulate many responses to ethanol consumption, changes in activity of this opiomelanocortinergic system in response to chronic ethanol consumption, withdrawal, and subsequent abstinence remain unresolved. METHODS: We investigated the effects of chronic daily ethanol consumption, withdrawal, and subsequent abstinence on adult male Sprague-Dawley rat forebrain opiomelanocortinergic activity as reflected by changes in hypothalamic POMC messenger RNA (mRNA) content by using a well characterized liquid diet model that we have previously demonstrated to accurately simulate not only daily oral ethanol consumption quantity and pattern, but also both neuroendocrine and behavioral changes characteristic of actively drinking and subsequently abstinent alcoholics. RESULTS: After 7 weeks of daily ethanol consumption at night and withdrawal during the day, evening mediobasal hypothalamus POMC mRNA concentrations were suppressed versus both ad libitum-fed and pair-fed controls. Morning POMC mRNA concentrations were also suppressed versus ad libitum-fed controls and tended to be decreased versus pair-fed controls. Three weeks after gradual removal of ethanol from the diet, mediobasal hypothalamus POMC mRNA concentrations were increased relative to ad libitum-fed and pair-fed controls. Plasma concentrations of corticosterone, testosterone, and leptin were also altered by the daily ethanol/withdrawal treatment and by subsequent abstinence. CONCLUSIONS: Because each of these hormones has been demonstrated to modify forebrain POMC gene expression under some conditions, the overall changes in forebrain opiomelanocortinergic regulation in response to chronic daily ethanol/withdrawal and subsequent abstinence probably reflect, at least in part, regulation by multiple endocrine mechanisms, together with responses to stress, development of tolerance during chronic daily ethanol consumption, and rebound of function after termination of this consumption. Overall, the demonstrated changes in forebrain POMC gene expression are consistent with significant roles for forebrain opiomelanocortinergic regulation in mediating alcohol dependence, propensity to relapse, and the alcohol deprivation effect.