A Reexamination of the Accuracy of the Broselow Tape as an Instrument for Weight Estimation.

BACKGROUND: Accurate weight estimation is important for calculating appropriate medication dosages, determining rates of fluid replacement, and selecting correct equipment sizes in critically ill children requiring resuscitation. The actual measurement of the weight of a critically ill or injured child is often not possible. The Broselow Pediatric Emergency Tape (BT) is an important tool for predicting a child's weight based on his/her height. Although BT has previously been validated, given the increasing prevalence of obesity in today's society, it behooves clinicians relying on this resuscitation aid to revisit the issue. OBJECTIVE: The aim of this study was to evaluate the accuracy of the color-coded BT in weight estimation and the influence of obesity on its accuracy. METHODS: This is a retrospective study conducted in a pediatric clinic of urban hospital. This study reviewed the medical records of children up to 96 months of age, who presented during 2008-2010. We recorded the child's age (in months), actual (measured) weight (in kilograms), and height (in centimeters). Based on the height, weight estimation was obtained using the color-coded BT. The actual weight was compared with the predicted weight obtained by the height-based BT. Patients presenting with any medical condition that would substantially affect growth of the child were excluded. A univariate logistic regression model was utilized to predict any underestimation based on age, sex, and body mass index (BMI) percentile. RESULTS: The medical records of 538 children were reviewed. There was a discrepancy in 226 children (42%). Broselow Pediatric Emergency Tape underestimated weight (measured weight was higher than predicted weight) in 158 children (29.4%) and overestimated (measured weight was lower than predicted weight) in 68 children (12.6%). Of the 158 underestimated children, 138 were off by 1 color zone, 16 by 2 color zones, and 4 by more than 2 color zones. When characterized by BMI, 46 children (13.6%) had normal BMI, 27 (45.8%) were overweight, and 84 (80.8%) were obese, whereas one child (2.8%) was underweight. CONCLUSIONS: In our population, BT was inaccurate in predicting weight in 42% of children (underestimation in 158 children [29.4%] and overestimation weight in 68 children [12.6%]). However, the majority of discrepancies involved only 1 BT color zone. Emergency physicians should be aware of this discrepancy until more accurate methods become available.

Blood-Brain Barrier Permeability in Aneurysmal Subarachnoid Hemorrhage: Correlation With Clinical Outcomes.

OBJECTIVE: The current understanding of the utility of blood-brain barrier permeability (BBBP) evaluation with extended-pass perfusion CT in the clinical setting is limited. We assessed whether BBBP parameters evaluated with perfusion CT correlate with unfavorable clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: A retrospective cross-sectional analysis was performed of 22 patients who underwent perfusion CT on days 0-3 after SAH. Extended perfusion CT data were postprocessed into BBBP quantitative maps of kep (washout rate constant of contrast agent from the extravascular extracellular space [EES] to the intravascular space), PS (permeability surface area product), Ktrans (volume transfer constant from blood plasma to EES), and Ve (EES volume per unit tissue volume) using Olea Sphere software (version 2.0). Clinical outcomes data regarding the presence of permanent neurologic deficits and modified Rankin scores were collected at discharge. ROC curve analyses and unpaired t tests were performed. RESULTS: The 22 patients were stratified on the basis of their clinical outcomes of permanent neurologic deficit and modified Rankin scores. In patients with unfavorable clinical outcomes (i.e., patients with permanent neurologic deficit and those with modified Rankin scores of 3-6), PS and Ve were significantly increased and kep and Ktrans were significantly decreased. A multiparameter ROC curve analysis combining the four parameters yielded an AUC of 0.80 for permanent neurologic deficit and an AUC of 0.89 for modified Rankin scores of 3-6. CONCLUSION: SAH patients with unfavorable outcomes had significantly elevated PS and Ve and significantly decreased kep, indicating increased BBBP, compared with SAH patients with unfavorable outcomes. Evaluation of BBBP parameters may provide prognostication of unfavorable outcomes in patients with SAH and help guide management.

New uses of old technology: Can nurse-pagers improve communication between resident-physicians and nurses.

BACKGROUND: Alphanumeric paging is underutilized, despite being the standard mode of communication between physicians and nurses at many hospitals across the United States. OBJECTIVE: We hypothesized that an educational program designed to teach optimal alphanumeric paging behavior in conjunction with providing nurses with alphanumeric pagers would improve the quality and efficiency of nurse pages. METHODS: We implemented an educational program to teach nurses about optimal alphanumeric paging, defined as including four important components-patient identification, clinical scenario, sender identification, and callback number. We also provided each nurse with their own unique pager. Alphanumeric paging logs were reviewed prior to the intervention (baseline study period), and again following implementation of the intervention (intervention study period). Questionnaires were also completed by resident-physicians and nurses before and after implementation. RESULTS: During the intervention period, the percentage of ideal pages increased, and the percentage of suboptimal pages decreased. Compared to baseline, pages during the intervention period more often included patient identity, clinical scenario, and page-sender. Resident-physicians rated the paging-system's impact on patient care and job satisfaction more highly, and reported that disruptions and nurse accessibility were less of a problem during the intervention period compared to baseline. Nurses reported less problems with disruptions, ignored pages, miscommunication, and contentious relationships with resident-physicians. CONCLUSIONS: This study underscores the importance of two-way communication, which can be achieved without expensive technology. Creative use of old technology, such as providing nurses with traditional pagers, can improve communication and workflow, and potentially quality of care and patient safety.

Diagnostic accuracy of intracellular uptake rates calculated using dynamic Gd-EOB-DTPA-enhanced MRI for hepatic fibrosis stage.

PURPOSE: To assess the diagnostic accuracy of intracellular uptake rates (Ki ), and other quantitative pharmacokinetic (PK) parameters, for hepatic fibrosis stage; to compare this accuracy with a previously published semiquantitative metric, contrast enhancement index (CEI); and to assess variability of these parameters between liver regions. MATERIALS AND METHODS: This was a case-control study design. Dynamic Gd-EOB-DTPA-enhanced 1.5T magnetic resonance imaging (MRI) was performed prospectively in 22 subjects with varying known stages of hepatic fibrosis. PK parameters and CEI were derived from the whole livers and from three fixed regions of interest (ROIs) in all subjects. Spearman rank correlation coefficients were computed to assess the relationship between fibrosis stages and each parameter. Receiver operating characteristic (ROC) curves were constructed to discriminate severe fibrosis (stages 3-4) from nonsevere fibrosis (stages 0-2). The coefficient of variation (CV) was calculated to assess variability in parameters between ROIs. RESULTS: Ki and fibrosis stage were significantly correlated (R = -0.55, 95% confidence interval [CI] [-0.79, -0.14], P = 0.01). Area under ROC curve (AUC) in distinguishing severe from nonsevere fibrosis for Ki was 0.84 (95% CI [0.65,1.00]), and for CEI was 0.64 (95% CI [0.39, 0.89]) (P = 0.0248). CV for Ki and CEI were 33.4 and 5.8, respectively. The only other parameter in the PK model having significant correlation with fibrosis stage was absolute arterial blood flow (Fa ) (R = -0.48, 95% CI [-0.75,-0.05], P = 0.03). CONCLUSION: Hepatocyte intracellular uptake rate, Ki , derived from dynamic contrast-enhanced MRI, correlates with fibrosis stage and may contribute to a noninvasive biomarker of hepatic fibrosis. LEVEL OF EVIDENCE: 2 J. Magn. Reson. Imaging 2017;45:1177-1185.

Correlation Between Aeroallergen Levels and New Diagnosis of Eosinophilic Esophagitis in New York City.

OBJECTIVE: The relation between food allergies and eosinophilic esophagitis (EoE) is well established. Aeroallergens may also contribute to the development of EoE; however, there are limited data to support or refute this hypothesis. The objectives of this pilot study were to determine whether there is a seasonal variation in the onset of symptoms and/or diagnosis of EoE and whether these variations correlate with a specific pollen concentration within New York City. METHODS: We performed a retrospective chart review to identify all pediatric patients at New York Presbyterian Weill Cornell Medical Center diagnosed with EoE between 2002 and 2012. Sixty-six patients were identified and 28 were excluded. Cases were classified by both date of initial symptoms and date of histologic diagnosis. Pollen counts from a certified New York City counting station and the percentage of EoE cases were collated monthly and seasonally and compared. RESULTS: There was a seasonal variation in onset of symptoms and diagnosis of EoE, with the highest number of patients reporting onset of symptoms of EoE in July to September, and those being diagnosed with EoE in October to December. There was a seasonal correlation between peak levels of grass pollen and peak onset of EoE symptoms, which were both highest in July to September. The diagnosis of EoE peaked one season later. CONCLUSIONS: The study findings suggest that there is a correlation between specific aeroallergens and both the onset of symptoms and time of diagnosis of patients with EoE.

Diagnostic utility of intravenous contrast for MR imaging in pediatric appendicitis.

BACKGROUND: Magnetic resonance imaging (MRI) is increasingly employed as a diagnostic modality for suspected appendicitis in children. However, there is uncertainty as to which MRI sequences are sufficient for safe, timely and accurate diagnosis. Several recent studies have described different MRI protocols, including exams both with and without the use of intravenous contrast. OBJECTIVE: We hypothesized that intravenous contrast may be useful in some patients but could be safely omitted in others. MATERIALS AND METHODS: All MRI examinations (n=112) performed at our institution for evaluating appendicitis in children were retrospectively reevaluated. Exams were reread by pediatric radiologists under three conditions: With postcontrast images, Without postcontrast images, and Without/With - selective use of postcontrast sequences only when needed for diagnostic certainty. Samples were scored as positive, negative or equivocal for appendicitis. Findings were compared to pathological or clinical follow-up in the medical record. RESULTS: Without the use of intravenous contrast yielded more equivocal results (12.4%) compared to With contrast (3.4%). By selectively using postcontrast sequences, the Without/With group yielded fewer equivocal results (1.1%) compared to Without while also reducing contrast use 79.8% compared to the With contrast group. No significant differences in conditional sensitivity or conditional specificity were detected among the three groups. CONCLUSION: MRI diagnosis of acute appendicitis can be performed without contrast for most patients; injection of contrast can be reserved for only those patients with equivocal non-contrast imaging.

The Association between Carotid Artery Atherosclerosis and Silent Brain Infarction: A Systematic Review and Meta-analysis.

BACKGROUND: Carotid atherosclerosis is responsible for ~20% of ischemic strokes, but it is unclear whether carotid disease is associated with the presence of downstream silent brain infarction (SBI). We performed a systematic review and meta-analysis to study the relationship between SBI and 2 separate manifestations of carotid atherosclerosis, carotid intima-media thickening (IMT) and luminal stenosis. METHODS: Ovid MEDLINE, Ovid Embase, and the Cochrane Library Database were searched with an additional search of references and citing articles of target studies. Articles were included if they reported an association between carotid IMT or stenosis and magnetic resonance imaging-defined SBI, excluding SBIs found after carotid intervention. RESULTS: We pooled 7 studies of carotid IMT reporting on 1469 subjects with SBI and 5102 subjects without SBI. Subjects with SBI had a larger mean IMT than subjects without SBI (pooled standardized mean difference, .37; 95% confidence interval [CI], .23-.51; P < .0001). We pooled 11 studies of carotid stenosis reporting on 12,347 subjects (2110 subjects with carotid stenosis and 10,237 subjects without carotid stenosis). We found a higher prevalence of SBI among subjects with carotid stenosis (30.4% versus 17.4%). Our pooled random-effects analysis showed a significant positive relationship between carotid stenosis and SBI (odds ratio, 2.78; 95% CI, 2.19-3.52; P < .0001). CONCLUSIONS: Two forms of atherosclerotic disease, carotid IMT and stenosis, are both significantly associated with SBI. This review highlights a lack of consistent definitions for carotid disease measures and little evidence evaluating SBI prevalence downstream from carotid stenosis.

Cryptogenic Stroke and Nonstenosing Intracranial Calcified Atherosclerosis.

OBJECTIVE: Because some cryptogenic strokes may result from large-artery atherosclerosis that goes unrecognized as it causes <50% luminal stenosis, we compared the prevalence of nonstenosing intracranial atherosclerotic plaques ipsilateral to cryptogenic cerebral infarcts versus the unaffected side using imaging biomarkers of calcium burden. METHODS: In a prospective stroke registry, we identified patients with cerebral infarction limited to the territory of one internal carotid artery (ICA). We included patients with stroke of undetermined etiology and, as controls, patients with cardioembolic stroke. We used noncontrast computed tomography to measure calcification in both intracranial ICAs, including qualitative calcium scoring and quantitative scoring utilizing the Agatston-Janowitz (AJ) calcium scoring. Within subjects, the Wilcoxon signed-rank sum test for nonparametric paired data was used to compare the calcium burden in the ICA upstream of the infarction versus the ICA on the unaffected side. RESULTS: We obtained 440 calcium measures from 110 ICAs in 55 patients. Among 34 patients with stroke of undetermined etiology, we found greater calcium in the ICA ipsilateral to the infarction (mean Modified Woodcock Visual Scale score, 6.7 ± 4.6) compared with the contralateral side (5.4 ± 4.1) (P = .005). Among 21 patients with cardioembolic stroke, we found no difference in calcium burden ipsilateral to the infarction (6.7 ± 5.9) versus the contralateral side (7.3 ± 6.3) (P = .13). The results were similar using quantitative calcium measurements, including the AJ calcium scores. CONCLUSION: In patients with strokes of undetermined etiology, the burden of calcified intracranial large-artery plaque was associated with downstream cerebral infarction.

Silent Brain Infarction and Risk of Future Stroke: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Silent brain infarction (SBI) on magnetic resonance imaging has been proposed as a subclinical risk marker for future symptomatic stroke. We performed a systematic review and meta-analysis to summarize the association between magnetic resonance imaging-defined SBI and future stroke risk. METHODS: We searched the medical literature to identify cohort studies involving adults with SBI detected by magnetic resonance imaging who were subsequently followed up for incident clinically defined stroke. Study data and quality assessment were recorded in duplicate with disagreements in data extraction resolved by a third reader. Strength association between magnetic resonance imaging-detected SBI and future symptomatic stroke was measured by an hazard ratio. RESULTS: The meta-analysis included 13 studies (14 764 subjects) with a mean follow-up ranging from 25.7 to 174 months. SBI predicted the occurrence of stroke with a random effects crude relative risk of 2.94 (95% confidence interval, 2.24-3.86, P<0.001; Q=39.65, P<0.001). In the 8 studies of 10 427 subjects providing hazard ratio adjusted for cardiovascular risk factors, SBI was an independent predictor of incident stroke (hazard ratio, 2.08 [95% confidence interval, 1.69-2.56; P<0.001]; Q=8.99; P=0.25). In a subgroup analysis pooling 9483 stroke-free individuals from large population-based studies, SBI was present in ≈18% of participants and remained a strong predictor of future stroke (hazard ratio, 2.06 [95% confidence interval, 1.64-2.59]; P<0.01). CONCLUSIONS: SBI is present in ≈1 in 5 stroke-free older adults and is associated with a 2-fold increased risk of future stroke. Future studies of in-depth stroke risk evaluations and intensive prevention measures are warranted in patients with clinically unrecognized radiologically evident brain infarctions.

Pancreatic Cysts in Autosomal Dominant Polycystic Kidney Disease: Prevalence and Association with PKD2 Gene Mutations.

Purpose To define the magnetic resonance (MR) imaging prevalence of pancreatic cysts in a cohort of patients with autosomal dominant polycystic kidney disease (ADPKD) compared with a control group without ADPKD that was matched for age, sex, and renal function. Materials and Methods In this HIPAA-compliant, institutional review board-approved study, all patients with ADPKD provided informed consent; for control subjects, informed consent was waived. Patients with ADPKD (n = 110) with mutations identified in PKD1 or PKD2 and control subjects without ADPKD or known pancreatic disease (n = 110) who were matched for age, sex, estimated glomerular filtration rate, and date of MR imaging examination were evaluated for pancreatic cysts by using axial and coronal single-shot fast spin-echo T2-weighted images obtained at 1.5 T. Total kidney volume and liver volume were measured. Univariate and multivariable logistic regression analyses were conducted to evaluate potential associations between collected variables and presence of pancreatic cysts among patients with ADPKD. The number, size, location, and imaging characteristics of the cysts were recorded. Results Patients with ADPKD were significantly more likely than control subjects to have at least one pancreatic cyst (40 of 110 patients [36%] vs 25 of 110 control subjects [23%]; P = .027). In a univariate analysis, pancreatic cysts were more prevalent in patients with ADPKD with mutations in PKD2 than in PKD1 (21 of 34 patients [62%] vs 19 of 76 patients [25%]; P = .0002). In a multivariable logistic regression model, PKD2 mutation locus was significantly associated with the presence of pancreatic cysts (P = .0004) and with liver volume (P = .038). Patients with ADPKD and a pancreatic cyst were 5.9 times more likely to have a PKD2 mutation than a PKD1 mutation after adjusting for age, race, sex, estimated glomerular filtration rate, liver volume, and total kidney volume. Conclusion Pancreatic cysts were more prevalent in patients with ADPKD with PKD2 mutation than in control subjects or patients with PKD1 mutation. (©) RSNA, 2016 Online supplemental material is available for this article.

Longitudinal change in magnetic susceptibility of new enhanced multiple sclerosis (MS) lesions measured on serial quantitative susceptibility mapping (QSM).

PURPOSE: To measure the longitudinal change in multiple sclerosis (MS) lesion susceptibility using quantitative susceptibility mapping (QSM). MATERIALS AND METHODS: The study was approved by our Institutional Review Board. Longitudinal changes in quantitative susceptibility values of new enhanced-with-Gd MS lesions were measured at baseline magnetic resonance imaging (MRI) and on a follow-up MRI in 29 patients within 2 years using a 3D multiple echo gradient echo sequence on a 3T scanner. Paired t-test and the generalized estimating equations (GEE) model was used to analyze the longitudinal change. RESULTS: Lesion susceptibility values relative to normal-appearing white matter (NAWM) changed from 3.61 ± 6.11 ppb when enhanced-with-Gd at the baseline MRI to 20.42 ± 10.23 ppb when not-enhanced-with-Gd at the follow-up MRI (P < 0.001). CONCLUSION: MS lesion susceptibility value increases significantly as the lesion evolves from enhanced-with-Gd to not-enhanced-with-Gd, serving as a disease biomarker. J. Magn. Reson. Imaging 2016;44:426-432.

Validity of self-reported vitamin D deficiency among midlife Arab women living in Qatar.

OBJECTIVES: This study evaluates the level of agreement between self-reported vitamin D deficiency and serum vitamin D measured within the previous calendar year. METHODS: In a study in which serum 25(OH)D levels were retrieved from electronic health records, 523 women were asked whether they considered themselves to have vitamin D deficiency. Serum vitamin D levels were categorized as vitamin D deficiency if serum 25(OH)D was <20 ng/ml and as insufficiency if <30 ng/ml. The kappa statistic was computed to assess the level of agreement between serum 25(OH)D level and self-report responses. RESULTS: Agreement between self-reported and measured 25(OH)D levels was poor. The kappa statistic was -0.041 when using a cutpoint of <20 ng/ml and -0.008 using the cutpoint of <30 ng/ml. Among women with levels ≥20 ng/ml, 82.4% believed that they were vitamin D deficient, while 13.3% who were below <20 ng/ml did not self-report deficiency. Among women who did not report vitamin D deficiency, 46.3% (37/80) had levels <20 ng/ml while 82.5% (66/80) had levels <30 ng/ml. CONCLUSIONS: These findings suggest that, although the prevalence of 25(OH)D <20 and <30 ng/ml was quite high (53.2% and 84.7%, respectively), there was little agreement between measured levels and self-report of vitamin D deficiency. This may be due to belief in this region that low levels of serum vitamin D is widespread. Better communication is needed between healthcare providers and patients regarding transmission of laboratory results.

Long-Term Prognosis After Coronary Artery Calcification Testing in Asymptomatic Patients: A Cohort Study.

BACKGROUND: The extent of coronary artery calcification (CAC) and near-term adverse clinical outcomes are strongly related through 5 years of follow-up. OBJECTIVE: To describe the ability of CAC scores to predict long-term mortality in persons without symptoms of coronary artery disease. DESIGN: Observational cohort. SETTING: Single-center, outpatient cardiology laboratory. PATIENTS: 9715 asymptomatic patients. MEASUREMENTS: Coronary artery calcification scoring and binary risk factor data were collected. The primary end point was time to all-cause mortality (median follow-up, 14.6 years). Univariable and multivariable Cox proportional hazards models were used to compare survival distributions. The net reclassification improvement statistic was calculated. RESULTS: In Cox models adjusted for risk factors for coronary artery disease, the CAC score was highly predictive of all-cause mortality (P < 0.001). Overall 15-year mortality rates ranged from 3% to 28% for CAC scores from 0 to 1000 or greater (P < 0.001). The relative hazard for all-cause mortality ranged from 1.68 for a CAC score of 1 to 10 (P < 0.001) to 6.26 for a score of 1000 or greater (P < 0.001). The categorical net reclassification improvement using cut points of less than 7.5% to 22.5% or greater was 0.21 (95% CI, 0.16 to 0.32). LIMITATIONS: Data collection was limited to a single center with generalizability limitations. Only binary risk factor data were available, and CAC was only measured once. CONCLUSION: The extent of CAC accurately predicts 15-year mortality in a large cohort of asymptomatic patients. Long-term estimates of mortality provide a unique opportunity to examine the value of novel biomarkers, such as CAC, in estimating important patient outcomes. PRIMARY FUNDING SOURCE: None.

Hypertension Prevalence in New York City Adults: Unmasking Undetected Racial/Ethnic Variation, NYC HANES 2004.

OBJECTIVE: Using 2004 New York City Health and Nutrition Examination Survey (NYC HANES) data, we sought to examine variation in hypertension (HTN) prevalence across eight Asian and Hispanic subgroups. DESIGN: Cross-sectional. SETTING: New York City, 2004. MAIN OUTCOME MEASURES: Logistic regression was performed to identify differences in HTN prevalence between ethnic subgroups controlling for age, sex, education and BMI. RESULTS: Overall HTN prevalence among NYC adults was 25.5% (95% CI: 23.4-27.8), with 21.1% (95% CI: 18.2-24.3) among Whites, 32.8% (95% CI: 28.7-37.2) Black, 26.4% (95% CI: 22.3-31.0) Hispanics, and 24.7% (95% CI: 19.9-30.3) Asians. Among Hispanic subgroups, Dominicans had the highest HTN prevalence (32.2%), followed by Puerto Ricans (27.7%), while Mexicans had the lowest prevalence (8.1%). Among Asian subgroups, HTN prevalence was slightly higher among South Asians (29.9%) than among Chinese (21.3%). Adjusting for age, Dominican adults were nearly twice as likely to have HTN as non-Hispanic (NH) Whites (OR=1.96, 95% CI: 1.24-3.12), but this was attenuated after adjusting for sex and education (OR=1.27, 95% CI: .76 - 2.12). When comparing South Asians with NH Whites, results were also non-significant after adjustment (OR=2.00, 95% CI: .90-4.43). CONCLUSIONS: When analyzing racial/ethnic subgroups, NH Black and Hispanic adults from Dominican Republic had the highest HTN prevalence followed by South Asian and Puerto Rican adults. Mexican adults had the lowest prevalence of all groups. These findings highlight that ethnic subgroup differences go undetected when stratified by broader racial/ethnic categories. To our knowledge, this is the first population-based study using objective measures to highlight these differences.

The Diagnostic Accuracy of Serum Procalcitonin for Bacteremia in Critically Ill Children.

BACKGROUND: Bacterial sepsis is frequently encountered in children admitted to the Pediatric Intensive Care Unit (PICU) and requires early recognition and treatment. Procalcitonin (PCT) is a serum biomarker with a high sensitivity to predict bacteremia in critically-ill adults. This study sought to evaluate the diagnostic accuracy of PCT for bacteremia in febrile children in the PICU. METHODS: This retrospective observational study used data from children admitted to the PICU from October 2010 to October 2012. Patients up to 21 years of age were included if they had an abnormal temperature, serum PCT and blood culture assayed, and were not receiving empiric antibiotics at the time. RESULTS: There were 202 PCT values that met inclusion criteria. The prevalence of positive blood cultures was 13.2% (27 total positive blood cultures). The area under the curve (AUC) for PCT was 0.79 (95% CI, 0.70-0.89), the AUC for lactate was 0.76 (95% CI, 0.65-0.87), and the AUC for C-reactive protein was 0.68 (95% CI, 0.57-0.80). The optimal threshold of PCT for accuracy was determined to be 2 ng/mL (sensitivity = 69.2%, specificity = 74.4%, positive predictive value = 28.6%, negative predictive value = 94.2%). The combination of an abnormal lactate (> 2.0mmol/L) increased the specificity of PCT for diagnosing bacteremia. CONCLUSIONS: PCT has a good diagnostic accuracy to rule-out bacteremia in critically-ill, febrile children. The combination of PCT and an abnormal lactate value increases the specificity and may improve the ability to diagnose bacteremia.

Plaque echolucency and stroke risk in asymptomatic carotid stenosis: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Ultrasonographic plaque echolucency has been studied as a stroke risk marker in carotid atherosclerotic disease. We performed a systematic review and meta-analysis to summarize the association between ultrasound-determined carotid plaque echolucency and future ipsilateral stroke risk. METHODS: We searched the medical literature for studies evaluating the association between carotid plaque echolucency and future stroke in asymptomatic patients. We included prospective observational studies with stroke outcome ascertainment after baseline carotid plaque echolucency assessment. We performed a meta-analysis and assessed study heterogeneity and publication bias. We also performed subgroup analyses limited to patients with stenosis ≥50%, studies in which plaque echolucency was determined via subjective visual interpretation, studies with a relatively lower risk of bias, and studies published after the year 2000. RESULTS: We analyzed data from 7 studies on 7557 subjects with a mean follow-up of 37.2 months. We found a significant positive relationship between predominantly echolucent (compared with predominantly echogenic) plaques and the risk of future ipsilateral stroke across all stenosis severities (0% to 99%; relative risk, 2.31; 95% confidence interval, 1.58-3.39; P<0.001) and in subjects with ≥50% stenosis (relative risk, 2.61; 95% confidence interval, 1.47-4.63; P=0.001). A statistically significant increased relative risk for future stroke was preserved in all additional subgroup analyses. No statistically significant heterogeneity or publication bias was present in any of the meta-analyses. CONCLUSIONS: The presence of ultrasound-determined carotid plaque echolucency provides predictive information in asymptomatic carotid artery stenosis beyond luminal stenosis. However, the magnitude of the increased risk is not sufficient on its own to iden tify patients likely to benefit from surgical revascularization.

Semiautomated CT-Based Quantification of Donor Kidney Volume Applied to a Predictive Model of Outcomes in Renal Transplantation.

OBJECTIVE: The purpose of this study was to assess the use of semiautomated CT-based quantification of renal graft volume as a preoperative predictor of graft function. MATERIALS AND METHODS: All transplants over a 3-year period in which donors underwent CT and for which recipient outcomes were available were included. Two blinded readers used a commercially available reconstruction tool to independently measure donated kidney cortical volume and total parenchymal kidney volume. Transplant characteristics obtained by chart review included subject demographics, recipient pretransplant weight, immunologic matching, and recipient creatinine values at multiple time points. Intraclass correlation of measurements by the two readers was calculated. The ratios between donated kidney cortical volume and recipient pretransplant weight were correlated with graft function over 24 months and used in logistic regression models to calculate the odds of development of diminished renal function. RESULTS: After application of the inclusion and exclusion criteria, 153 transplants were included in the study. Donated kidney cortical and total parenchymal volume measurements had high correlation (R > 0.9) and high reproducibility (intraclass correlation coefficient, 0.93-0.94). Unadjusted correlations existed between estimated glomerular filtration rate (eGFR) and the ratio between donated kidney cortical volume and recipient pretransplant weight 12 months (R = 0.8489) and 24 months (R = 0.6839) after transplant. After adjustment for transplant parameters, recipients in the highest tertile for ratio between donated kidney cortical volume and recipient pretransplant weight (2.7 mL/kg) had higher mean eGFR values at all time points in the 24 months than did recipients in the lower tertiles (1.2 and 1.6 mL/kg). Recipients in the highest tertile had a significantly lower risk of development of diminished renal function 12 and 24 months after transplant (adjusted odds ratios, 0.25 at 12 months [95% CI, 0.09-0.66]; 0.27 at 24 months [95% CI, 0.10-0.71]). CONCLUSION: The CT-derived ratio between donated kidney cortical volume and recipient pretransplant weight is a noninvasively and readily obtained reproducible biomarker that is predictive of 12- and 24-month renal transplant outcomes.

Longitudinal diffusion-weighted imaging changes in children with small bowel Crohn's disease: preliminary experience.

PURPOSE: Crohn's disease has been associated with restricted diffusion in diseased small bowel segments on diffusion-weighted imaging (DWI). However, data addressing longitudinal changes in DWI findings and their potential clinical ramifications in the pediatric population are lacking. The purpose of this study was to follow DWI changes in diseased small bowel segments between serial magnetic resonance enterography (MRE) examinations, and to correlate these changes with other imaging parameters and clinical status. METHODS: This retrospective study evaluated patients less than 21 years of age undergoing serial MRE examinations including DWI for Crohn's disease involving the small bowel. All patients carried a diagnosis of Crohn's disease established by pathology or corroborative clinical and imaging findings. Longitudinal changes in mean apparent diffusion coefficient (ADC) values within the wall of affected small bowel lesions were recorded and normalized to both unaffected bowel and skeletal muscle. ADC changes were correlated with qualitative imaging phenotype, as reflected by a defined set of non-DWI imaging parameters, as well as with clinical disease activity. RESULTS: Seventeen lesions were evaluated longitudinally, distributed among 13 patients (9 boys and 4 girls, mean age at baseline 16.6 years), each of whom had two sequential MRE examinations. Lesions demonstrating a fibrostenotic imaging phenotype at follow-up MRE had a significantly lower change in mean ADC value between examinations than lesions that did not have a fibrostenotic imaging phenotype (p = 0.0005), an effect that persisted when ADC values were normalized to unaffected bowel and skeletal muscle. Across all studies, lesions with a fibrostenotic imaging phenotype had lower ADC values than those with an inflammatory imaging phenotype, which were in turn lower than those with a normal imaging phenotype (p = 0.0001). CONCLUSION: Patterns of longitudinal DWI changes in Crohn's disease may differ among small bowel lesions depending upon their specific natural histories. These findings may assist in the evaluation of the ADC value as a potential imaging surrogate when evaluating lesion status, particularly as it pertains to relative contributions of inflammation and fibrosis.

Emergency Radiology "Boot Camp": Educating Emergency Medicine Residents Using E-learning Radiology Modules.

OBJECTIVES: There is an overall paucity of literature on the radiologic education of emergency medicine (EM) clinicians. Given the fact that many EM clinicians preliminarily review images for their patients, we hypothesized that a brief imaging curriculum could be efficacious in teaching basic and relevant radiologic interpretation. METHODS: We designed a 4-hour "radiology boot camp" for a group of 20 EM residents (from all years of training) covering several subject specific e-learning modules. They completed precourse and postcourse quizzes to evaluate the efficacy of these modules. These modules included interactive PowerPoint-based tutorials, games, and imaging decision support simulators. Matched results from the pre- and posttests were analyzed using paired t test. An additional questionnaire was administered to the EM residents to evaluate their perception of the educational experience. RESULTS: The precourse and postcourse quizzes demonstrated a statistically significant level of improved knowledge due to the educational modules (p < 0.0001). In addition, all of the participants believed the modules were a useful learning experience (100%) and a vast majority described them as a valuable resource for future reference (95%). CONCLUSION: We demonstrate a model for providing an easy and effective means of educating EM residents on basic imaging interpretation and utilization, using e-learning modules.

Improving Care and Education Through a Radiology Resident-driven Clinical Consultation Service.

RATIONALE AND OBJECTIVE: As health care moves toward bundled payment systems and merit-based incentive models, increasing awareness of the value of the radiologist is essential. A resident-driven clinical imaging rounds (CIR) program initiated at our institution allows radiologists to actively and directly participate in the team-based medical model. A retrospective review of survey data evaluated the qualitative and quantitative effects of CIR on clinical management, communication, and education of referring providers and radiology residents. MATERIALS AND METHODS: The initial 10 months of a resident-organized CIR were evaluated in a retrospective study. Twenty radiology residents and 150 internal medicine physicians and medical students participated in imaging rounds. An anonymous survey of participants was performed and results were analyzed. RESULTS: Eighty-five percent of radiology resident participants completed the survey (N = 17). Approximately 30% of internal medicine participants completed the survey (N = 45). There was an overwhelming positive review of imaging rounds, with a large majority of all groups agreeing that imaging rounds improve education, communication, and patient care. CONCLUSIONS: Resident-driven imaging rounds provide a valuable opportunity to improve communication, education, and patient care. We have created a CIR with a sustainable workflow that allows direct and regularly scheduled imaging-medicine consultation valued by both radiologists and internal medicine physicians, improving the quality of patient care and providing education to our radiology residents in value-based care.