Optimizing emergency department imaging utilization for pulmonary emboli: A study on the effects of IV contrast rationing.

PURPOSE: To study the impact of a contrast mitigation protocol on imaging utilization for pulmonary embolism (PE) in the emergency department (ED). MATERIAL AND METHODS: Medical records of ED patients with suspected PE who underwent CT pulmonary angiography (CTPA) or ventilation-perfusion (VQ) scans were analyzed in control (3/15/22-4/15/22) and test (5/15/22-6/15/22) periods. The test period included a contrast mitigation protocol due to a global iodinated contrast shortage (05/2022-06/2022). Out of 610 scans, 28 were excluded for non-PE indications. Patient demographics, time metrics, and imaging reports were recorded. RESULTS: Among 11,019 ED visits, there were 582 imaging events for suspected PE. The test period exhibited a significantly lower imaging rate of 4.16 % compared to 6.54 % in the control period (p < 0.001). CTPA usage decreased by 47.73 %, while VQ scan usage increased by 775.00 % during the test period. Test period positivity rate was 0.82 %, with CTPA at 0.58 % (1/173) and VQ scan at 1.43 % (1/70). In the control period, the positivity rate was 0.29 %, with CTPA at 0.30 % (1/331) and VQ scan at 0.00 % (0/8). Previous hospitalization history was significantly higher in the test period (70/243 vs. 39/339, p < 0.001). The positivity rates between the two periods showed no significant difference (p = 0.57). There were no significant differences in ED length of stay and image acquisition times. CONCLUSION: The contrast mitigation protocol reduced CTPA use, increased VQ scans, and maintained positivity rates and image acquisition times. However, concerns persist about unnecessary imaging and low positivity rates, necessitating further research to optimize PE diagnostic algorithms.

Performing Quality Control on Magnetic Resonance Imaging Liver Fat/Iron Quantification Studies: A Critical Requirement.

OBJECTIVE: Nonalcoholic fatty liver and iron overload can lead to cirrhosis requiring early detection. Magnetic resonance (MR) imaging utilizing chemical shift-encoded sequences and multi-Time of Echo single-voxel spectroscopy (SVS) are frequently used for assessment. The purpose of this study was to assess various quality factors of technical acceptability and any deficiencies in technologist performance in these fat/iron MR quantification studies. METHODS: Institutional review board waived retrospective quality improvement review of 87 fat/iron MR studies performed over a 6-month period was evaluated. Technical acceptability/unacceptability for chemical shift-encoded sequences (q-Dixon and IDEAL-IQ) included data handling errors (missing maps), liver field coverage, fat/water swap, motion, or other artifacts. Similarly, data handling (missing table/spectroscopy), curve-fit, fat- and water-peak separation, and water-peak sharpness were evaluated for SVS technical acceptability. RESULTS: Data handling errors were found in 11% (10/87) of studies with missing maps or entire sequence (SVS or q-Dixon). Twenty-seven percent (23/86) of the q-Dixon/IDEAL-IQ were technically unacceptable (incomplete liver-field [39%], other artifacts [35%], significant/severe motion [18%], global fat/water swap [4%], and multiple reasons [4%]). Twenty-eight percent (21/75) of SVS sequences were unacceptable (water-peak broadness [67%], poor curve-fit [19%] overlapping fat and water peaks [5%], and multiple reasons [9%]). CONCLUSIONS: A high rate of preventable errors in fat/iron MR quantification studies indicates the need for routine quality control and evaluation of technologist performance and technical deficiencies that may exist within a radiology practice. Potential solutions such as instituting a checklist for technologists during each acquisition procedure and routine auditing may be required.

Are Academic Emergency Radiologists Systematically Disadvantaged Compared With Diagnostic Radiology Subspecialty Counterparts When It Comes to Promotion?

PURPOSE: The aim of this study was to assess academic rank differences between academic emergency and other subspecialty diagnostic radiologists. METHODS: Academic radiology departments likely containing emergency radiology divisions were identified by inclusively merging three lists: Doximity's top 20 radiology programs, the top 20 National Institutes of Health-ranked radiology departments, and all departments offering emergency radiology fellowships. Within departments, emergency radiologists (ERs) were identified via website review. Each was then matched on career length and gender to a same-institutional nonemergency diagnostic radiologist. RESULTS: Eleven of 36 institutions had no ERs or insufficient information for analysis. Among 283 emergency radiology faculty members from 25 institutions, 112 career length- and gender-matched pairs were included. Average career length was 16 years, and 23% were women. The mean h indices for ERs and non-ERs were 3.96 ± 5.60 and 12.81 ± 13.55, respectively (P < .0001). Non-ERs were twice as likely as ERs (0.21 versus 0.1) to be associate professors at h index < 5. Men had nearly 3 times the odds of advanced rank compared with women (odds ratio, 2.91; 95% confidence interval, 1.02-8.26; P = .045). Radiologists with at least one additional degree had nearly 3 times the odds of advancing rank (odds ratio, 2.75; 95% confidence interval, 1.02-7.40; P = .045). Each additional year of practice increased the odds of advancing rank by 14% (odds ratio, 1.14; 95% confidence interval, 1.08-1.21; P < .001). CONCLUSIONS: Academic ERs are less likely to achieve advanced rank compared with career length- and gender-matched non-ERs, and this persists even after adjusting for h index, suggesting that academic ERs are disadvantaged in current promotions systems. Longer term implications for staffing and pipeline development merit further attention as do parallels to other nonstandard subspecialties such as community radiology.

Time ratio disparities among ED patients undergoing head CT.

PURPOSE: To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities. METHODS: This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups. RESULTS: A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001). CONCLUSIONS: Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.

Are disparities in emergency department imaging exacerbated during high-volume periods?

PURPOSE: Evaluate if disparities in the emergency department (ED) imaging timeline exist, and if disparities are altered during high volume periods which may stress resource availability. METHODS: This retrospective study was conducted at a four-hospital healthcare system. All patients with at least one ED visit containing imaging from 1/1/2016 to 9/30/2020 were included. Peak hours were defined as ED encounters occurring between 5 pm and midnight, while all other ED encounters were non-peak hours. Patient-flow data points included ED length of stay (LOS), image acquisition time, and diagnostic image assessment time. RESULTS: 321,786 total ED visits consisted of 102,560 during peak hours and 219,226 during non-peak hours. Black patients experienced longer image acquisition and image assessment times across both time periods (TR = 1.030; p < 0.001 and TR = 1.112; p < 0.001, respectively); Black patients also had increased length of stay compared to White patients, which was amplified during peak hours. Likewise, patients with primary payer insurance experienced significantly longer image acquisition and image assessment times in both periods (TR > 1.00; p < 0.05 for all). Females had longer image acquisition and image assessment time and the difference was more pronounced in image acquisition time during both peak and non-peak hours (TR = 1.146 and TR = 1.139 respectively with p < 0.001 for both). CONCLUSION: When measuring radiology time periods, patient flow throughout the ED was not uniform. There was unequal acceleration and deceleration of patient flow based on racial, gender, age, and insurance status. Segmentation of patient flow time periods may allow identification of causes of inequity such that disparities can be addressed with targeted actions.

Diagnostic Value of Elastography, Strain Ratio, and Elasticity to B-Mode Ratio and Color Doppler Ultrasonography in Breast Lesions.

PURPOSE: The aim of this study was to investigate the sensitivity, specificity, and diagnostic accuracy of sonoelastography (SE), strain ratio (SR), elasticity to B-mode (E/B) ratio, and color Doppler ultrasonography (US) in suspected breast lesions. MATERIALS AND METHODS: This prospective study was conducted on women referred to Alzahra university hospital of Tabriz for annual screening of breast cancer between May 2017 and December 2018. B-mode US, SE, and color Doppler imaging were conducted in females with suspected mammography reports. The lesions in B-mode were classified according to the Breast Imaging Reporting and Data System (B-RADS). The results of SE imaging were graded based on five-grade SE score. SR and E/B ratio of each lesion were also analyzed in SE images. Color Doppler findings were categorized from 0 (no visible vessel) to 2 (> two vessels) based on the vascularity of the tumor. Pathology results were used as the gold standard to measure the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and diagnostic accuracy of each modality. RESULTS: One-hundred and ten breast lesions of 104 women aged 42.05±10.33 years were included in the study. Seventy-seven of the lesions were benign and 3 were malignant. Sensitivity and specificity of 97.0% and 77.9% for B-mode US, 93.9% and 87.0% for SE score, 81.8% and 66.2% for color Doppler US, 72.7% and 77.6% for E/B ratio (cutoff: 1.05), and 77.3% and 79.6% for SR (cutoff: 1.90) were obtained, respectively. Addition of SE score to B-mode US increased the sensitivity to 93.9%, specificity to 93.5%, and AUC from 0.95 to 0.97. Cumulative color Doppler US with B-mode US did not enhance the diagnostic accuracy of B-mode US. CONCLUSION: SE was more effective than color Doppler US for distinguishing malignant from benign breast lesion. Among the three different SE features, five-grade SE score was superior to E/B ratio and SR.

The predictive value of red cell distribution width for stroke severity and outcome.

OBJECTIVES: In the present study, we sought to investigate the association between red cell distribution width (RDW) and stroke severity and outcome in patients who underwent anti-thrombolytic therapy with tissue plasminogen activator (tPA). RESULTS: In this prospective study, 282 stroke patients who underwent tPA injection were included. The categorization of RDW to < 12.9% and > 13% values revealed insignificant difference in stroke severity score, accounting for the mean 36-h NIHSS of 8.19 ± 8.2 in normal RDW values and 9.94 ± 8.28in higher RDW group (p = 0.64). In seventh day, NIHSS was 6.46 ± 7.28 in normal RDW group and was 8.52 ± 8.35 in increased RDW group (p = 0.058). Neither the 36-h, nor the seventh day and 3-month mRS demonstrated significant difference between those with normal and higher RDW values.

The Effect of Females' Reproductive Factors on Pituitary Gland Size in Women at Reproductive Age.

Background and Objectives: The brain imaging of the pituitary gland in females has shown a change in pituitary size and volume in the female's population. It has been proven that the pituitary gland is affected by pregnancy, giving birth, and hormone-related factors. Therefore, this study aimed to evaluate the factors which may have an impact on the pituitary size in females at reproductive age and compare the pituitary size in females with a history of pregnancy, those at the postpartum period, and nullipara females. Materials and Methods: This population-based study was conducted on 208 healthy women aged 12-55 years old. Participants underwent cranial Magnetic resonance imaging (MRI), and pituitary diameters (craniocaudal, anteroposterior, and transverse) and volume were measured for each subject. The correlation of age, gravity, parity, lactation, and intake of oral contraceptives with pituitary size were analyzed. Results: One-hundred and eighty females met the criteria for participation. The pituitary volume correlated negatively with hormone-related factors. The gravity (r = -0.35) and parity (r = -0.35) had significant negative effects on the pituitary volume (p < 0.001). The use of oral contraceptives and lactation were also in negative correlation with the pituitary volume (r = -0.20, p = 0.006, r = -0.56, p < 0.001, respectively). The craniocaudal diameter was also affected by gravity (r = -0.62), parity (r = -0.57), intake of contraceptives (r = -0.32), and lactation (r = -0.70), p < 0.001. The anteroposterior diameter of the pituitary gland associated significantly with gravity (r = -0.19, p = 0.009), parity (r = -0.20, p = 0.007), and lactation (r = -0.25, p = 0.001). The transverse diameter of the pituitary gland also related negatively with reproductive factors such as gravity (r = -0.15, p = 0.04), parity (r = -0.17, p = 0.02), and lactation (r = -0.17, p = 0.02). The pituitary gland of nullipara females was the greatest in size. Recent pregnancy led to increased craniocaudal and anteroposterior diameters. Conclusions: In this study, we found a negative effect of pregnancy and giving birth on pituitary size. Nullipara females were found to have the greatest pituitaries, even greater than the females in the postpartum period.

Microbes involving in carcinogenesis; growing state of the art.

Lateral gene transfer (LGT) has been demonstrated as a transfer process of novel genes between different species. LGT proceedings are occurring between microbes and plants, as well as between microbes and animals. New evidence demonstrates that bacterial insertional mutagenesis may occur in cancer cells. Due to the important role of genetic changes in the increase of cell proliferation and cancer development, we reviewed the effects of microbial-animal LGT in human oncogenesis. In addition, viral DNA can induce cancer development by random insertion into cancer-related genes or by inducing translocations. In conclusion, growing evidence shows the contribution of the microbial genome in cancer and autoimmune disease.

Diagnostic Accuracy of a 64-Slice Multi-Detector CT Scan in the Preoperative Evaluation of Periampullary Neoplasms.

Periampullary tumors are highly malignant masses with poor prognosis. Surgical resection is the only treatment for patients with this disease. The preoperative evaluation of masses is essential to determine the tumor resectability and vascular invasion. The aim of this study was to determine the diagnostic accuracy of 64-slice multi-detector computed tomography (MDCT) in detecting the resectability of periampullary masses. A cross-sectional study was conducted on patients with a definite diagnosis of periampullary cancer. All the participants underwent an MDCT scan before the surgical pancreaticoduodenectomy. The preoperative results were compared to the intraoperative findings and the diagnostic accuracy was determined based on the sensitivity and specificity of the MDCT. From June 2015 until June 2016, 32 patients with periampullary carcinoma were enrolled in the study. Of 32 masses, one of them considered nonresectable because of the gross vascular invasion in th CT images. After the operation, the overall resectability rate was 81.3%. The sensitivity and specificity of MDCT for tumor resectability was 100% and 16.7%, respectively, with an overall accuracy of 84.4%. To sum up, MDCT had high sensitivity but low specificity in the preoperative evaluation of preampullary carcinomas. The low specificity resulted from the low accuracy of the CT scan in detecting vascular involvement.