Management of Acute Contrast Reactions-Understanding Radiologists' Preparedness and the Efficacy of Simulation-Based Training in Canada.

PURPOSE: Acute radiologic emergencies, primarily severe contrast reactions, are rare but life-threatening events. Given a generalized paucity of formalized or mandated training, studies have shown that radiologists and trainees perform poorly when acutely managing such events. Moreover, skill base, knowledge, and comfort levels precipitously decline over time given the infrequent occurrence of these events during one's daily practice. The primary aim of this study was to assess radiologists' preparedness for managing acute radiologic emergencies and to determine the efficacy of a high-fidelity simulation based training model in an effort to provide a rationale for similar programs to be implemented on a provincial or national level. METHODS: This was a prospective, observational study of radiology residents and attending radiologists throughout the province who were recruited to attend a full-day simulation-based course presenting various cases of acute radiologic emergencies. Participant demographics were collected at the time of commencement of the workshop. Course materials were disseminated 4 weeks prior to the workshop, and a 17-question knowledge quiz was administered before and after the workshop. Likert-type questionnaires were also distributed to survey comfort levels and equipment familiarity. The knowledge quiz and questionnaire were redistributed at 3- and 6-month intervals for acquisition of follow-up data. RESULTS: A total of 14 attending radiologists and 7 residents attended the workshop, with all participants completing the preworkshop questionnaire and 90.5% (19 of 21) completing the post-workshop questionnaire. Participants' principle locations of practice were as follows: academic institutions (50%), community hospitals (36.9%), and private clinics (13.1%). A significant increase in knowledge was demonstrated, with average scores of 10 out of 17 (59%) and 14.5 out of 17 (85%) (P < .001) before and after the workshop, respectively. A significant increase in participants' comfort levels in recognizing acute anaphylactic reactions (3.5; 4.7, P < .001), commencing initial management for acute radiologic emergencies (3.3; 5.0, P < .001), and administering the correct dose for anaphylactic reactions (2.5; 4.8, P < .001) was also demonstrated. Moreover, participants became increasingly familiar with the contents and equipment found within contrast reaction kits (2.8; 3.8, P < .01). Repeat evaluations at 3 and 6 months found an average knowledge test score of 13.8 out of 17 (81%) and 10.8 out of 17 (64%), respectively. Comfort levels were also reassessed in recognizing acute anaphylactic reactions (4.5; 4.1), commencing initial management (4.0; 3.9) and administering the correct dose of medication (4.0; 3.7) at 3- and 6-month intervals. CONCLUSIONS: Acute radiologic emergencies are rare but life-threatening events that require rapid diagnosis and treatment to mitigate associated morbidity and mortality. Simulation-based workshops are a highly efficacious training model to increase knowledge, comfort levels, and equipment familiarity for radiologists and trainees alike; however, retraining at regular intervals is required.

The contribution of thoracic vertebral deformity and arthropathy to trunk pain in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND: Pain, commonly localized to the trunk in individuals with COPD, may be due to osteoporosis-related vertebral deformity and chest wall hyper-expansion causing misalignment of joints between the ribs and vertebrae. The purpose of this study was to determine if thoracic vertebral deformity and arthropathy were independent contributors to trunk pain in COPD patients compared to people with a significant smoking history. METHOD: Participants completed the Brief Pain Inventory (BPI) on the same day as chest CT scans and spirometry. Current and ex-smokers were separated into COPD (n = 91) or non-COPD (n = 80) groups based on spirometry. Subsequently, CT images were assessed for thoracic vertebral deformity, bone attenuation values, and arthropathy of thoracic vertebral joints. RESULTS: The trunk area was the most common pain location in both COPD and non-COPD groups. Thoracic vertebral deformity and costotransverse joint arthropathy were independent contributors to trunk pain in COPD patients (adjusted OR = 3.55 and 1.30, respectively) whereas alcohol consumption contributed to trunk pain in the non-COPD group (adjusted OR = 0.35 in occasional alcohol drinkers; 0.08 in non-alcohol drinkers). The spinal deformity index and the number of narrowed disc spaces were significantly positively related to the BPI intensity, interference, and total scores significantly in COPD patients. CONCLUSION: Trunk pain, at least in part, is caused by thoracic vertebral deformity, and costotransverse and intervertebral arthropathy in patients living with COPD. The results of this study provided the foundation for the management of pain, which requires further exploration.

Popping the cap: the constellation of MRI findings in patellofemoral syndrome.

Patellofemoral syndrome (PFS) is a common etiology of anterior knee pain, particularly among young female athletes. Despite recent advancements in the resolution of MRI, there still remains a paucity of literature that has investigated the MRI findings associated with PFS. This pictorial essay will describe our institution's experience with cases of PFS and review what we believe to be a constellation of findings associated with this diagnostic entity. This review will also describe common pitfalls encountered during the diagnosis of PFS.

The Hopeless Case? Palliative Cryoablation and Cementoplasty Procedures for Palliation of Large Pelvic Bone Metastases.

BACKGROUND: Metastases to the bone are common in cancer patients, and it has been estimated that up to 50% of patients with pelvic bone metastases will not achieve adequate pain control with medications alone. This has led to a paradigm shift over recent years towards the use and development of minimally invasive image-guided treatment options for palliation of bony metastases. Despite these developments, large metastatic lesions are still often considered to be "hopeless cases" that would garner little to no benefit from image-guided intervention. This study is the first large series to describe the novel use of combination percutaneous cryoablation and cementoplasty for palliation of such large metastases to the pelvis. OBJECTIVES: We aim to evaluate the efficacy and safety of image-guided percutaneous cryoablation and cementoplasty for palliation of large pelvic bone metastases. STUDY DESIGN: This retrospective analysis was approved by our institutional review board. This study was conducted from January 2013 to December 2016, where consecutive patients referred for pain management of large pelvic bone metastases underwent combination percutaneous cryoablation and cementoplasty. SETTING: This study took place at a tertiary care center after patients were referred following formal review from a multidisciplinary conference, which was comprised of interventional radiologists, pain management and palliative care physicians, radiation and medical oncologists, and when available, anesthesiologists. METHODS: Forty-eight patients (36 men and 12 women) with a mean cohort age of 77.5 years (range: 52 - 89 years) were referred from the multidisciplinary conference for palliation of pelvic bone metastases. The inclusion criteria included patients with metastases greater or equal to 5.0 cm and significant pain refractory to conventional pain management regimens. All of the patients were deemed not to be surgical candidates. Mean pain scores were collected at numerous time-points along with procedural technical success rates and complication rates. RESULTS: Combination cryoablation and cementoplasty was performed on 48 consecutively referred patients with a 100% technical success rate and no immediate complications. The pain levels demonstrated a significant decrease (P < 0.001) following intervention, with mean pain scores of 7.9 (range: 5 - 10) and 1.2 (range: 0 - 7) throughout the week prior to intervention and at 24 hours post-intervention, respectively. The post-intervention pain scores remained stable at 1 to 9 weeks follow-up (mean: 4.1 weeks). Three patents (6.3%) reported no change in pain following the intervention; however, no patients reported worsened pain. LIMITATIONS: The limitations of this study include its retrospective nature and the length of follow-up, which was often restricted given the life expectancy of our patient cohort. CONCLUSION: Combination cryoablation and cementoplasty is a novel and efficacious treatment option for palliation of large pelvic bone metastases. Marked improvements in pain, as well as mobility and quality of life, are often attainable. KEY WORDS: Pain, palliative care, palliation, percutaneous, cryoablation, cementoplasty, metastases, pelvis, interventional radiology, thermal ablation.

Dual-Energy CT for the Musculoskeletal System.

The principal advantages of dual-energy computed tomography (CT) over conventional CT in the musculoskeletal setting relate to the additional information provided regarding tissue composition, artifact reduction, and image optimization. This article discusses the manifestations of these in clinical practice-urate and bone marrow edema detection, metal artifact reduction, and tendon analysis, with potential in arthrography, bone densitometry, and metastases surveillance. The basic principles of dual-energy CT physics and scanner design will also be discussed. © RSNA, 2016.

Getting the Most From Your Dual-Energy Scanner: Recognizing, Reducing, and Eliminating Artifacts.

OBJECTIVE: Dual-energy CT (DECT) is an innovative imaging modality that allows superior detection of pulmonary embolism, enhanced detection of urate in gout, and improved assessment of metal prostheses when compared with conventional CT. CONCLUSION: The primary aim of this review is to describe these DECT protocols and compare each to its respective diagnostic reference standards. Moreover, this review will describe how to recognize, reduce, and eliminate DECT artifacts, thereby maximizing its diagnostic capabilities.

CT-guided percutaneous cryoablation for osteoid osteoma: initial experience in adults.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of CT-guided percutaneous cryoablation for the treatment of osteoid osteoma in adults. MATERIALS AND METHODS: A retrospective case series over a 30-month period involved 10 consecutive adult patients (nine male and one female patients; mean age, 27.9 years; age range, 16-49 years) who underwent CT-guided percutaneous cryoablation for management of osteoid osteoma. Clinical and technical success was evaluated with postprocedure MRI at 4-5 weeks and with digital numeric pain scores taken before and immediately after the procedure, as well as at primary follow-up (4-10 weeks; average, 5 weeks) and secondary follow-up (23-29 weeks; average, 24 weeks). RESULTS: Clinical and technical success rates were 100%. Average digital numeric pain scores were 7.4 before the procedure, 1.5 after procedure, 0.5 at the primary follow-up, and 0.3 at secondary follow-up. No minor or major complications were noted during the procedure, recovery period, primary follow-up, or secondary follow-up. CONCLUSION: CT-guided percutaneous cryoablation is safe and effective in the treatment of osteoid osteoma in adults.

Peering through the glare: using dual-energy CT to overcome the problem of metal artefacts in bone radiology.

OBJECTIVE: Imaging of patients with large metal implants remains one of the most difficult endeavours for radiologists. This article reviews the theory of dual-energy CT (DECT) and its ability to reduce metal artefact, thus enhancing the diagnostic value of musculoskeletal imaging. The strengths, weaknesses, and alternative applications of DECT, as well as areas requiring further research, will also be reviewed. CONCLUSION: Currently, DECT stands as the frontier for metal artefact reduction in musculoskeletal imaging. DECT requires no additional radiation and provides significantly enhanced image acquisition. When considered along with its other capabilities, DECT is a promising new tool for musculoskeletal and trauma radiologists.