Determining Follow-Up Imaging Study Using Radiology Reports.

Radiology reports often contain follow-up imaging recommendations. Failure to comply with these recommendations in a timely manner can lead to delayed treatment, poor patient outcomes, complications, unnecessary testing, lost revenue, and legal liability. The objective of this study was to develop a scalable approach to automatically identify the completion of a follow-up imaging study recommended by a radiologist in a preceding report. We selected imaging-reports containing 559 follow-up imaging recommendations and all subsequent reports from a multi-hospital academic practice. Three radiologists identified appropriate follow-up examinations among the subsequent reports for the same patient, if any, to establish a ground-truth dataset. We then trained an Extremely Randomized Trees that uses recommendation attributes, study meta-data and text similarity of the radiology reports to determine the most likely follow-up examination for a preceding recommendation. Pairwise inter-annotator F-score ranged from 0.853 to 0.868; the corresponding F-score of the classifier in identifying follow-up exams was 0.807. Our study describes a methodology to automatically determine the most likely follow-up exam after a follow-up imaging recommendation. The accuracy of the algorithm suggests that automated methods can be integrated into a follow-up management application to improve adherence to follow-up imaging recommendations. Radiology administrators could use such a system to monitor follow-up compliance rates and proactively send reminders to primary care providers and/or patients to improve adherence.

Improving Outcomes in the Patient with Polytrauma: A Review of the Role of Whole-Body Computed Tomography.

Whole-body computed tomography (WBCT) is used for the workup of the patient with blunt polytrauma. WBCT is associated with improved patient survival and reduces the emergency department length of stay. However, randomized studies are needed to determine whether early WBCT improves survival, to clarify which patients benefit the most, and to model the costs of this technique compared with traditional workup. Advancements in modern multidetector computed tomography technology and an improved understanding of optimal protocols have enabled one to scan the entire body and achieve adequate image quality for a comprehensive trauma assessment in a short period.

Imaging of Urinary System Trauma.

Computed tomography (CT) imaging of the kidney, ureter, and bladder permit accurate and prompt diagnosis or exclusion of traumatic injuries, without the need to move the patient to the fluoroscopy suite. Real-time review of imaging permits selective delayed imaging, reducing time on the scanner and radiation dose for patients who do not require delays. Modifying imaging parameters to obtain thicker slices and noisier images permits detection of contrast extravasation from the kidneys, ureters, and bladder, while reducing radiation dose on the delayed or cystographic imaging. The American Association for the Surgery of Trauma grading system is discussed, along with challenges and limitations.

Core curriculum illustration: blunt cerebrovascular injury.

This is the 15th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Core curriculum illustration: testicular torsion.

This is the 7th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Variability in management recommendations for incidental thyroid nodules detected on CT of the cervical spine in the emergency department.

PURPOSE: Incidental thyroid nodules are common on CT. Variability in management recommendations for these nodules due to a lack of accepted CT base guidelines has not been demonstrated. METHODS: Consecutive CT cervical spine radiology reports describing thyroid nodules performed in an emergency department from January 1, 2009, to December 31, 2011, were retrospectively reviewed. Number of nodules, nodule size, and type of recommended management were recorded. RESULTS: Three hundred fifteen examinations met the inclusion criteria. The mean study age was 64 ± 20 years. Fifty-eight percent were women. Thirty percent (n = 95) of thyroid nodules measured <10 mm, 20% (n = 63) were ≥10 but <15 mm, 11% (n = 36) were ≥15 but <20 mm, and 15.5% (n = 49) were ≥20 mm. Size was not reported for 22.9% (n = 72). Two hundred twenty-seven recommendations were made in 181 (57.5%) studies. Recommendations were made for 51.6% (49 of 95) of nodules <10 mm, for 52.4% (33 of 63) of those ≥10 but <15 mm, for 83.3% (30 of 36) of those ≥15 but <20 mm, and for 81.6% (40 of 49) of those ≥20 mm. Management was recommended in 40.0% (29 of 72) of nodules with no size reported. Fifty-four percent (123 of 227) of recommendations were for ultrasound, followed by no follow-up recommended (17.2% [39 of 227]), clinical correlation (13.7% [31 of 227]), thyroid serology (6.2% [14 of 227]), clinical follow-up (4.8% [11 of 227]), comparison with prior studies (2.2% [5 of 227]), fine-needle aspiration (1.3% [3 of 227]), and nuclear scintigraphy (0.4% [1 of 227]). Nodule size was significantly associated with the likelihood of recommendation (odds ratio, 1.79; 95% confidence interval, 1.37-2.35). CONCLUSIONS: Management recommendations for incidental thyroid nodules detected on cervical spine CT are made inconsistently, and the type of management recommended is variable.

Minimal aortic injury of the thoracic aorta: imaging appearances and outcome.

The aim of this study is to describe the frequency, computed tomographic angiography (CTA) imaging appearance, management, and outcome of patients who present with minimal thoracic aortic injury. This retrospective study was Institutional Review Board-approved. Eighty-one patients with blunt traumatic aortic injuries (BTAI) were identified between 2004 and 2008, comprising 23 patients with minimal aortic injury (MAI) (mean age, 43.2 years ±18.2 years; 12 males and 11 females) and 58 patients with non-minimal aortic injury (mean age, 42.6 years ±22.7 years). CTA imaging was reviewed for each patient to differentiate those with MAI from those with non-MAI BTAI. Inclusion criteria for MAI on CTA were: post-traumatic abnormality of the internal contour of the aorta wall projecting into the lumen, intimal flap, intraluminal filling defect, intramural hematoma, and no evidence of an abnormality to the external contour of the aorta. Relevant follow-up imaging for MAI patients was also reviewed for resolution, stability, or progression of the vascular injury. The electronic medical record of each patient was reviewed and mechanism of injury, injury severity score, associated injuries, type and date of management, outcome, and days from injury to last medical consultation. Minimal aortic injury represented 28.4 % of all BTAI over the study period. Mean injury severity score (37.1), age (43.2 years), and gender did not differ significantly between MAI and non-MAI types of BTAI. Most MAI occurred in the descending thoracic aorta (16/23, 69 %). Without operative or endovascular repair, there was no death or complication due to MAI. One death occurred secondary to MAI (4.4 %) in a patient who underwent endovascular repair and surgical bypass, compared with an overall mortality rate of 8.6 % in the non-MAI BTAI group (p = 0.508). The most common CT appearance of MAI was a rounded or triangular intra-luminal aortic filling detect (18/23 patients, 78 %). In a mean of 466 days of clinical follow-up, no complications were observed in survivors treated without endovascular repair or operation. Minimal aortic injury is identified by multi-detector row CT in more than a quarter of cases of BTAI and has a low mortality. Conservative management is associated with an excellent outcome.

Lower male genitourinary trauma: a pictorial review.

Blunt and penetrating trauma to the male pelvis and external genitalia may result in significant injury to the lower genitourinary system including the bladder, urethra, penis, and scrotum. Emergent imaging plays an important role in identifying these injuries and directing appropriate, timely management. In this article, we review indications for dedicated genitourinary system imaging in trauma and illustrate the imaging features of injuries to the lower male genitourinary system in order to facilitate accurate and rapid diagnosis.

A comprehensive review of the retroperitoneal anatomy, neoplasms, and pattern of disease spread.

A clear understanding of the normal anatomy and pattern of disease spread is important in evaluating many retroperitoneal disorders. Primary retroperitoneal tumors are uncommon, accounting for 0.1%-0.2% of all malignancies in the body; 80%-90% of all primary retroperitoneal tumors are malignant. The primary retroperitoneal neoplasms can be divided into solid or cystic masses. The solid neoplasms can be classified according to their tissue of origin into 3 main categories: mesodermal tumors, neurogenic tumors, and extragonadal germ cell tumors. Computed tomography and magnetic resonance imaging play a vital role in the localization, characterization, evaluation of the extent of local invasion, assessment of metastases, and determination of treatment response for these tumors. The diagnosis of a primary retroperitoneal malignancy is often challenging owing to overlap of imaging findings. A definitive diagnosis can be established only at histopathologic analysis. However, knowledge of the important tumor characteristics, growth pattern, and vascularity can assist in narrowing the differential diagnosis.

Torsion of an accessory spleen: Case report and review of the literature.

Torsion of an accessory spleen is an uncommon cause of abdominal pain. Only a few cases have been reported in the literature. Most cases occur in children, and in most cases the diagnosis is made at surgery. We report a case of torsion of an accessory spleen in an adult female who presented with acute left-flank pain. The diagnosis was made on contrast-enhanced computed tomography (CT) and was confirmed at surgery. Without treatment, torsion of an accessory spleen can lead to hemorrhagic shock, peritonitis, and bowel obstruction. It is useful for the radiologist to make this diagnosis on imaging so that biopsy can be avoided and surgery performed to avoid complications.

Utility of ultrasound for evaluating the appendix during the second and third trimester of pregnancy.

This study aims to retrospectively evaluate the right lower quadrant ultrasounds in women presenting during the second or third trimester of pregnancy for the frequency of appendix visualization and accuracy in diagnosing appendicitis. Institutional Review Board approval was obtained for this Health Insurance Portability and Accountability Act-compliant study. We reviewed imaging records from 99 consecutive pregnant women from 2001 to 2011 who presented during the second (≥14 weeks gestation) or third trimester for right lower quadrant ultrasound to evaluate the appendix. Visualization of the appendix as well as the size and compressibility, if identified, were recorded. The medical records and labs related to the initial patient presentation, subsequent management, and follow-up were reviewed for surgical and clinical outcomes. Pathology records were reviewed to determine if appendicitis was present when appendectomy was performed. Patients who underwent appendectomy were considered to have appendicitis based on pathology results, and patients managed non-operatively with symptom improvement and those with a normal appendix at pathology were considered to not have appendicitis. During the study period, 99 women meeting inclusion criteria presented to our institution for right lower quadrant ultrasound to evaluate the appendix during the second or third trimester of pregnancy. The mean gestational age at presentation was 23 weeks (±7 weeks). The mean maternal age was 28 years (±6.6 years). The appendix was not visualized in 97% (96/99) of right lower quadrant ultrasound examinations. Of the three studies in which the appendix was visualized, two were considered positive for appendicitis and one was considered negative. Eight patients in this group ultimately underwent appendectomy, including the two patients with positive right lower quadrant ultrasounds, and appendicitis confirmed at pathology in seven of these cases (87.5%). Right lower quadrant ultrasound successfully demonstrated an abnormal appendix in 28.7% (two of seven) of surgically confirmed cases; however, this technique did not detect appendicitis in 71% (five of seven) of patients with surgically proven disease due to nonvisualization of the appendix. Retrospective review of right lower quadrant ultrasounds performed during the second and third trimester of pregnancy suggests that this modality has limited utility for diagnosing appendicitis due to infrequent visualization of the appendix.

Needle embolism in intravenous drug abuse.

Although intravenous drug users report the breaking of a needle as a relatively common occurrence, central embolism of needle fragments occurs infrequently in the literature. Central needle embolism also poses a conundrum for the radiologist, as the needle may be easily overlooked when the clinical history is nonspecific. We present two cases of needle embolism to the lung, one complicated by inflammatory mass and progressive pleuritic chest pain requiring wedge resection. We hope that our experiences may increase radiologists' and emergency physicians' familiarity with this unusual cause of chest pain. The radiological findings are subtle and may be easily overlooked, particularly without thorough clinical history.

Detection of ventricular shunt malfunction in the ED: relative utility of radiography, CT, and nuclear imaging.

The study objective was to determine the relative diagnostic utility of the radiographic shunt series (SS), head computed tomography (CT), and nuclear imaging performed in our Emergency Department (ED) for evaluating ventricular shunt malfunction. We retrospectively reviewed medical records, head CT (if performed), and nuclear imaging (if performed) for all ED patients with suspected shunt malfunction from 2002 to 2007 who underwent plain film shunt evaluation (296 cases/186 individuals) to determine if surgical shunt revision was performed. Logistic regression analysis was applied. Four percent (12/296) of radiographic SS were abnormal. Only 0.3% (1/296) underwent surgical revision in the absence of an abnormal head CT or nuclear imaging. Eighteen percent (51/282) of head CT exams were positive and 19% (24/128) of nuclear imaging exams were positive for shunt malfunction. Twenty-three percent (67/296) underwent surgical shunt revisions. Statistical analysis demonstrated that SS evaluation was not significantly associated with surgical shunt revision (OR 0.92; 95% CI, 0.7-1.2; p=0.47). Head CT demonstrated a significant association with surgical revision (OR 1.4; 95% CI, 1.2-1.5; p<0.001), as did nuclear imaging (OR 1.4; 95% CI, 1.2-1.6; p<0.001). Patients with suspected ventricular shunt malfunction frequently require surgical revision. Abnormal radiographic SS was not associated with progression to surgical shunt revision, whereas abnormal head CT and abnormal nuclear imaging were significantly associated with surgical revision. We conclude that radiographic SS in the ED is of low diagnostic utility and that patients with suspected shunt malfunction should instead initially undergo CT and/or nuclear imaging.

Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?

PURPOSE: The aim of this study was to retrospectively analyze a large group of CT and MRI examinations for appropriateness using evidence-based guidelines. METHODS: The authors reviewed medical records from 459 elective outpatient CT and MR examinations from primary care physicians. Evidence-based appropriateness criteria from a radiology benefit management company were used to determine if the examination would have met criteria for approval. Submitted clinical history at the time of interpretation and clinic notes and laboratory results preceding the date of the imaging study were examined to simulate a real-time consultation with the referring provider. The radiology reports and subsequent clinic visits were analyzed for outcomes. RESULTS: Of the 459 examinations reviewed, 284 (62%) were CT and 175 (38%) were MRI. Three hundred forty-one (74%) were considered appropriate, and 118 (26%) were not considered appropriate. Examples of inappropriate examinations included brain CT for chronic headache, lumbar spine MR for acute back pain, knee or shoulder MRI in patients with osteoarthritis, and CT for hematuria during a urinary tract infection. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only thirteen percent [corrected] of inappropriate studies had positive results and affected management. CONCLUSION: A high percentage of examinations not meeting appropriateness criteria and subsequently yielding negative results suggests a need for tools to help primary care physicians improve the quality of their imaging decision requests. In the current environment, which stresses cost containment and comparative effectiveness, traditional radiology benefit management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order entry systems.

Beryllium induces premature senescence in human fibroblasts.

After cells have completed a sufficient number of cell divisions, they exit the cell cycle and enter replicative senescence. Here, we report that beryllium causes proliferation arrest with premature expression of the principal markers of senescence. After young presenescent human fibroblasts were treated with 3 microM BeSO(4) for 24 h, p21 cyclin-dependent kinase inhibitor mRNA increased by >200%. Longer periods of exposure caused mRNA and protein levels to increase for both p21 and p16(Ink4a), a senescence regulator that prevents pRb-mediated cell cycle progression. BeSO(4) also caused dose-dependent induction of senescence-associated beta-galactosidase activity (SA-beta-gal). Untreated cells had 48 relative fluorescence units (RFU)/microg/h of SA-beta-gal, whereas 3 microM BeSO(4) caused activity to increase to 84 RFU/microg/h. In chromatin immunoprecipitation experiments, BeSO(4) caused p53 protein to associate with its DNA binding site in the promoter region of the p21 gene, indicating that p53 transcriptional activity is responsible for the large increase in p21 mRNA elicited by beryllium. Forced expression of human telomerase reverse transcriptase (hTERT) rendered HFL-1 cells incapable of normal replicative senescence. However, there was no difference in the responsiveness of normal HFL-1 fibroblasts (IC(50) = 1.9 microM) and hTERT-immortalized cells (IC(50) = 1.7 microM) to BeSO(4) in a 9-day proliferation assay. The effects of beryllium resemble those of histone deacetylase-inhibiting drugs, which also cause large increases in p21. However, beryllium produced no changes in histone acetylation, suggesting that Be(2+) acts as a novel and potent pharmacological inducer of premature senescence.

Abnormal DNA repair in selenium-treated human cells.

Selenium (Se), a micronutrient and an environmental, a chemical and an industrial agent in many products, can have genotoxic effects as well as antimutagenic and/or anticarcinogenic properties, depending on its concentration and oxidation state. We investigated the cytotoxic response of human osteosarcoma (U2OS) cells to low doses of sodium selenite and assayed their resistivity to cisplatin treatment and their capacity to reactivate cisplatin-treated reporter system, whose repair occurs through the transcription coupled repair (TCR) pathway, using the Host Cell Reactivation (HCR) Assay. In addition, we examined the ability of Se-treated human primary lymphocytes for normal double-strand breaks rejoining (DSBR) using the Challenge assay. Although, U2OS cells did not demonstrate cytotoxicity to all Se doses used, as measured by the cell proliferation MTT assay, their resistivity to cisplatin was significantly reduced. Moreover, Se-treated cells exhibited a significant reduction in their capacity for TCR as compared with untreated control cells. Primary human blood lymphocytes demonstrated cytotoxicity to Se treatment at only a concentration of 10 microM. There were no significant increases in chromosome-type deletions or chromatid breaks or in mitotic indices in cells treated with Se alone or Se plus ionizing irradiation. However, dicentric chromosomes significantly increased upon treatment with 1 microM Se plus irradiation as compared with Se-untreated irradiated control. These findings demonstrate direct evidence on the inhibitory effect of inorganic Se on cellular DNA repair capacity.