151
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Gedberg N, Karmisholt J, Gade M, Fisker RV, Iyer V, Petersen LJ. The Frequency of Focal Thyroid Incidental Findings and Risk of Malignancy Detected by 18F-Fluorodeoxyglucose Positron Emission Tomography in an Iodine Deficient Population. Diagnostics (Basel) 2018; 8:diagnostics8030046. [PMID: 30018271 PMCID: PMC6165051 DOI: 10.3390/diagnostics8030046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/11/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
Incidental focal uptake of 18F-fluorodeoxyglucose (FDG) in the thyroid on positron emission tomography (PET/CT) is rare but often associated with malignancy. The epidemiology of thyroid incidentalomas has only to some extent been described in countries with iodine deficiency. Here we report data from Denmark, a country with known iodine deficiency and wide access to PET/CT. All FDG PET/CT comprising the head and neck region, during 2014, were retrospectively reviewed, and patients with focal FDG uptake in the thyroid gland were identified. A total of 2451 patients had an FDG PET/CT of which 59 (2.4%) patients presented with FDG-avid focal lesions in the thyroid gland. Among the 59 patients with FDG-avid lesions, 33 patients (56%) received work up with ultrasound, thyroid technetium scintigraphy, fine needle aspiration, and/or histology of which 20 patients had a conclusive pathology report. Ten patients with FDG-avid lesions were identified with thyroid malignancy. The risk of thyroid malignancy was 16.9% among patient with incidental FDG-avid thyroid lesions. Our findings indicated a similar frequency of FDG thyroid incidentalomas and malignancy rates in an iodine deficient population compared to summary data from prior studies, studies mostly performed in geographical areas of normal or excess iodine supplementation.
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Affiliation(s)
- Nina Gedberg
- Department of Otolaryngology, Aarhus University Hospital, DK-8000 Aarhus, Denmark.
| | - Jesper Karmisholt
- Department of Endocrinology, Aalborg University Hospital, DK-9000 Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, DK-9000 Aalborg, Denmark.
| | - Michael Gade
- Department of Nuclear Medicine, Clinical Cancer Research Centre, Aalborg University Hospital, DK-9000 Aalborg, Denmark.
| | - Rune V Fisker
- Department of Nuclear Medicine, Clinical Cancer Research Centre, Aalborg University Hospital, DK-9000 Aalborg, Denmark.
- Department of Radiology, Aalborg University Hospital, DK-9000 Aalborg, Denmark.
| | - Victor Iyer
- Department of Nuclear Medicine, Clinical Cancer Research Centre, Aalborg University Hospital, DK-9000 Aalborg, Denmark.
| | - Lars J Petersen
- Department of Clinical Medicine, Aalborg University, DK-9000 Aalborg, Denmark.
- Department of Nuclear Medicine, Clinical Cancer Research Centre, Aalborg University Hospital, DK-9000 Aalborg, Denmark.
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152
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Bozovic G, Adlercreutz C, Björkman-Burtscher IM, Reinstrup P, Ingemansson R, Skansebo E, Geijer M. Impact of donor chest radiography on clinical outcome after lung transplantation. Acta Radiol Open 2018; 7:2058460118781419. [PMID: 29977606 PMCID: PMC6024291 DOI: 10.1177/2058460118781419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 05/11/2018] [Indexed: 11/23/2022] Open
Abstract
Background Organ donation guidelines recommend a “clear” conventional bedside chest
radiograph before lung transplantation despite only moderate accuracy for
cardiopulmonary abnormalities. Purpose To evaluate the influence of donor image interpretation on lung
transplantation outcome in recipients by following early and late
complications, one-year survival, and to correlate imaging findings and
blood gas analysis with lung transplantation outcome in recipients. Material and Methods In 35 lung donors from a single institution clinical reports and study
reviews of imaging findings of the mandatory bedside chest radiographs and
blood gas analyses were compared with clinical outcome in 38 recipients.
Hospitalization time, peri- and postoperative complications, early
complications (primary graft dysfunction, infection), 30-day and one-year
survival, and forced expiratory volume in 1 s percentage of predicted normal
value (FEV1%) at one-year follow-up were analyzed. Results Findings in clinical reports and study reviews differed substantially, e.g.
regarding reported decompensation, edema, infection, and atelectasis. No
correlation was shown between imaging findings in clinical report or study
review and blood gas analyses in the lung donors compared to postoperative
outcome in recipients. Conclusion The interpretation of the mandatory chest radiograph in its present form does
not influence one-year outcome in lung transplantation. Larger imaging
studies or a change in clinical routine including computed tomography may
provide evidence for future guidelines.
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Affiliation(s)
- Gracijela Bozovic
- Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | | | - Isabella M Björkman-Burtscher
- Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Lund University BioImaging Centre, Lund University, Sweden
| | - Peter Reinstrup
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Elin Skansebo
- Department of Thoracic surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Geijer
- Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Clinical Sciences Lund, Lund University, Lund, Sweden
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153
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O'Sullivan JW, Muntinga T, Grigg S, Ioannidis JPA. Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ 2018; 361:k2387. [PMID: 29914908 PMCID: PMC6283350 DOI: 10.1136/bmj.k2387] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To provide an overview of the evidence on prevalence and outcomes of incidental imaging findings. DESIGN Umbrella review of systematic reviews. DATA SOURCES Searches of MEDLINE, EMBASE up to August 2017; screening of references in included papers. ELIGIBILITY CRITERIA Criteria included systematic reviews and meta-analyses of observational studies that gave a prevalence of incidental abnormalities ("incidentalomas"). An incidental imaging finding was defined as an imaging abnormality in a healthy, asymptomatic patient or an imaging abnormality in a symptomatic patient, where the abnormality was not apparently related to the patient's symptoms. Primary studies that measured the prevalence of incidentalomas in patients with a history of malignancy were also considered in sensitivity analyses. RESULTS 20 systematic reviews (240 primary studies) were identified from 7098 references from the database search. Fifteen systematic reviews provided data to quantify the prevalence of incidentalomas, whereas 18 provided data to quantify the outcomes of incidentalomas (13 provided both). The prevalence of incidentalomas varied substantially between imaging tests; it was less than 5% for chest computed tomography for incidental pulmonary embolism in patients with and without cancer and whole body positron emission tomography (PET) or PET/computed tomography (for patients with and without cancer). Conversely, incidentalomas occurred in more than a third of images in cardiac magnetic resonance imaging (MRI), chest computed tomography (for incidentalomas of thorax, abdomen, spine, or heart), and computed tomography colonoscopy (for extra-colonic incidentalomas). Intermediate rates occurred with MRI of the spine (22%) and brain (22%). The rate of malignancy in incidentalomas varied substantially between organs; the prevalence of malignancy was less than 5% in incidentalomas of the brain, parotid, and adrenal gland. Extra-colonic, prostatic, and colonic incidentalomas were malignant between 10% and 20% of the time, whereas renal, thyroid, and ovarian incidentalomas were malignant around a quarter of the time. Breast incidentalomas had the highest percentage of malignancy (42%, 95% confidence interval 31% to 54%). Many assessments had high between-study heterogeneity (15 of 20 meta-analyses with I2 >50%). CONCLUSIONS There is large variability across different imaging techniques both in the prevalence of incidentalomas and in the prevalence of malignancy for specific organs. This umbrella review will aid clinicians and patients weigh up the pros and cons of requesting imaging scans and will help with management decisions after an incidentaloma diagnosis. Our results can underpin the creation of guidelines to assist these decisions. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42017075679.
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Affiliation(s)
- Jack W O'Sullivan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Tim Muntinga
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Sam Grigg
- University of Melbourne, Victoria, Australia
| | - John P A Ioannidis
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, CA, USA
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
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154
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Fleischmann M, Vaughan B. The challenges and opportunities of using patient reported outcome measures (PROMs) in clinical practice. INT J OSTEOPATH MED 2018. [DOI: 10.1016/j.ijosm.2018.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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155
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Mier-Hicks A, Raj M, Do RK, Yu KH, Lowery MA, Varghese A, O'Reilly EM. Incidence, Management, and Implications of Visceral Thrombosis in Pancreatic Ductal Adenocarcinoma. Clin Colorectal Cancer 2018; 17:121-128. [PMID: 29477452 PMCID: PMC7382360 DOI: 10.1016/j.clcc.2018.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 01/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Visceral or splanchnic thrombosis is defined as thrombi within the hepatoportal venous system, including portal (PV), mesenteric (MV), and splenic vein (SV), as well as thrombi in renal or gonadal veins. There are limited data to evaluate the prognostic significance, incidence, and clinical management of visceral thromboses in patients with pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS We conducted an analysis of 95 patients treated at Memorial Sloan Kettering Cancer Center with PDAC who had a visceral thrombosis. RESULTS A total of 153 visceral thromboses (VsT) were identified in 95 patients (n = 51, 54% woman). A total of 36 patients (37%) had locally advanced disease, and n = 59 (62%) had metastatic disease. Systemic therapies received included FOLFIRINOX (n = 57, 60%) and GC/PTX (n = 27, 28%). All VsT events were incidentally detected. Overall survival of cohort was 12.3 months (range, 10.2-14.4 months). Visceral thrombosis incidence in the cohort was as follows: portal vein (PV) (45%), MV (26%), SV (17%), and gonadal veins (8%). Time to develop first VsT was 4.3 months (range, 3-5.6 months), and time to death from VsT development was 1.87 months (range, 0.8-2.8 months). Forty-five patients (47%) developed a second VsT. Sixty percent had a Khorana risk score of > 3. Thirty-nine patients (41%) were treated with short-term anticoagulation (AC) (< 1 month) (low-molecular-weight heparin, n = 34). Forty-five patients (47%) were treated with long-term AC (> 1 month) (low-molecular-weight heparin, n = 32; 23 were transitioned to an oral anticoagulant). Twenty-two patients (23%) were not treated with AC. Eight patients (8%) had a bleeding complication from AC. Portal vein thrombosis had the shortest overall survival at 3.6 months (range, 2.3-4.8 months). CONCLUSION In PDAC, VsT can frequently present as an incidental finding on routine abdominal imaging. The most common location is PV, followed by MV and SV. We observed that AC is underutilized in this setting despite a low bleeding complication rate. PV was associated with the least overall survival of the VsT. Future large prospective studies should explore the role of AC and value in this setting.
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Affiliation(s)
| | - Michael Raj
- Department of Diagnostic Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Richard Kinh Do
- Department of Diagnostic Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H Yu
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Maeve A Lowery
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medicine, New York, NY.
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156
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Raphel TJ, Weaver DT, Berland LL, Herts BR, Megibow AJ, Knudsen AB, Pandharipande PV. Imaging Follow-up of Low-Risk Incidental Pancreas and Kidney Findings: Effects of Patient Age and Comorbidity on Projected Life Expectancy. Radiology 2018; 287:504-514. [DOI: 10.1148/radiol.2018171701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Tiana J. Raphel
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
| | - Davis T. Weaver
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
| | - Lincoln L. Berland
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
| | - Brian R. Herts
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
| | - Alec J. Megibow
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
| | - Amy B. Knudsen
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
| | - Pari V. Pandharipande
- From the Department of Radiology (T.J.R., D.T.W., A.B.K., P.V.P.) and Institute for Technology Assessment (T.J.R., D.T.W., A.B.K., P.V.P.), Massachusetts General Hospital, 101 Merrimac St, 10th Floor, Boston, MA 02114; Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (L.L.B.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (B.R.H.); and Department of Radiology, NYU-Langone Medical Center, New York, NY (A.J.M.)
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157
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Chaulk AL, Wang JI, Makam AN. A Depressing Diagnostic Error. Am J Med 2018; 131:e191-e192. [PMID: 29284114 DOI: 10.1016/j.amjmed.2017.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
| | - Joseph I Wang
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Anil N Makam
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
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158
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System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings. J Am Coll Radiol 2018; 15:639-647. [DOI: 10.1016/j.jacr.2017.11.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 12/21/2022]
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159
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Nielsen ME, Birken SA. Implementation science theories to inform efforts for de-implementation of urologic oncology care practices resulting in overuse and misuse. Urol Oncol 2018; 36:252-256. [PMID: 29566976 DOI: 10.1016/j.urolonc.2018.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/21/2022]
Abstract
The field of implementation science has been conventionally applied in the context of increasing the application of evidence-based practices into clinical care, given evidence of underusage of appropriate interventions in many settings. Increasingly, however, there is recognition of the potential for similar frameworks to inform efforts to reduce the application of ineffective or potentially harmful practices. In this article, we provide some examples of clinical scenarios in which the quality problem may be overuse and misuse, and review relevant theories and frameworks that may inform improvement activities.
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Affiliation(s)
- Matthew E Nielsen
- Department of Urology, University of North Carolina School of Medicine, Chapel Hill, NC; Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC; Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC; Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC.
| | - Sarah A Birken
- Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC; Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
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160
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Abstract
PURPOSE Multiparametric magnetic resonance imaging (mp-MRI) and MRI/Ultrasound (US) fusion-guided biopsy are relatively new techniques for improved detection, staging, and active surveillance of prostate cancer (PCa). As with all imaging modalities, MRI reveals incidental findings (IFs) which carry the risk of increased cost, patient anxiety, and iatrogenic morbidity due to workup of IFs. Herein, we report the IFs from 684 MRIs for evaluation of PCa and consider their characteristics and clinical significance. METHODS Patients underwent mp-MRI prostate protocol incorporating triplanar T2-weighted, diffusion-weighted, and dynamic contrast-enhanced pelvic MRI as well as a post-contrast abdominopelvic MRI with the primary indication of detection or evaluation of PCa. A total of 684 consecutive prostate MRI reports performed in a series of 580 patients were reviewed. All extraprostatic findings reported were logged and then categorized by organ system and potential clinical significance. RESULTS There were 349 true IFs found in 233 (40%) of the 580 patients. One hundred nineteen additional extraprostatic findings were unsuspected but directly related to PCa staging, while the 349 IFs were unrelated and thus truly incidental beyond study indication. While the majority of true IFs were non-urologic, only 6.6% of IFs were considered clinically significant, non-urologic findings, and more than a third of MRI reports had urologic IFs not related to PCa. CONCLUSIONS Rates of incidental findings on prostate indication MRI are similar to other abdominopelvic imaging studies. However, only 6.6% of the IFs were considered to be clinically significant non-urologic findings. Further investigations are needed to assess downstream workup of these IFs and resulting costs.
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161
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Incidence and Economic Impact of Incidental Findings on 18F-FDG PET/CT Imaging. Can Assoc Radiol J 2018; 69:63-70. [PMID: 29458956 DOI: 10.1016/j.carj.2017.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/23/2017] [Accepted: 08/01/2017] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The study sought to determine the incidence of incidental findings on whole-body positron emission tomography with computed tomography (PET/CT) imaging and the average costs of investigations to follow-up or further characterize incidental findings. METHODS Imaging reports of 215 patients who underwent whole-body PET/CT imaging were retrospectively reviewed. Our provincial picture archiving and communication system was queried and patient charts were reviewed to identify all investigations performed to follow-up incidental findings within 1 year of the initial PET/CT study. Costs of follow-up imaging studies (professional and technical components) and other diagnostic tests and procedures were determined in Canadian dollars (CAD) and U.S. dollars (USD) using the 2015 Ontario Health Insurance Plan Schedule of Benefits and Fees and 2016 U.S. Medicare Physician Fee Schedule, respectively. RESULTS At least 1 incidental finding was reported in 161 reports (74.9%). The mean number of incidental findings ranged from 0.64 in patients <45 years of age to 2.2 in patients 75 years of age and older. Seventy-five recommendations for additional investigations were made for 64 (30%) patients undergoing PET/CT imaging, and 14 of those were carried out specifically to follow-up incidental findings. Averaged across all 215 patients, the total cost of investigations recommended to follow-up incidental findings was CAD$105.51 (USD$127.56) per PET/CT study if all recommendations were acted on, and CAD$22.77 (USD$29.14) based on investigations actually performed. CONCLUSIONS As the incidence of incidental findings increases with age and a larger proportion of elderly patients is expected as population demographics change, it will be increasingly important to consider incidental findings on PET/CT imaging with standardized approaches to follow-up.
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162
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O'Sullivan JW, Albasri A, Nicholson BD, Perera R, Aronson JK, Roberts N, Heneghan C. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open 2018; 8:e018557. [PMID: 29440142 PMCID: PMC5829845 DOI: 10.1136/bmjopen-2017-018557] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. OBJECTIVE To identify overuse and underuse of diagnostic tests in primary care. DESIGN Systematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. RESULTS We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively. CONCLUSIONS There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO REGISTRATION NUMBER CRD42016048832.
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Affiliation(s)
- Jack W O'Sullivan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Ali Albasri
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Rafael Perera
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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163
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McGettigan MJ, Gatenby RA. Radiologic Pearls for Internists: A Case-Based Review. Am J Med 2018; 131:9-16. [PMID: 28889930 DOI: 10.1016/j.amjmed.2017.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 08/19/2017] [Accepted: 08/23/2017] [Indexed: 02/07/2023]
Abstract
Modern technologic advances in medical imaging and the increasing use of imaging across all disciplines in medicine have led to a striking rise in incidental findings unrelated to the original study indication. Often, these findings have no clinical relevance and will not impact the current or future health status of the patient. It is incumbent on radiologists to report these findings in a definitive and unambiguous manner. Similarly, it is essential for clinicians to restrain from further diagnostic investigation of incidental findings that are conclusive by imaging. A classic and common example is the finding of a cyst. This article presents several cases of incidentally found cysts for which a confident diagnosis can be made without any need for follow-up.
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Affiliation(s)
- Melissa J McGettigan
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center and Research Institute, Tampa, Fla.
| | - Robert A Gatenby
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center and Research Institute, Tampa, Fla
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164
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Incidental Thoracic and Abdominal Findings in Diagnostic Imaging. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4051606. [PMID: 29789789 PMCID: PMC5896332 DOI: 10.1155/2018/4051606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/29/2022]
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165
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A Randomized Study of Patient Risk Perception for Incidental Renal Findings on Diagnostic Imaging Tests. AJR Am J Roentgenol 2017; 210:369-375. [PMID: 29140116 DOI: 10.2214/ajr.17.18485] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study is to assess differences in patient distress, risk perception, and treatment preferences for incidental renal findings with descriptive versus combined descriptive and numeric graphical risk information. MATERIALS AND METHODS A randomized survey study was conducted for adult patients about to undergo outpatient imaging studies at a large urban academic institution. Two survey arms contained either descriptive or a combination of descriptive and numeric graphical risk information about three hypothetical incidental renal findings at CT: 2-cm (low risk) and 5-cm (high risk) renal tumors and a 2-cm (low risk) renal artery aneurysm. The main outcomes were patient distress, perceived risk (qualitative and quantitative), treatment preference, and valuation of lesion discovery. RESULTS Of 374 patients, 299 participated (79.9% response rate). With inclusion of numeric and graphical, rather than only descriptive, risk information about disease progression for a 2-cm renal tumor, patients reported less worry (3.56 vs 4.12 on a 5-point scale; p < 0.001) and favored surgical consultation less often (29.3% vs 46.9%; p = 0.003). The proportion choosing surgical consultation for the 2-cm renal tumor decreased to a similar level as for the renal artery aneurysm with numeric risk information (29.3% [95% CI, 21.7-36.8%] and 27.9% [95% CI, 20.5-35.3%], respectively). Patients overestimated the absolute risk of adverse events regardless of risk information type, but significantly more so when given descriptive information only, and valued the discovery of lesions regardless of risk information type (range, 4.41-4.81 on a 5-point scale). CONCLUSION Numeric graphical risk communication for patients about incidental renal lesions may facilitate accurate risk comprehension and support patients in informed decision making.
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Tamburello A, Treglia G, Albano D, Bertagna F, Giovanella L. Prevalence and clinical significance of focal incidental 18F-FDG uptake in different organs: an evidence-based summary. Clin Transl Imaging 2017. [DOI: 10.1007/s40336-017-0253-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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167
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Knox M, Slanetz P, Phillips J, Fein Zachary V, Venkataraman S, Dialani V, Mehta T. Incidental liver lesions seen on Breast MRI: When is additional imaging warranted? Eur J Radiol 2017; 95:319-324. [DOI: 10.1016/j.ejrad.2017.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 12/21/2022]
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168
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Meyer HJ, Schramm D, Bach AG, Beeskow A, Surov A. Cardiovascular findings on computed tomography in patients with unclear finding situation and trauma of unknown origin. Medicine (Baltimore) 2017; 96:e8263. [PMID: 29049218 PMCID: PMC5662384 DOI: 10.1097/md.0000000000008263] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Incidental cardiovascular findings are common and can be found in up to 70% of patients. Previously, several reports about incidental findings (IFs) on whole body computed tomography (CT) were published. However, no previous study investigated cardiovascular IFs in patients with unclear finding situation and trauma of unknown origin on whole body CT.The radiological database of 2 university hospitals was screened for patients with trauma of unknown origin and unclear finding situation investigated by whole body CT. The images were retrospectively analyzed by 2 radiologists in consensus. The findings were classified according to their clinical relevance. Clinically nonrelevant findings like valvular sclerosis, aortic sclerosis, or anatomic variants were excluded from this study. Moreover, the radiology reports were analyzed to assess initial reporting by the radiologist.Overall, we identified 60 patients with a mean age of 63 years. A total of 98 clinically relevant cardiovascular IFs (CRCIF) were identified in 60 (75%) patients (1.6 CRCIF per patient). The most prevalent finding was cardiomegaly in 23 patients, followed by coronary sclerosis in 21 patients and aortic ectasia in 11 patients; other findings were rarer. Sixty-one findings were reported (62.2%) and 37 were nonreported (37.8%). Thirty patients (50%) showed no traumatic event on whole body CT.CRCIFs are common in patients with unclear finding situation and trauma of unknown origin. Despite initial indication for trauma detection, the whole body CT should carefully be evaluated for CRCIF because of the high prevalence of clinically relevant findings. Notably, 37.76% of the findings were not reported by the radiologist.
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Affiliation(s)
- Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig
| | - Dominik Schramm
- Department of Diagnostic Radiology, Martin-Luther University Halle(Saale), Halle (Saale), Germany
| | - Andreas Gunter Bach
- Department of Diagnostic Radiology, Martin-Luther University Halle(Saale), Halle (Saale), Germany
| | - Anne Beeskow
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig
| | - Alexey Surov
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig
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169
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Khan MS, Chaudhry MBH, Shahzad N, Tariq M, Memon WA, Alvi AR. Risk of appendicitis in patients with incidentally discovered appendicoliths. J Surg Res 2017; 221:84-87. [PMID: 29229158 DOI: 10.1016/j.jss.2017.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/30/2017] [Accepted: 08/10/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND An appendicolith-related appendiceal obstruction leading to appendicitis is a commonly encountered surgical emergency that has clear evidence-based management plans. However, there is no consensus on management of asymptomatic patients when appendicoliths are found incidentally. The objective of this study was to determine the risk of appendicitis in patients with an incidental finding of the appendicolith. METHODS A retrospective matched cohort study of patients with appendicolith discovered incidentally on computed tomographic scan from January 2008 to December 2014 at our institution was completed. The size and position of the appendicolith were ascertained. The study group was matched by age and gender to a control group. Both groups were contacted and interviewed regarding development of appendicitis. RESULTS In total, 111 patients with appendicolith were successfully contacted and included in the study. Mean age was found to be 38 ± 15 y with 36 (32%) of the study population being females. Mean length of appendix was 66 ± 16 mm, and mean width was 5.8 ± 0.9 mm. Mean size of the appendicolith was 3.6 ± 1.1 mm (1.4-7.8 mm). Fifty-eight percent of appendicoliths was located at the proximal end or whole of appendix, 31% at mid area, and 11% at the distal end of appendix. All patients of the study and control groups were contacted, and at a mean follow-up of 4.0 ± 1.7 y, there was no occurrence of acute appendicitis in either group. CONCLUSIONS Patients with incidentally discovered appendicolith on radiological imaging did not develop appendicitis. Hence, the risk of developing acute appendicitis for these patients does not seem higher than the general population.
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Affiliation(s)
| | | | - Noman Shahzad
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Marvi Tariq
- Department of Surgery, Aga Khan University, Karachi, Pakistan
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170
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Abstract
Failure to follow-up on test results represents a serious breakdown point in the diagnostic process which can lead to missed or delayed diagnoses and patient harm. Amidst discussions to ensure fail-safe test result follow-up, an important, yet under-discussed question emerges: how do we determine who is ultimately responsible for initiating follow-up action on the tests that are ordered? This seemingly simple question belies its true complexity. Although many of these complexities are also applicable to other diagnostic specialities, the field of medical imaging provides an ideal context to discuss the challenges of attributing responsibility of test result follow-up. In this review, we summarize several key concepts and challenges in the context of critical results, wet reads, and incidental findings to stimulate further discussion on responsibility issues in radiology. These discussions could help establish reliable closed-loop communication to ensure that every test result is sent, received, acknowledged and acted upon without failure.
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Affiliation(s)
- Janice L Kwan
- Department of Medicine, Division of General Internal Medicine, University of Toronto, Mount Sinai Hospital, 427-600 University Avenue, Toronto, Ontario M5G 1X5, Canada
| | - Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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171
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Wolfe JM, Alaoui Soce A, Schill HM. How did I miss that? Developing mixed hybrid visual search as a 'model system' for incidental finding errors in radiology. COGNITIVE RESEARCH-PRINCIPLES AND IMPLICATIONS 2017; 2:35. [PMID: 28890920 PMCID: PMC5569644 DOI: 10.1186/s41235-017-0072-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 07/10/2017] [Indexed: 12/21/2022]
Abstract
In a real world search, it can be important to keep ‘an eye out’ for items of interest that are not the primary subject of the search. For instance, you might look for the exit sign on the freeway, but you should also respond to the armadillo crossing the road. In medicine, these items are known as “incidental findings,” findings of possible clinical significance that were not the main object of search. These errors (e.g., missing a broken rib while looking for pneumonia) have medical consequences for the patient and potential legal consequences for the physician. Here we report three experiments intended to develop a ‘model system’ for incidental findings – a paradigm that could be used in the lab to develop strategies to reduce incidental finding errors in the clinic. All the experiments involve ‘hybrid’ visual search for any of several targets held in memory. In this ‘mixed hybrid search task,’ observers search for any of three specific targets (e.g., this rabbit, this truck, and this spoon) and three categorical targets (e.g., masks, furniture, and plants). The hypothesis is that the specific items are like the specific goals of a real world search and the categorical targets are like the less well-defined incidental findings that might be present and that should be reported. In all these experiments, varying target prevalence, number of targets, etc., the categorical targets are missed at a much higher rate than the specific targets. This paradigm shows promise as a model of the incidental finding problem.
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Affiliation(s)
- Jeremy M Wolfe
- Ophthalmology and Radiology Departments, Harvard Medical School, 64 Sidney St. Suite 170, Cambridge, MA 02139 USA.,Visual Attention Lab, Brigham and Women's Hospital, 64 Sidney St. Suite 170, Cambridge, MA 02139 USA
| | - Abla Alaoui Soce
- Visual Attention Lab, Brigham and Women's Hospital, 64 Sidney St. Suite 170, Cambridge, MA 02139 USA
| | - Hayden M Schill
- Visual Attention Lab, Brigham and Women's Hospital, 64 Sidney St. Suite 170, Cambridge, MA 02139 USA
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172
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Desimini EM, Aldredge P, Gardner K. Development & Evolution of an Incidental Lung Lesion Program. ACTA ACUST UNITED AC 2017. [DOI: 10.1080/10463356.2015.11884000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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173
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Ng P, McGowan M, Goldstein M, Kassardjian CD, Steinhart BD. The impact of CT head scans on ED management and length of stay in bizarre behavior patients. Am J Emerg Med 2017; 36:213-217. [PMID: 28789887 DOI: 10.1016/j.ajem.2017.07.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/26/2017] [Accepted: 07/26/2017] [Indexed: 12/21/2022] Open
Abstract
METHODS A 5-year retrospective chart review was conducted at 3 EDs. Inclusion criteria were patients ≥18years old triaged as "mental health - bizarre behavior" (deviation from normal cognitive behaviour with no obvious cause) with a CT head scan ordered in the ED. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by an Emergency Physician for inter-rater reliability. RESULTS 266 cases met study criteria. Population demographics: 49% percent female, average age 51years old, 28% homeless, 58% arrived by police or ambulance. CT head results: 1 (0.4%) case with possible acute findings, 105 (39%) with incidental findings (i.e. cerebral atrophy) that did not impact clinical management. Average time to physician assessment was 1:48 (hour:min) (sd 1:11), time to CT completion was 5:05 (sd 7:28) and an average delay of 3:17 awaiting results. Subgroup analysis revealed a net increase in ED length of stay (ED LOS) of 5:02 from obtaining neuroimaging. 85% of patients were referred to a consultant, 92% were to psychiatry. CONCLUSIONS CT head results prolonged ED LOS, delayed patient disposition and did not change the patient's clinical management. A prospective trial for ordering CT head scans in these patients is warranted.
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Affiliation(s)
- P Ng
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Canada.
| | - M McGowan
- Emergency Medicine, St. Michael's Hospital, Canada
| | - M Goldstein
- Department of Psychiatry, University of Toronto, Canada
| | - C D Kassardjian
- Division of Neurology, Department of Medicine, University of Toronto, Canada
| | - B D Steinhart
- Department of Medicine, Division of Emergency Medicine, University of Toronto, Canada; Emergency Medicine, St. Michael's Hospital, Canada
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174
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Blecher G, Meek R, Egerton-Warburton D, McCahy P. Introduction of a new imaging guideline for suspected renal colic in the ED reduces CT urography utilisation. Emerg Med J 2017; 34:749-754. [PMID: 28720719 DOI: 10.1136/emermed-2016-206572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients presenting to the ED with suspected renal colic are frequently imaged with CT urography (CTU), which rarely alters diagnosis or management. To reduce use of CTU in this population, we instigated a new imaging and management guideline in our ED. METHODS This was a quasi-experimental prospective study, whereby a new guideline was commenced at the intervention site (Monash Medical Centre) and the existing guideline continued at the control site (Dandenong Hospital). The new guideline promotes focused ultrasound for diagnosing renal colic and restricts CT to those with poor response to analgesia or 'red flags'. A consecutive series of patients with suspected renal colic were prospectively enrolled and outcomes compared between the sites. The primary outcome was CTU utilisation and secondary outcomes were radiation exposure, stone rate on CTU, admission, ED length of stay and rates of urological intervention and returns to ED at 4-week follow-up. RESULTS Preintervention CTU rates were 76.7% at Monash and 72.1% at Dandenong. 324 patients were enrolled; 148 at Monash and 176 at Dandenong. Median age 47 years vs 49 years, males 76.4% vs 66.5% and medianSex, Timing, Origin, Nausea, Erythrocytes (STONE) score 10 vs 10 for Monash and Dandenong, respectively. CTU was performed in 54.1% vs 75.0% (p<0.001), median radiation exposure 2.8 vs 4.0 mSv (p<0.001) and urological intervention occurred in 16.4% vs 15.7% for Monash and Dandenong, respectively. CONCLUSIONS We found that use of CTU for renal colic was significantly reduced by introduction of a guideline promoting ultrasound and encouraging selective CTU. Although intervention rates were similar between the two sites, further prospective study is needed to ensure other patient-centred outcomes do not differ.
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Affiliation(s)
- Gabriel Blecher
- Emergency Program, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.,Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Rob Meek
- Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Emergency Program, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
| | - Diana Egerton-Warburton
- Emergency Program, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia.,Monash Emergency Research Collaborative, Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Philip McCahy
- Urology, Monash Health, Clayton, Victoria, Australia
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175
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Abstract
OBJECTIVES Physician variation in the use of computed tomography (CT) is concerning due to the risks of ionizing radiation, cost, and downstream effects of unnecessary testing. The objectives of this study were to describe variation in CT-ordering rates among emergency physicians (EPs), to measure correlation between perceived and actual CT-ordering rates, to assess attitudes that influence decisions to order imaging tests, and to identify EP attitudes associated with higher CT utilization. METHODS This study was a retrospective review of imaging and administrative billing records at two emergency department sites of a tertiary care adult teaching hospital. The study also included a cross-sectional survey of EPs at this hospital. We asked physicians about their perceived ordering behaviour, and what factors influenced their decision to order a CT. We examined correlations between perceived and actual CT-ordering rates. We adjusted ordering rates for shift distribution using a logistic regression model and identified outlier physicians whose ordering rate was significantly lower or higher than expected. We used multivariable regression analysis to determine which survey responses predicted higher CT utilization. RESULTS During the study period, 59 EPs saw 45,854 patients, and ordered 6,609 CTs - a mean ordering rate of 14.4% (standard deviation (SD)=4.3%). The ordering rate for individual physicians ranged from 5.9% to 25.9%. Of the 59 EPs, 13 EPs were low-ordering outliers; 12 were high-ordering outliers. Forty-five EPs (76.3%) completed the survey. Mean perceived ordering rate was 12.6%, and was weakly correlated with actual ordering (r=0.19, p=0.21). 42 EPs (93.3%) believed they ordered "about the same" or "fewer" CTs than their peers. Of the 17 EPs in the two highest ordering quintiles, only 3 (18%) knew they were high orderers. In the multivariable analysis, higher ordering was associated with increasing strength of response to the following predictors: medico-legal risk (relative risk [RR]=1.18, 95% CI: 1.03-1.21), risk of contrast (RR=1.14, 95% CI: 1.07-1.22), what colleagues would do (RR=1.09, 95% CI: 0.99-1.19), risk of missing a diagnosis (RR=1.08, 95% CI: 0.98-1.21), and patient wishes (RR=1.07, 95% CI: 0.97-1.17). CONCLUSIONS There is large variation in CT ordering among EPs. Physicians' self-reported ordering rate correlates poorly with actual ordering. High CT orderers were rarely aware that they ordered more than their colleagues. Higher rates of ordering were observed among physicians who reported increased concern with 1) risk of missing a diagnosis, 2) medico-legal risk, 3) risk of contrast, 4) patient wishes, and 5) what colleagues would do.
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176
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Detection of unexpected emergency diseases using FDG-PET/CT in oncology patients. Jpn J Radiol 2017; 35:539-545. [PMID: 28674772 DOI: 10.1007/s11604-017-0664-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 06/22/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the frequency of emergency diseases that were detected unexpectedly using FDG-PET/CT. MATERIALS AND METHODS Interpretation reports for 11,663 FDG-PET/CT studies in our hospital were retrospectively reviewed. Patients with major emergency diseases were extracted according to the following exclusion criteria: (1) relevant findings had been recognized prior to the PET/CT; (2) an intervention or operation that may have been relevant to the present findings was performed within 1 month prior to the PET/CT; and (3) the clinical course could not be investigated sufficiently (e.g., in cases where the patients were introduced from other hospitals). RESULTS Forty-one patients (0.35%) with unexpected emergency diseases were identified. The most frequent disease was pneumothorax (8 patients), followed by chronic subdural hematoma (CSH) (7 patients), ureteral stone (7 patients), and abdominal aortic aneurysm (AAA) with a dirty fat sign or a high-attenuation crescent sign visualized on CT (4 patients). Nine patients (2 pneumothorax, 3 CSH, 1 cerebral hemorrhage, 1 acute cholecystitis, 1 acute pancreatitis, and 1 acute appendicitis) were hospitalized and/or underwent therapeutic intervention within 1 week after the PET/CT. CONCLUSION Although rare, an unexpected emergency disease requiring urgent management can be detected using FDG-PET/CT in oncology patients.
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177
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Secchi F, Di Leo G, Zanardo M, Alì M, Cannaò PM, Sardanelli F. Detection of incidental cardiac findings in noncardiac chest computed tomography. Medicine (Baltimore) 2017; 96:e7531. [PMID: 28723768 PMCID: PMC5521908 DOI: 10.1097/md.0000000000007531] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The aim of the study was to estimate the rate of incidental cardiac findings (ICF) in patients undergoing noncardiac chest CT.An experienced radiologist retrospectively reviewed 237 consecutive patients (147 males and 90 females with median age of 69 years) undergoing a noncardiac chest CT. ICF at targeted review were compared to those mentioned in original reports (χ test).At review, ≥1 ICF was detected in 124/237 patients (52%), for a total of 229 ICF, 158 of them (69%) not originally mentioned. Valvular calcifications were unmentioned in 23/23 (100%) patients, main pulmonary artery dilation in 21/22 (96%), coronary calcifications in 69/86 (80%), right or left atrial dilation in 7/11 (64%), aortic atherosclerosis in 29/62 (47%), and ascending aorta dilatation in 8/18 (44%). All 6 pericardial effusions were originally mentioned. No association with sex (P ≥ .189); positive correlation with age (P < .001).Half of patients undergoing noncardiac chest CT presented ≥1 ICF, independently from sex but increasing with age. Moreover, 69% of detectable ICFs were not originally mentioned.
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Affiliation(s)
- Francesco Secchi
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese
| | - Giovanni Di Leo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese
| | - Moreno Zanardo
- Integrative Biomedical Research, Università degli Studi di Milano, Via Mangiagalli, Milan
| | - Marco Alì
- Integrative Biomedical Research, Università degli Studi di Milano, Via Mangiagalli, Milan
| | - Paola Maria Cannaò
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese
| | - Francesco Sardanelli
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Morandi 30, San Donato Milanese, Italy
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178
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Meyer HJ, Uhlig J, Schramm D, Bach AG, Surov A. Radiological findings on irradiation-CT in patients with non metastatic breast cancer. Br J Radiol 2017; 90:20170162. [PMID: 28511549 DOI: 10.1259/bjr.20170162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the number of incidental findings on native CT treatment-planning scans for radiation in breast cancer patients. METHODS The treatment-planning scans of 382 patients with non-metastatic breast cancer were retrospectively analyzed for additional findings. The planning scan area covered the entire thorax and the upper part of the abdomen. Incidental findings were classified according to their clinical relevance. RESULTS Overall 892 incidental findings were detected in the CT treatment-planning scans (mean 2.34 findings per patient). Only a small proportion of patients (n = 63, 16.4%) had no finding. Most findings were located in the thorax (683, 76.57%), and 209 findings (23.43%) were abdominal. 79 findings (8.87%) were of major clinical relevance, 232 findings (26.01%) were of moderate clinical relevance and 580 findings (65.02%) were of minor clinical relevance. Most clinically relevant findings were in the thorax (p = 0.006). Abdominal findings were more of significantly minor clinical relevance (p < 0.0001). CONCLUSION Radiological findings are frequent in native CT treatment-planning scans for radiation of breast cancer patients. Therefore, the radiologist should use this performed sectional image to obtain additional information of the patient. Advances in knowledge: Treatment-planning CT scans can show several radiological findings, namely 2.34 findings per patient. Major clinically relevant findings account for 8.87%.
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Affiliation(s)
- Hans J Meyer
- 1 Department of Radiology, Martin Luther University Halle-Wittenberg, Saale, Germany
| | - Johannes Uhlig
- 2 Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Dominik Schramm
- 1 Department of Radiology, Martin Luther University Halle-Wittenberg, Saale, Germany
| | - Andreas G Bach
- 1 Department of Radiology, Martin Luther University Halle-Wittenberg, Saale, Germany
| | - Alexey Surov
- 3 Department of Diagnostic and Interventional Radiology, Leipzig University Hospital, Leipzig, Germany
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179
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Remedios D, France B, Alexander M. Making the best value of clinical radiology: iRefer Guidelines, 8th edition. Clin Radiol 2017. [PMID: 28622797 DOI: 10.1016/j.crad.2017.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
New uses of medical imaging as well as over-diagnosis and wasteful imaging have led to a 10% per annum growth in computed tomography (CT) and magnetic resonance imaging (MRI). Personalised value to the patient will be helped by referral guidelines for the best test first, adding evidence-based technical value to the investigation to answer the clinical question, thus providing allocative value to the commissioners of medical imaging. Appropriate imaging is driven by the need for effective decisions, radiation safety, and cost awareness. The eighth edition of The Royal College of Radiologists' iRefer guidelines addresses 270 common clinical settings providing imaging referral advice, particularly for primary care practitioners. There is a new section addressing asymptomatic individuals for screening and health assessment. Multiple formats, including print and web formats, will be augmented by a clinical decision support tool to bring guidance closer to referrers. Established evidence identified a reduction in requested examination numbers by typically 20%, with more recent studies showing appropriate imaging in 80-90% of cases, correctly allowing some flexibility for individual circumstances. The perceived value of referral guidance may be judged by the mandated use in the USA, the requirement for availability in Europe, and the wish by many elsewhere to avail their patients of best imaging practice.
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Affiliation(s)
- D Remedios
- The Royal College of Radiologists (RCR), 63 Lincoln's Inn Fields, London WC2A 3JW, UK.
| | - B France
- The Royal College of Radiologists (RCR), 63 Lincoln's Inn Fields, London WC2A 3JW, UK
| | - M Alexander
- The Royal College of Radiologists (RCR), 63 Lincoln's Inn Fields, London WC2A 3JW, UK
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180
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Sohns JM, Menke J, Bergau L, Weiss BG, Schmuck S, Weiberg D, Staab W, Derlin T, Dorenkamp M, Sohns C. Extra-vascular findings in patients undergoing magnetic resonance angiography of the abdomen, pelvis and lower extremities: A retrospective study of 352 patients. Vascular 2017; 26:27-38. [DOI: 10.1177/1708538117714401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The aim of this study was to assess the prevalence and clinical significance of extra-vascular findings in patients undergoing magnetic resonance angiography of the abdomen, pelvis and lower extremities. Materials and methods Three hundred fifty-two patients underwent abdominal, pelvic and lower extremity 1.5 T magnetic resonance angiography. Clinically relevant vascular and extra-vascular findings were identified. Relevant vascular findings were classified as stenosis, occlusion, aneurysm, sclerosis, dissection or vasculitis. Relevant extra-vascular findings were categorized as ‘safe’ (Group A), intermediate – requiring additional investigation – (Group B) and malignant/endangering – requiring change of therapy (Group C). Results A total of 2152 clinically relevant vascular findings was identified (6.1/patient). The most frequent vascular finding was femoral artery stenosis (10.6%). Four hundred fifty-one extra-vascular findings were observed (1.3/patient) and classified into Group A (78%), Group B (19.5%) and Group C findings (2.4%). The most frequent malignant findings were lung cancer, lymphoma, osteosarcoma, hepatocellular carcinoma and renal cell carcinoma (7/352 patients). Conclusions Extravascular findings are frequently encountered in magnetic resonance angiography performed for vascular indications. Clinically relevant findings are seen in a substantial part of patients and should prompt further diagnostic work-up.
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Affiliation(s)
- Jan M Sohns
- Department of Nuclear Medicine, Hannover Medical School, MHH, Hannover, Germany
- German Center for Cardiovascular Research, DZHK, Berlin, Germany
| | - Jan Menke
- Institute for Diagnostic and Interventional Radiology, Georg-August University, UMG, Göttingen, Germany
| | - Leonard Bergau
- German Center for Cardiovascular Research, DZHK, Berlin, Germany
- Department of Cardiology and Pneumology, Georg-August University, UMG, Göttingen, Germany
| | - Bernhard G Weiss
- Department of Otorhinolaryngology-Head and Neck Surgery, Georg-August University, UMG, Göttingen, Germany
| | - Sebastian Schmuck
- Department of Nuclear Medicine, Hannover Medical School, MHH, Hannover, Germany
| | - Desiree Weiberg
- Department of Nuclear Medicine, Hannover Medical School, MHH, Hannover, Germany
| | - Wieland Staab
- German Center for Cardiovascular Research, DZHK, Berlin, Germany
- Institute for Diagnostic and Interventional Radiology, Georg-August University, UMG, Göttingen, Germany
| | - Thorsten Derlin
- Department of Nuclear Medicine, Hannover Medical School, MHH, Hannover, Germany
| | - Marc Dorenkamp
- Department of Medicine, Cardiology Division, Charité Campus Virchow Klinikum, Berlin, Germany
| | - Christian Sohns
- Electrophysiology Bremen, Heart Center Bremen, Am Klinikum Links der Weser, Bremen, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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181
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Meyer HJ, Pfeil A, Schramm D, Bach AG, Surov A. Renal incidental findings on computed tomography: Frequency and distribution in a large non selected cohort. Medicine (Baltimore) 2017; 96:e7039. [PMID: 28658098 PMCID: PMC5500020 DOI: 10.1097/md.0000000000007039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Renal incidental findings (IFs) are common. However, previous reports investigated renal IFs were limited to patient selection. The purpose of this study was to estimate the prevalence and distribution of all renal IFs on computed tomography (CT) in a large patient collective.All patients, who underwent CT investigations of the abdominal region at our institution in the time period between January 2006 and February 2014 were included in this study. Inclusion criteria were as follows: no previous history of renal diseases and well image quality. Patients with known kidney disorders were excluded from the study. Overall, 7365 patients meet the inclusion criteria were identified. There were 2924 (39.7%) women and 4441 men (60.3%) with a mean age of 59.8 ± 16.7 years. All CTs were retrospectively analyzed in consensus by 2 radiologists. Collected data were evaluated by means of descriptive statistics.Overall, 2756 patients (37.42% of all included patients) showed 3425 different renal IFs (1.24 findings per patient). Of all renal IFs, 123 (3.6%) findings were clinically relevant, 259 (7.6%) were categorized as possibly clinically relevant, and 3043 (88.8%) were clinically non relevant.Different renal IFs can be detected on CT. The present study provides a real prevalence and proportion of them in daily clinical routine. Kidneys should be thoroughly evaluated because of the fact that incidental renal findings occur frequently.
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Affiliation(s)
- Hans Jonas Meyer
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Alina Pfeil
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle
| | - Dominik Schramm
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle
| | | | - Alexey Surov
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
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182
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Mackley MP, Capps B. Expect the unexpected: screening for secondary findings in clinical genomics research. Br Med Bull 2017; 122:109-122. [PMID: 28398474 DOI: 10.1093/bmb/ldx009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Due to decreasing cost, and increasing speed and precision, genomic sequencing in research is resulting in the generation of vast amounts of genetic data. The question of how to manage that information has been an area of significant debate. In particular, there has been much discussion around the issue of 'secondary findings' (SF)-findings unrelated to the research that have diagnostic significance. SOURCES OF DATA The following includes ethical commentaries, guidelines and policies in respect to large-scale clinical genomics studies. AREAS OF AGREEMENT Research participant autonomy and their informed consent are paramount-policies around SF must be made clear and participants must have the choice as to which results they wish to receive, if any. AREAS OF CONTROVERSY While many agree that clinically 'actionable' findings should be returned, some question whether they should be actively sought within a research protocol. GROWING POINTS SF present challenges to a growing field; diverse policies around their management have the potential to hinder collaboration and future research. AREAS TIMELY FOR DEVELOPING RESEARCH The impact of returning SF and accurate estimates of their clinical utility are needed to inform future protocol design.
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Affiliation(s)
- Michael P Mackley
- Radcliffe Department of Medicine, University of Oxford, Level 6 West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Benjamin Capps
- Department of Bioethics, Faculty of Medicine, Dalhousie University, 5849 University Avenue, Room C-312, CRC Bldg, PO Box 15000, Halifax NS, Canada B3H 4R2
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183
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Mefford JM, Tungate RM, Amini L, Suh D, Anderson CL, Rudkin SE, Boysen-Osborn M. A Comparison of Urolithiasis in the Presence and Absence of Microscopic Hematuria in the Emergency Department. West J Emerg Med 2017; 18:775-779. [PMID: 28611901 PMCID: PMC5468086 DOI: 10.5811/westjem.2017.4.33018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 04/13/2017] [Accepted: 04/13/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Urolithiasis is a common medical condition that accounts for a large number of emergency department (ED) visits each year and contributes significantly to annual healthcare costs. Urinalysis is an important screening test for patients presenting with symptoms suspicious for urolithiasis. At present there is a paucity of medical literature examining the characteristics of ureteral stones in patients who have microscopic hematuria on urinalysis versus those who do not. The purpose of this study was to examine mean ureteral stone size and its relationship to the incidence of clinically significant hydronephrosis in patients with and without microscopic hematuria. Methods This is a retrospective chart review of patient visits to a single, tertiary academic medical center ED between July 1, 2008, and August 1, 2013, of patients who underwent non-contrast computed tomography of the abdomen and pelvis and urinalysis. For patient visits meeting inclusion criteria, we compared mean stone size and the rate of moderate-to-severe hydronephrosis found on imaging in patients with and without microscopic hematuria on urinalysis. Results Out of a total of 2,370 patient visits 393 (16.6%) met inclusion criteria. Of those, 321 (82%) had microscopic hematuria present on urinalysis. Patient visits without microscopic hematuria had a higher rate of moderate-to-severe hydronephrosis (42%), when compared to patients with microscopic hematuria present (25%, p=.005). Mean ureteral stone size among patient visits without microscopic hematuria was 5.7 mm; it was 4.7 mm for those patients with microscopic hematuria (p=.09). For ureteral stones 5 mm or larger, the incidence of moderate-to-severe hydronephrosis was 49%, whereas for ureteral calculi less than 5 mm in size, the incidence of moderate-to-severe hydronephrosis was 14% (p < 0.0001). Conclusion Patients visiting the ED with single-stone ureterolithiasis without microscopic hematuria on urinalysis could be at increased risk of having moderate-to-severe hydronephrosis compared to similar patients presenting with microscopic hematuria on urinalysis. Although the presence of hematuria on urinalysis is a moderately sensitive screening test for urolithiasis, these results suggest patients without hematuria tend to have more clinically significant ureteral calculi, making their detection more important. Clinicians should maintain a high index of suspicion for urolithiasis, even in the absence of hematuria, since ureteral stones in these patients were found to be associated with a higher incidence of obstructive uropathy.
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Affiliation(s)
- Jason M Mefford
- University of California, Davis, Department of Emergency Medicine, Sacramento, California
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184
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Smereka P, Doshi AM, Ream JM, Rosenkrantz AB. The American College of Radiology Incidental Findings Committee Recommendations for Management of Incidental Lymph Nodes: A Single-Center Evaluation. Acad Radiol 2017; 24:603-608. [PMID: 28169142 DOI: 10.1016/j.acra.2016.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 12/12/2016] [Indexed: 12/21/2022]
Abstract
RATIONALE AND OBJECTIVES To assess the American College of Radiology Incidental Findings Committee's (ACR-IFC) recommendations for defining and following up abnormal incidental abdominopelvic lymph nodes. MATERIALS AND METHODS A total of 59 lymph nodes satisfying ACR-IFC criteria as incidental (no malignancy or lymphoproliferative disorder) and with sufficient follow-up to classify as benign (biopsy, decreased size, ≥12-month stability) or malignant (biopsy, detection of primary malignancy combined with either fluorodeoxyglucose hyperactivity or increase in size of the node) were included. Two radiologists independently assessed nodes for suspicious features by ACR-IFC criteria (round with indistinct hilum, hypervascularity, necrosis, cluster ≥3 nodes, cluster ≥2 nodes in ≥2 stations, size ≥1 cm in retroperitoneum). Outcomes were assessed with attention to ACR-IFC's recommendation for initial 3-month follow-up. RESULTS A total of 8.5% of nodes were malignant; 91.5% were benign. Two of six malignant nodes were stable at 3 to <6-month follow-up before diagnosis; diagnosis of four of five malignant nodes was facilitated by later development of non-nodal sites of tumor. A total of 13, 5, 8, and 9 nodes were deemed benign given a decrease at <3 months, 3-5 months, 6-11 months, or ≥12 months of follow-up. No ACR-IFC feature differentiated benign and malignant nodes (P = 0.164-1.0). A cluster ≥3 nodes was present in 88.1%-93.2% of nodes. A total of 96.6%-98.3% had ≥1 suspicious feature for both readers. Necrosis and hypervascularity were not identified in any node. CONCLUSIONS ACR-IFC imaging features overwhelmingly classified incidental nodes as abnormal, although did not differentiate benign and malignant nodes. Nodes stable at the ACR-IFC's advised initial 3-month follow-up were occasionally proven malignant or decreased on further imaging. Refinement of imaging criteria to define nodes of particularly high risk, integrated with other clinical criteria, may help optimize the follow-up of incidental abdominopelvic lymph nodes.
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185
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Gundareddy VP, Maruthur NM, Chibungu A, Bollampally P, Landis R, Eid SM. Association Between Radiologic Incidental Findings and Resource Utilization in Patients Admitted With Chest Pain in an Urban Medical Center. J Hosp Med 2017; 12:323-328. [PMID: 28459900 DOI: 10.12788/jhm.2722] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Increasing use of testing among hospitalized patients has resulted in an increase in radiologic incidental findings (IFs), which challenge the provision of high-value care in the hospital setting. OBJECTIVE To understand impact of radiologic incidental findings on resource utilization in patients hospitalized with chest pain. DESIGN Retrospective observational cross sectional study. SETTING Academic medical center. PARTICIPANTS Adult patients hospitalized with principal diagnosis of chest pain. MEASUREMENTS Demographic, imaging, and length of stay (LOS) data were abstracted from the medical charts. We used multiple logistic regression to evaluate factors associated with radiologic IFs and negative binomial regression to evaluate the association between radiologic IFs and LOS. RESULTS 1811 consecutive admissions with chest pain were analyzed retrospectively over a period of 24 months; 376 patients were included in the study after exclusion criteria were applied and readmissions removed. Of these, 197 patients (52%) had 364 new radiologic IFs on imaging; most IFs were of minor (50%) or moderate clinical significance (42%), with only 7% of major significance. Odds of finding radiologic IFs increased with age (adjusted odds ratio, 1.04; 95% confidence interval [CI], 1.01-1.06) and was associated with a 26% increase in LOS (adjusted incidence rate ratio, 1.26; 95% CI, 1.07-1.49). CONCLUSION Radiologic IFs were very common among patients hospitalized with chest pain of suspected cardiac origin and independently associated with an increase in the LOS. Interventions to address radiologic IFs may reduce LOS and, thereby, support high-value care. Journal of Hospital Medicine 2017;12:323-328.
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Affiliation(s)
- Venkat P Gundareddy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
| | - Abednego Chibungu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Regina Landis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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186
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Alsufyani NA. Cone beam computed tomography incidental findings of the cervical spine and clivus: retrospective analysis and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 123:e197-e217. [PMID: 28411008 DOI: 10.1016/j.oooo.2017.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 02/14/2017] [Accepted: 02/20/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to analyze and describe incidental findings in the cervical spine (C-spine) and the clivus encountered in cone beam computed tomography (CBCT) imaging. The wide range of possible anatomic variants and pathoses is discussed in the context of the medical and dental literature to clarify their radiographic appearance and clinical implications as a guide for the oral and maxillofacial radiologist. STUDY DESIGN A retrospective analysis of radiographic reports was conducted based on CBCT images from 2 oral and maxillofacial imaging centers. Reports documenting incidental findings in the C-spine or the clivus were selected. Data on patient age and sex were collected, and each incidental finding was categorized as degenerative, congenital, or developmental/pathologic. Each finding is discussed with clinical importance and is pictorially presented. RESULTS From a total of 7689 CBCT reports, there were 732 incidental findings (9.5%) in the C-spine or the clivus. Most findings were in the C-spine (92.3%), were degenerative in nature (78.7%), and occurred in females in their sixth decade. Logistic regression analysis showed that the odds of presenting with a degenerative incidental finding in the C-spine or the clivus did not differ based on sex but were 5.5 times (95% confidence interval, 3.77-8.04) higher if the patient was aged 50 years or older. CONCLUSIONS This review is the largest and the first to characterize incidental findings in the C-spine and the clivus. Such findings were reported in 9.5% of radiographic reports. Several presented as uncommon congenital variants that are not usually spotlighted during oral and maxillofacial radiology training.
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Affiliation(s)
- Noura A Alsufyani
- Assistant Professor, Oral & Maxillofacial Radiology, School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Canada; Assistant Professor, College of Dentistry, King Saud University, Saudi Arabia.
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187
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Voigt P, Fahnert J, Schramm D, Bach AG, Kahn T, Surov A. [Clinically relevant incidental cardiovascular findings in CT examinations]. Radiologe 2017; 57:296-301. [PMID: 28255791 DOI: 10.1007/s00117-017-0226-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND METHOD Incidental cardiovascular findings are a frequent phenomenon in computed tomography (CT) examinations. As the result of a dedicated PubMed search this article gives a systemic overview of the current literature on the most important incidental cardiovascular findings, their prevalence and clinical relevance. RESULTS The majority of incidental cardiovascular findings are of only low clinical relevance; however, highly relevant incidental findings, such as aortic aneurysms, thromboses and thromboembolic events can also occasionally be found, especially in oncology patients. CONCLUSION The scans from every CT examination should also be investigated for incidental findings as they can be of decisive importance for the further clinical management of patients, depending on their clinical relevance.
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Affiliation(s)
- P Voigt
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - J Fahnert
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - D Schramm
- Klinik für Radiologie, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06097, Halle, Deutschland
| | - A G Bach
- Klinik für Radiologie, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06097, Halle, Deutschland
| | - T Kahn
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - A Surov
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
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188
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Kroczek EK, Wieners G, Steffen I, Lindner T, Streitparth F, Hamm B, Maurer MH. Non-traumatic incidental findings in patients undergoing whole-body computed tomography at initial emergency admission. Emerg Med J 2017; 34:643-646. [PMID: 28130347 DOI: 10.1136/emermed-2016-205722] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 12/06/2016] [Accepted: 12/24/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the number, localisation and importance of non-traumatic incidental findings (IFs) in patients with suspected or obvious multiple trauma undergoing whole-body CT (WBCT) in a level-1 trauma centre. METHODS Between January 2009 and December 2013, a total of 2440 patients with trauma undergoing WBCT at admission to a level-1 trauma centre of a university hospital were retrospectively analysed, through imaging IFs unrelated to trauma with the radiological reports. All IFs were grouped into four categories according to their clinical relevance. Category 1: urgent treatment or further clarification needed; category 2: further examination and follow-up within 3-6 months required; category 3: findings with no immediate consequences for the treatment of the patient but of potential relevance in the future; category 4: harmless findings. RESULTS Altogether, 5440 IFs in 2440 patients (1735 male, 705 female; mean age 45.1 years) were documented. In 204 patients (8.4%) urgent category 1 findings were reported, 766 patients (31.4%) had category 2 findings, 1236 patients (50.7%) had category 3 findings and 1173 patients (48.1%) had category 4 findings. Most IFs were detected in the abdomen/pelvis (42.5%). 602 (24.7%) of the patients had no IFs. CONCLUSIONS WBCT scans of unrelated trauma patients demonstrate a high rate of IF. A substantial percentage (8.4%) of patients had urgent category 1IFs and a high percentage (31.4%) had category 2 IFs requiring a follow-up. This high number of patients with polytrauma undergoing WBCT, having IFs of high relevance, poses a major challenge for the level-1 trauma centre in the acute and postacute management of these patients.
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Affiliation(s)
- Eduard K Kroczek
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany.,Department for Diagnostic and Interventional Neuroradiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Gero Wieners
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany
| | - Ingo Steffen
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany
| | - Tobias Lindner
- Department of Emergency Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Florian Streitparth
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany
| | - Martin H Maurer
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany.,Department of Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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189
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Imaging of the Lungs in Organ Donors and its Clinical Relevance: A Retrospective Analysis. J Thorac Imaging 2017; 32:107-114. [PMID: 28060192 DOI: 10.1097/rti.0000000000000255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of the study was to retrospectively evaluate the diagnostic imaging that potential lung donors undergo, the reader variability of image interpretation and its relevance for donation, and the potential information gained from imaging studies not primarily intended for lung evaluation but partially including them. MATERIALS AND METHODS Bedside chest radiography and computed tomography (CT), completely or incompletely including the lungs, of 110 brain-dead potential organ donors in a single institution during 2007 to 2014 were reviewed from a donation perspective. Two chest radiologists in consensus analyzed catheters and cardiovascular, parenchymal, and pleural findings. Clinical reports and study review were compared for substantial differences in findings that could have led to a treatment change, triggered additional examinations such as bronchoscopy, or were considered important for donation. RESULTS Among 136 bedside chest radiographs, no differences between clinical reports and study reviews were found in 37 (27%), minor differences were found in 28 (21%), and substantial differences were found in 71 (52%) examinations (P<0.0001). In 31 of 42 (74%) complete or incomplete CT examinations, 50 of 74 findings with relevance for lung donation were not primarily reported (P<0.0001). CONCLUSIONS The majority of donor patients undergo only chest radiography. A targeted imaging review of abnormalities affecting the decision to use donor lungs may be useful in the preoperative stage. With a targeted list, substantial changes were made from initial clinical interpretations. CT can provide valuable information on donor lung pathology, even if the lungs are only partially imaged.
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190
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Schramm D, Justus A, Bach AG, Surov A. Incidental findings in the skeletal musculature on computed tomography. Br J Radiol 2016; 90:20160727. [PMID: 27936890 DOI: 10.1259/bjr.20160727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to analyze intramuscular incidental findings identified on CT in a large patient cohort. METHODS In the time period from 2010 to 2015, a total of 44,794 patients with several diagnoses were investigated by CT. Only those patients who underwent body CT including the neck, thorax, abdomen and pelvic regions after the i.v. application of a contrast medium were involved in the study. There were 4085 patients. On further analysis, only patients with intramuscular findings (IFs) incidentally detected on CT were included. Osseous or soft-tissue lesions with invasion into the musculature were excluded from the study. Patients with known or clinically suspicious muscle disorders were also excluded. Overall, 639 (15.64% of the 4085 analyzed cases) patients, 253 females and 386 males, with mean age 72.43 ± 12.02 years, were identified. Collected data were evaluated by means of descriptive statistics. RESULTS In the 639 patients, 917 IFs were identified. More often, several benign disorders were diagnosed (n = 803, 87.6%). There were hernias (33.5%), atrophy of different muscles (22%), lipomas (21%), intramuscular calcifications (8.7%), bursitis (1.2%) and intramuscular bleeding (1.1%). Malignant IFs (n = 114, 12.4%) included intramuscular metastases (11.9%) and lymphomas (0.6%). Most frequently, the identified IFs were localized in the abdominal wall musculature, paravertebral and gluteal muscles. In 657 cases (71.6% of all IFs), the identified muscle findings were not diagnosed by the radiologist who initially assessed the investigation. CONCLUSION CT can detect different incidental disorders within the skeletal musculature. Most of them were benign. However, malignant lesions can also occur. Therefore, skeletal muscles should be carefully evaluated on CT performed for other reasons. Advances in knowledge: IFs occur in 15.6% of CT investigations. Benign findings represent 87.6% and malignant lesions can be identified in 12.4%.
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Affiliation(s)
- Dominik Schramm
- Department of Radiology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Annkathrin Justus
- Department of Radiology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Andreas G Bach
- Department of Radiology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Alexey Surov
- Department of Radiology, Martin Luther University Halle-Wittenberg, Halle, Germany
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191
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Wolfe JM. Use-inspired basic research in medical image perception. Cogn Res Princ Implic 2016; 1:17. [PMID: 28180168 PMCID: PMC5256442 DOI: 10.1186/s41235-016-0019-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/08/2016] [Indexed: 12/21/2022] Open
Abstract
This journal is dedicated to "use-inspired basic research" where a problem in the world shapes the hypotheses for a study in the laboratory. This brief review presents several examples of "use-inspired basic research" in the area of medical image perception. These are cases where the field of radiology raises an interesting issue in visual cognition. Basic research on those issues may then lead to proposals to improve performance on clinical tasks in medical image perception. Of the six examples given here, the first three ask essentially perceptual questions: How can stereopsis improve medical image perception? How shall we assess the tradeoff between radiation dose and image quality? How does the choice of colors change the interpretation of medical images? The second three examples address attentional issues in those aspects of radiology that can be described as visual search problems: Can eye tracking help us understand errors in radiologic search? What happens if the number of targets in an image is unknown? What happens if, as in radiology screening programs, the target of search is very rare?
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Affiliation(s)
- Jeremy M. Wolfe
- Ophthalmology & Radiology, Harvard Medical School, 64 Sidney St. Suite 170, Cambridge, MA 02139-4170 USA
- Visual Attention Lab, Department of Surgery, Brigham & Women’s Hospital, 64 Sidney St. Suite 170, Cambridge, MA 02139-4170 USA
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192
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Treskes K, Bos SA, Beenen LFM, Sierink JC, Edwards MJR, Beuker BJA, Muradin GSR, Hohmann J, Luitse JSK, Hollmann MW, Dijkgraaf MGW, Goslings JC. High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial. Eur Radiol 2016; 27:2451-2462. [PMID: 27709280 PMCID: PMC5408082 DOI: 10.1007/s00330-016-4598-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/21/2016] [Accepted: 09/05/2016] [Indexed: 12/21/2022]
Abstract
Objectives To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning. Methods Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings. Results In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088–1.854; p < 0.010). Conclusions Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning. Key points • Total-body CT scanning in trauma results in 1.5 times more incidental findings. • Evaluation by TBCT in trauma results in more patients with incidental findings. • In every category of clinical relevance, TBCT detects more incidental findings.
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Affiliation(s)
- K Treskes
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - S A Bos
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - L F M Beenen
- Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J C Sierink
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M J R Edwards
- Department of Trauma and emergency surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - B J A Beuker
- Trauma Unit, Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - G S R Muradin
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - J Hohmann
- Department of Radiology and Nuclear Medicine, University of Basel Hospital, Petersgraben 4, 4031, Basel, Switzerland
| | - J S K Luitse
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M W Hollmann
- Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Abstract
Health care costs in the US have grown rapidly over the past several decades. As a result, there has been increasing interest in strategies to contain health care costs, without sacrificing the quality of medical care. While many factors contribute to rising costs, one major contributor to health care expenditure is diagnostic imaging. In this article, we address the growth of diagnostic imaging, the financial and clinical adverse effects of over-utilization, and discuss a variety of strategies to encourage appropriate use of diagnostic testing.
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Affiliation(s)
- Patricia E Litkowski
- Department of Internal Medicine at Washington University School of Medicine, St. Louis, Mo
| | - Gerald W Smetana
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Mass
| | - Mark L Zeidel
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Mass
| | - Melvin S Blanchard
- Department of Internal Medicine at Washington University School of Medicine, St. Louis, Mo.
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194
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L’échographie équivaut-elle à la tomodensitométrie dans la prise en charge des patients avec suspicion d’urolithiase se présentant à l’urgence? CAN J EMERG MED 2016; 18:402-4. [DOI: 10.1017/cem.2016.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Article Chosen: Smith-Bindman R, Aubin C, Bailitz J., et al. Ultrasonography versus Computed Tomography for Suspected Nephrolithiasis.New Engl J Med2014;371;1100-10.
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195
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The Utility of Routine Ultrasound Imaging after Elective Transplant Ureteric Stent Removal. J Transplant 2016; 2016:1231567. [PMID: 27493793 PMCID: PMC4963558 DOI: 10.1155/2016/1231567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/19/2016] [Indexed: 12/21/2022] Open
Abstract
Background. Ureteric stent insertion during kidney transplantation reduces the incidence of major urological complications (MUCs). We evaluated whether routine poststent removal graft ultrasonography (PSRGU) was useful in detecting MUCs before they became clinically or biochemically apparent. Methods. A retrospective analysis was undertaken of clinical outcomes following elective stent removals from adult single renal transplant recipients (sRTRs) at our centre between 1 January 2011 and 31 December 2013. Results. Elective stent removal was performed for 338 sRTRs. Of these patients, 222 had routine PSRGU (median (IQR) days after stent removal = 18 (11–31)), 79 had urgent PSRGU due to clinical or biochemical indications, 12 had CT imaging, and 25 had no further renal imaging. Of the 222 sRTRs who underwent routine PSRGU, 210 (94.6%) had no change of management, three (1.4%) required repeat imaging only, and eight patients (3.6%) had incidental (nonureteric) findings. One patient (0.5%) had nephrostomy insertion as a result of routine PSRGU findings, but no ureteric stenosis was identified. Of 79 patients having urgent PSRGU after elective stent removal, three patients required transplant ureteric reimplantation. Conclusions. This analysis found no evidence that routine PSRGU at two to three weeks after elective stent removal provides any added value beyond standard clinical and biochemical monitoring.
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196
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Lumbreras B, Vilar J, González-Álvarez I, Gómez-Sáez N, Domingo ML, Lorente MF, Pastor-Valero M, Hernández-Aguado I. The Fate of Patients with Solitary Pulmonary Nodules: Clinical Management and Radiation Exposure Associated. PLoS One 2016; 11:e0158458. [PMID: 27392032 PMCID: PMC4938621 DOI: 10.1371/journal.pone.0158458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 06/16/2016] [Indexed: 12/21/2022] Open
Abstract
Background The appropriate management of the large number of lung nodules detected during the course of routine medical care presents a challenge. We aimed to evaluate the usual clinical practice in solitary pulmonary nodule (SPN) management and associated radiation exposure. Methods We examined 893 radiology reports of consecutive patients undergoing chest computed tomography (CT) and radiography at two public hospitals in Spain. Information on diagnostic procedures from SPN detection and lung cancer diagnosis was collected prospectively for 18 months. Results More than 20% of patients with SPN detected on either chest radiograph (19.8%) or CT (26.1%) underwent no additional interventions and none developed lung cancer (100% negative predictive value). 346 (72.0%) patients with SPN detected on chest radiograph and 254 (61.5%) patients with SPN detected on CT had additional diagnostic tests and were not diagnosed with lung cancer. In patients undergoing follow-up imaging for SPNs detected on CT median number of additional imaging tests was 3.5 and the mean cumulative effective dose was 24.4 mSv; for those detected on chest radiograph the median number of additional imaging tests was 2.8 and the mean cumulative effective dose was 10.3 mSv. Conclusions Patients who did not have additional interventions were not diagnosed of lung cancer. There was an excessive amount of interventions in a high percentage of patients presenting SPN, which was associated with an excess of radiation exposure.
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Affiliation(s)
- Blanca Lumbreras
- Public Health Department, Miguel Hernández University, Alicante, Spain
- CIBER en Epidemiología y Salud Pública, Madrid, Spain
- * E-mail:
| | - José Vilar
- Radiodiagnostic Department, Peset Hospital, Valencia, Spain
| | | | - Noemí Gómez-Sáez
- Public Health Department, Miguel Hernández University, Alicante, Spain
| | | | | | - María Pastor-Valero
- Public Health Department, Miguel Hernández University, Alicante, Spain
- CIBER en Epidemiología y Salud Pública, Madrid, Spain
| | - Ildefonso Hernández-Aguado
- Public Health Department, Miguel Hernández University, Alicante, Spain
- CIBER en Epidemiología y Salud Pública, Madrid, Spain
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197
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Adams SJ, Babyn PS, Danilkewich A. [Vers une stratégie de prise en charge complète des détections fortuites en imagerie]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:e358-e560. [PMID: 27412222 PMCID: PMC4955098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Scott J Adams
- Étudiant en médecine à l'Université de la Saskatchewan à Saskatoon.
| | - Paul S Babyn
- Professeur et directeur du Département d'imagerie médicale à l'Université de la Saskatchewan et au District sanitaire de Saskatoon
| | - Alanna Danilkewich
- Professeure agrégée et directrice du Département de médecine familiale universitaire de l'Université de la Saskatchewan
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198
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Adams SJ, Babyn PS, Danilkewich A. Toward a comprehensive management strategy for incidental findings in imaging. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:541-543. [PMID: 27412199 PMCID: PMC4955074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Scott J Adams
- Medical student at the University of Saskatchewan in Saskatoon.
| | - Paul S Babyn
- Professor and Head of the Department of Medical Imaging at the University of Saskatchewan and Saskatoon Health Region
| | - Alanna Danilkewich
- Associate Professor and Head of the Department of Academic Family Medicine at the University of Saskatchewan
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199
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Meltzer C, Båth M, Kheddache S, Ásgeirsdóttir H, Gilljam M, Johnsson ÅA. VISIBILITY OF STRUCTURES OF RELEVANCE FOR PATIENTS WITH CYSTIC FIBROSIS IN CHEST TOMOSYNTHESIS: INFLUENCE OF ANATOMICAL LOCATION AND OBSERVER EXPERIENCE. RADIATION PROTECTION DOSIMETRY 2016; 169:177-87. [PMID: 26842827 PMCID: PMC4911964 DOI: 10.1093/rpd/ncv556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The aims of this study were to assess the visibility of pulmonary structures in patients with cystic fibrosis (CF) in digital tomosynthesis (DTS) using computed tomography (CT) as reference and to investigate the dependency on anatomical location and observer experience. Anatomical structures in predefined regions of CT images from 21 patients were identified. Three observers with different levels of experience rated the visibility of the structures in DTS by performing a head-to-head comparison with visibility in CT. Visibility of the structures in DTS was reported as equal to CT in 34 %, inferior in 52 % and superior in 14 % of the ratings. Central and peripheral lateral structures received higher visibility ratings compared with peripheral structures anteriorly, posteriorly and surrounding the diaphragm (p ≤ 0.001). Reported visibility was significantly higher for the most experienced observer (p ≤ 0.01). The results indicate that minor pathology can be difficult to visualise with DTS depending on location and observer experience. Central and peripheral lateral structures are generally well depicted.
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Affiliation(s)
- Carin Meltzer
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Radiology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Magnus Båth
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Susanne Kheddache
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Radiology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
| | - Helga Ásgeirsdóttir
- Gothenburg CF-Center, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden Department of Respiratory Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Marita Gilljam
- Gothenburg CF-Center, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden Department of Respiratory Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Åse Allansdotter Johnsson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, SE-413 45 Gothenburg, Sweden Department of Radiology, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden
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200
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Zafar HM, Bugos EK, Langlotz CP, Frasso R. "Chasing a Ghost": Factors that Influence Primary Care Physicians to Follow Up on Incidental Imaging Findings. Radiology 2016; 281:567-573. [PMID: 27192458 DOI: 10.1148/radiol.2016152188] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose To explore provider and patient characteristics that influence how primary care providers (PCPs) communicate and manage incidental imaging findings. Materials and Methods This HIPAA-compliant study was approved by the institutional review board. Through semistructured interviews, researchers explored concerns and perspectives of 30 PCPs on receiving and acting on incidental imaging findings. Open-ended questions were designed to elicit a range of responses rather than quantifiable data. Thematic codes were developed and explicitly defined. Three research assistants independently coded all 30 deidentified transcripts and resolved discrepancies (κ = 0.85). Codes pertaining to PCP and patient characteristics were organized into an explanatory model. Results Some PCPs felt compelled but frustrated to pursue costly follow-up for incidental imaging findings of limited clinical importance. Other PCPs did not act on findings that were unfamiliar or occurred in an unusual clinical context when follow-up recommendations were not given; the challenges of researching the clinical importance of these findings or seeking specialist consultation led to inaction. Some PCPs reported using a uniform approach to communicate and manage incidental findings, while others adapted their approach to the patient and the finding. Sometimes PCP characteristics such as follow-up style superseded patient characteristics. At other times patient characteristics such as health literacy superseded PCP characteristics. Conclusion PCPs cited a variety of objective and subjective factors that influence how they communicate and manage incidental imaging findings. These results suggest that some patients may receive inappropriate follow-up of incidental imaging findings and present an opportunity for radiologists to help PCPs and patients to best use the information conveyed in imaging reports. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Hanna M Zafar
- From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (H.M.Z.); Leonard Davis Institute of Health Economics (H.M.Z.) and Center for Public Health Initiatives, School of Social Policy and Practice (R.F.), University of Pennsylvania, Philadelphia, Pa; Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (E.K.B.); and Departments of Radiology and Medicine, Stanford University School of Medicine, Stanford, Calif (C.P.L.)
| | - Eva K Bugos
- From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (H.M.Z.); Leonard Davis Institute of Health Economics (H.M.Z.) and Center for Public Health Initiatives, School of Social Policy and Practice (R.F.), University of Pennsylvania, Philadelphia, Pa; Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (E.K.B.); and Departments of Radiology and Medicine, Stanford University School of Medicine, Stanford, Calif (C.P.L.)
| | - Curtis P Langlotz
- From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (H.M.Z.); Leonard Davis Institute of Health Economics (H.M.Z.) and Center for Public Health Initiatives, School of Social Policy and Practice (R.F.), University of Pennsylvania, Philadelphia, Pa; Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (E.K.B.); and Departments of Radiology and Medicine, Stanford University School of Medicine, Stanford, Calif (C.P.L.)
| | - Rosemary Frasso
- From the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (H.M.Z.); Leonard Davis Institute of Health Economics (H.M.Z.) and Center for Public Health Initiatives, School of Social Policy and Practice (R.F.), University of Pennsylvania, Philadelphia, Pa; Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (E.K.B.); and Departments of Radiology and Medicine, Stanford University School of Medicine, Stanford, Calif (C.P.L.)
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