Incidental findings detected on emergency abdominal CT scans: a 1-year review

Spectral Differentiation of Hyperdense Non-Vascular and Vascular Renal Lesions Without Solid Components in Contrast-Enhanced Photon-Counting Detector CT Scans-A Pilot Study

Introduction: The number of incidental renal lesions identified in CT scans of the abdomen is increasing. Objective: The aim of this study was to determine whether hyperdense renal lesions without solid components in a portal venous CT scan can be clearly classified as vascular or non-vascular by material decomposition into iodine and water. Methods: This retrospective single-center study included 26 patients (mean age 72 years ± 9; 16 male) with 42 hyperdense renal lesions (>20 HU) in a contrast-enhanced Photon-Counting Detector CT scan (PCD-CT) between May and December 2022. Spectral decomposition into virtual non-contrast (VNC) images and iodine quantification maps was performed, and HU values were quantified within the lesions. Further imaging and histopathological reports served as reference standards. Results: Mean VNC values were 55.7 (±24.2) HU for non-vascular and 32.2 (±11.1) HU for vascular renal lesions. Mean values in the iodine maps were 5.7 (±7.8) HU for non-vascular and 33.3 (±19.0) HU for vascular renal lesions. Using a threshold of >20.3 HU in iodine maps, a total of 7/8 (87.5%) vascular lesions were correctly identified. Conclusion: This proof-of-principle study suggests that the routine use of spectral information acquired in PCD-CT scans might be able to reduce the necessary workup for hyperdense renal lesions without solid components. Further studies with larger patient cohorts are necessary to validate the results of this study and to determine the usefulness of this method in clinical routine.

Recommendations for the creation of benchmark datasets for reproducible artificial intelligence in radiology

Various healthcare domains have witnessed successful preliminary implementation of artificial intelligence (AI) solutions, including radiology, though limited generalizability hinders their widespread adoption. Currently, most research groups and industry have limited access to the data needed for external validation studies. The creation and accessibility of benchmark datasets to validate such solutions represents a critical step towards generalizability, for which an array of aspects ranging from preprocessing to regulatory issues and biostatistical principles come into play. In this article, the authors provide recommendations for the creation of benchmark datasets in radiology, explain current limitations in this realm, and explore potential new approaches. CLINICAL RELEVANCE STATEMENT: Benchmark datasets, facilitating validation of AI software performance can contribute to the adoption of AI in clinical practice. KEY POINTS: Benchmark datasets are essential for the validation of AI software performance. Factors like image quality and representativeness of cases should be considered. Benchmark datasets can help adoption by increasing the trustworthiness and robustness of AI.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Trends in the characteristics and perioperative outcomes of patients undergoing laparoscopic and open resections for benign liver lesions: An international multicenter retrospective cohort study of 845 patients

BACKGROUND

Solid benign liver lesions (BLL) are increasingly discovered, but clear indications for surgical treatment are often lacking. Concomitantly, laparoscopic liver surgery is increasingly performed. The aim of this study was to assess if the availability of laparoscopic surgery has had an impact on the characteristics and perioperative outcomes of patients with BLL.

METHODS

This is a retrospective international multicenter cohort study, including patients undergoing a laparoscopic or open liver resection for BLL from 19 centers in eight countries. Patients were divided according to the time period in which they underwent surgery (2008-2013, 2014-2016, and 2017-2019). Unadjusted and risk-adjusted (using logistic regression) time-trend analyses were performed. The primary outcome was textbook outcome (TOLS), defined as the absence of intraoperative incidents ≥ grade 2, bile leak ≥ grade B, severe complications, readmission and 90-day or in-hospital mortality, with the absence of a prolonged length of stay added to define TOLS+.

RESULTS

In the complete dataset comprised of patients that underwent liver surgery for all indications, the proportion of patients undergoing liver surgery for benign disease remained stable (12.6% in the first time period, 11.9% in the second time period and 12.1% in the last time period, p = 0.454). Overall, 845 patients undergoing a liver resection for BLL in the first (n = 374), second (n = 258) or third time period (n = 213) were included. The rates of ASA-scores≥3 (9.9%-16%,p < 0.001), laparoscopic surgery (57.8%-77%,p < 0.001), and Pringle maneuver use (33.2%-47.2%,p = 0.001) increased, whereas the length of stay decreased (5 to 4 days,p < 0.001). There were no significant changes in the TOLS rate (86.6%-81.3%,p = 0.151), while the TOLS + rate increased from 41.7% to 58.7% (p < 0.001). The latter result was confirmed in the risk-adjusted analyses (aOR 1.849,p = 0.004).

CONCLUSION

The surgical treatment of BLL has evolved with an increased implementation of the laparoscopic approach and a decreased length of stay. This evolution was paralleled by stable TOLS rates above 80% and an increase in the TOLS + rate.

Incidental Computed Tomography Findings Among Traumatized Adults: A One-Year Analysis at a Trauma Center

Background Computed tomography (CT) for patients with trauma represents a widely accepted diagnostic method. Non-trauma-related incidentalomas or incidental findings are commonly depicted based on CT examination. Our study aimed to assess the frequency of incidental findings on CT scans among traumatized adult patients during one year at a trauma center. Methods We performed a retrospective case review of all adult patients triaged at the King Abdullah Medical Complex trauma service in Jeddah, Saudi Arabia, between 31 May 2022 and 30 May 2023. Patients under the age of 18 were excluded from the study. Patients who could not complete radiographic studies due to deterioration in condition, patients with missing CT scan reports, and transfer patients who had CT scans done at outside facilities were excluded. Demographic data, including age, sex, type of trauma, and type of CT, were recorded. All CT studies were reviewed for incidental findings. Results A total of 106 incidental findings were discovered in 99 patients. The rate of incidental findings for one year was 1.87%. The average age was 41.19 ± 17.90 years, with 73 (73.7%) male and 26 (26.3%) female patients. In trauma classifications, road traffic accidents were the most common (59.60%), followed by falls (33.33%), penetrating trauma (3.03%), and others. A high number of scans for the whole body (56.57%); face, brain, and cervix (13.13%); chest and abdomen/pelvis (11%); and spine (5.05%) had incidental findings. Genitourinary-related incidental findings were observed in 27.36% of patients, followed by craniospinal (16.98%), pulmonary (12.26%), hepatobiliary (9.43%), endocrine (9.43%), and musculoskeletal (5.66%). Conclusion In trauma centers, incidental findings are frequently discovered during CT imaging. In contrast, our center has a lower incidental finding rate. A whole-body CT scan yielded more incident findings than a selective one. The incidental findings are prevalent in the genitourinary system and higher in young male patients. It is important to properly document, communicate, and follow up on these incidental discoveries.

The Value of Using a Quality Assurance Follow-Up Team to Address Incidental Findings After Emergency Department or Urgent Care Discharge: A Cost Analysis

BACKGROUND

Incidental finding (IF) follow-up is of critical importance for patient safety and is a source of malpractice risk. Laboratory, imaging, or other types of IFs are often uncovered incidentally and are missed, not addressed, or only result after hospital discharge. Despite a growing IF notification literature, a need remains to study cost-effective non-electronic health record (EHR)-specific solutions that can be used across different types of IFs and EHRs.

OBJECTIVE

The objective of this study was to evaluate the utility and cost-effectiveness of an EHR-independent emergency medicine-based quality assurance (QA) follow-up program in which an experienced nurse reviewed laboratory and imaging studies and ensured appropriate follow-up of results.

METHODS

A QA nurse reviewed preceding-day abnormal studies from a tertiary care hospital, a community hospital, and an urgent care center. Laboratory values outside preset parameters or radiology over-reads resulting in clinically actionable changes triggered contact with an on-call emergency physician to determine an appropriate intervention and its implementation.

RESULTS

Of 104,125 visits with 1,351,212 laboratory studies and 95,000 imaging studies, 6530 visits had IFs, including 2659 laboratory and 4004 imaging results. The most common intervention was contacting a primary care physician (5783 cases [88.6%]). Twenty-one cases resulted in a patient returning to the ED, at an average cost of $28,000 per potential life-/limb-saving intervention.

CONCLUSIONS

Although abnormalities in laboratory results and imaging are often incidental to patient care, a dedicated emergency department QA follow-up program resulted in the identification and communication of numerous laboratory and imaging abnormalities and may result in changes to patients' subsequent clinical course, potentially increasing patient safety.

Cardiac Incidental Findings on Abdominopelvic Computed Tomography: Prevalence and Association with Subsequent Cardiovascular Events

PURPOSE

The aim of this study was to assess the prevalence of reportable cardiac findings detected on abdominopelvic CTs and the association with subsequent cardiovascular events.

MATERIALS AND METHODS

We performed a retrospective search of electronic medical record of patients who underwent abdominopelvic CT between November 2006 and November 2011 with a clinical history of upper abdominal pain. A radiologist blinded to the original CT report reviewed all 222 cases for the presence of pertinent reportable cardiac findings. The original CT report was also evaluated for documentation of pertinent reportable cardiac findings. The following findings were recorded on all CTs: presence of coronary calcification, fatty metaplasia, ventricle wall thinning and thickening, valve calcification or prosthesis, heart/chamber enlargement, aneurysm, mass, thrombus, device, air within ventricles, abnormal pericardium, prior sternotomy, and adhesions if prior sternotomy. Medical records were reviewed to identify cardiovascular events on follow-up in patients with the presence or absence of cardiac findings. We compared the distribution findings in patients with and without cardiac events using the Wilcoxon test (for continuous variables) and the Pearson's chi-squared test (for categorical variables).

RESULTS

Eighty-five of 222 (38.3%) patients (52.7% females, median age 52.5 years) had at least one pertinent reportable cardiac finding on the abdominopelvic CT, with a total of 140 findings in this group. From the total 140 findings, 100 (71.4%) were not reported. The most common findings seen on abdominal CTs were: coronary artery calcification (66 patients), heart or chamber enlargement (25), valve abnormality (19), sternotomy and surgery signs (9), LV wall thickening (7), device (5), LV wall thinning (2), pericardial effusion (5), and others (3). After a mean follow-up of 43.9 months, 19 cardiovascular events were found in the cohort (transient ischemic attack, cerebrovascular accident, myocardial infarction, cardiac arrest, acute arrhythmia, palpitation, syncope and acute chest pain). Only 1 event occurred in the group of patients with no incidental pertinent reportable cardiac findings (1/137 = 0.73%). All other 18 events occurred in patients with incidental pertinent reportable cardiac findings (18/85 = 21.2%), which was significantly different (p < 0.0001). One out of the total 19 events in the overall group (5.24%) occurred in a patient with no incidental pertinent reportable cardiac findings while 18 of 19 total events (94.74%) occurred with patients with incidental pertinent reportable cardiac findings, which was also significantly different (p < 0.001). Fifteen of the total events (79%) occurred in patients in whom the incidental pertinent reportable cardiac findings were not reported, which was significantly different (p < 0.001) from the four events that occurred in patients in whom the incidental pertinent reportable cardiac findings were reported or had no findings.

CONCLUSIONS

Incidental pertinent reportable cardiac findings are common on abdominal CTs and are frequently not reported by radiologists. These findings are of clinical relevance since patients with pertinent reportable cardiac findings have a significantly higher incidence of cardiovascular events on follow-up.

Diagnosis of cancer in the Emergency Department: A scoping review

BACKGROUND

The Emergency Department (ED) plays a key role in the identification and care of acute medical conditions, including cancer. In this scoping review, we aimed to determine the role of the ED in the acute diagnosis of cancer.

METHODS

We conducted a scoping review of articles according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) using PubMed and Google Scholar. We screened studies of adults with a new diagnosis of cancer in the ED. We included randomized control trials, prospective, retrospective, and cross-sectional observational studies, and case reports published in English since 2000. We grouped the articles into categories based on their objectives and findings.

RESULTS

Of the 4459 articles, we included 47 in the review. The identified studies fell into three major categories: (1) studies describing the incidental diagnosis of cancer in the ED (n = 11, 23%), (2) studies characterizing the acute initial presentation of cancer in the ED (n = 19, 41%), and (3) studies describing the ED as a pathway to cancer diagnosis in the healthcare system (n = 17, 36%). Across the studies, cancer diagnoses in the ED were more likely in patients with higher comorbidities, occurred at later stages, and resulted in worse survival rates.

CONCLUSIONS

The ED plays a prominent role in the initial diagnosis of cancer. Efforts must be made to integrate the ED within the cancer care continuum.

Characterizing incidental mass lesions in abdominal dual-energy CT compared to conventional contrast-enhanced CT

BACKGROUND

Incidental findings are common in abdominal computed tomography (CT) and often warrant further investigations with economic implications as well as implications for patients.

PURPOSE

To evaluate the potential of dual-energy CT (DECT) in the identification and/or characterization of abdominal incidental mass lesions compared to conventional contrast-enhanced CT.

MATERIAL AND METHODS

This retrospective study from a major tertiary hospital included 96 patients, who underwent contrast-enhanced abdominal DECT. Incidental lesions in adrenals, kidneys, liver, and pancreas were evaluated by two board-certified abdominal radiologists. Observer 1 only had access to standard CT reconstructions, while observer 2 had access to standard CT as well as DECT reconstructions. Disagreements were resolved by consensus review and used as a reference for observers using McNemar's test.

RESULTS

Observers 1 and 2 identified a total of 40 and 34 findings, respectively. Furthermore, observer 1 registered 13 lesions requiring follow-up, of which seven (two renal and five adrenal lesions) were resolved following consensus review using DECT (P = 0.008). The inter-observer agreement was near perfect (κ = 0.82).

CONCLUSION

DECT has the potential to improve the immediate characterization of incidental findings when compared to conventional CT for abdominal imaging.

Psychosocial stress and cancer risk: a narrative review

BACKGROUND

It is unclear which psychological factors (stressors, emotional correlates, and psychophysiological markers) induce cancer risk. This currently limits the potential for prevention strategies.

PURPOSE

The aim of this review is to bring forth evidence of stress as a determinant of cancer risk from a public health perspective, written for a broad public of practitioners and scientists.

METHODS

Based on a semisystematic literature search, the impact of different aspects/types of stress and the potential physiological and behavioral pathways are summarized, while highlighting further research, public health and clinical implications.

RESULTS

Between 2007 and 2020, 65 case-control or cohort studies have been identified. Apart from overall cancer ( N = 24), 12 cancer types have been associated with psychological stress with most for breast ( N = 21), colorectal ( N = 11) and lung/prostate/pancreas cancer ( N = 8 each). Although the evidence regarding the mechanisms is still scarce, cancer development in relation to stress might be due to interacting and combined effects of different stress(or) types, but such interaction has not really been tested yet. The path from stress towards cancer incidence consists of a biological pathway with endocrinology and immunology as well as stress-induced behavioral pathways, including smoking, alcoholism, sleep disruption, an unhealthy diet, and low physical activity together with the related phenomenon of obesity.

CONCLUSION

Not only the stress but also the stress-induced lifestyle should be targeted for cancer prevention and treatment. Future research should include a more diverse spectrum of cancer types (not only hormonal related like breast cancer) and of stress measures while also considering behavioral covariates.

Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings

STUDY OBJECTIVE

Abnormal findings unrelated to the indication for testing are identified on emergency department (ED) imaging studies. We report the design and implementation of an electronic health record-based interdisciplinary referral system and our experience from the first 13 months of ensuring that patients with incidental radiology findings were connected with the appropriate outpatient surveillance.

METHODS

Our informatics team standardized the contemporaneous reporting of critical radiology alerts using our ED trackboard and created a companion follow-up request form for the treating ED clinicians to complete. The forms were routed to nurse case managers, who arranged follow-ups based on the findings and clinical significance. The primary outcome was the proportion of ED patient visits with identified incidental findings that had documented communication of the incidental findings and surveillance plans.

RESULTS

Over the first 13 months after implementation, 932 ED patient visits had critical radiology alert referrals, for a total of 982 incidental findings. The primary outcome (confirmed post-ED communication and documented follow-up plan) was attained in 888 (95.3%, 95% confidence interval [CI] 93.9% to 96.6%) ED patient visits with confirmed post-ED communication and documented follow-up plans. The team was unable to contact or confirm follow-up with 44 (4.7%, 95% CI 3.4 to 6.1) patients by telephone or through the health care system's electronic communication tools.

CONCLUSION

We report the implementation of a standardized notification and referral system for ED patients with incidental radiology findings. The development of a reliable notification and follow-up system is an important patient safety intervention given the opportunity to potentially identify undiagnosed malignancies.

Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis

STUDY OBJECTIVE

An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings.

METHODS

On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis.

RESULTS

A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED.

CONCLUSION

In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.

Radiological Screening Methods in Deceased Organ Donation: An Overview of Guidelines Worldwide

Organ transplantation is performed worldwide, but policies regarding donor imaging are not uniform. An overview of the policies in different regions is missing. This study aims to investigate the various protocols worldwide on imaging in deceased organ donation. An online survey was created to determine the current policies. Competent authorities were approached to fill out the survey based on their current protocols. In total 32 of the 48 countries approached filled out the questionnaire (response rate 67%). In 16% of the countries no abdominal imaging is required prior to procurement. In 50%, abdominal ultrasound (US) is performed to screen the abdomen and in 19% an enhanced abdominal Computed Tomography (CT). In 15% of the countries both an unenhanced abdominal CT scan and abdominal US are performed. In 38% of the countries a chest radiographic (CXR) is performed to screen the thorax, in 28% only a chest CT, and in 34% both are performed. Policies regarding radiologic screening in deceased organ donors show a great variation between different countries. Consensus on which imaging method should be applied is missing. A uniform approach will contribute to quality and safety, justifying (inter)national exchange of organs.

Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review

BACKGROUND

Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.

PURPOSE

To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.

STUDY SELECTION

Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes.

DATA EXTRACTION

6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies.

DATA SYNTHESIS

Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies).

LIMITATIONS

The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect.

CONCLUSION

Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians

DESCRIPTION

The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.

METHODS

The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.

TARGET AUDIENCE AND PATIENT POPULATION

The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis.

RECOMMENDATION 1

ACP suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence).

RECOMMENDATION 2

ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting (conditional recommendation; low-certainty evidence).

RECOMMENDATION 3

ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence).

Racial and ethnic differences in low-value pediatric emergency care

BACKGROUND

Disparities in health care quality frequently focus on underuse. We evaluated racial/ethnic differences in low-value services delivered in the pediatric emergency department (ED).

METHODS

We performed a retrospective cross-sectional study of low-value services in children discharged from 39 pediatric EDs from January 2018 to December 2019 using the Pediatric Hospital Information System. Our primary outcome was receipt of one of 12 low-value services across nine conditions, including chest radiography in asthma and bronchiolitis; beta-agonist and corticosteroids in bronchiolitis; laboratory testing and neuroimaging in febrile seizure; neuroimaging in afebrile seizure; head injury and headache; and any imaging in sinusitis, constipation, and facial trauma. We analyzed the association of race/ethnicity on receipt of low-value services using generalized linear mixed models adjusted for age, sex, weekend, hour of presentation, payment, year, household income, and distance from hospital.

RESULTS

We included 4,676,802 patients. Compared with non-Hispanic White (NHW) patients, non-Hispanic Black (NHB) and Hispanic patients had lower adjusted odds (aOR [95% confidence interval]) of receiving imaging for asthma (0.60 [0.56 to 0.63] NHB; 0.84 [0.79 to 0.89] Hispanic), bronchiolitis (0.84 [0.79 to 0.89] NHB; 0.93 [0.88 to 0.99] Hispanic), head injury (0.84 [0.80 to 0.88] NHB; 0.80 [0.76 to 0.84] Hispanic), headache (0.67 [0.63 to 0.72] NHB; 0.83 [0.78 to 0.88] Hispanic), and constipation (0.71 [0.67 to 0.74] NHB; 0.76 [0.72 to 0.80] Hispanic). NHB patients had lower odds (95% CI) of receiving imaging for afebrile seizures (0.89 [0.8 to 1.0]) and facial trauma (0.69 [0.60 to 0.80]). Hispanic patients had lower odds (95% CI) of imaging (0.57 [0.36 to 0.90]) and blood testing (0.82 [0.69 to 0.98]) for febrile seizures. NHB patients had higher odds (95% CI) of receiving steroids (1.11 [1.00 to 1.21]) and beta-agonists (1.38 [1.24 to 1.54]) for bronchiolitis compared with NHW patients.

CONCLUSIONS

NHW patients more frequently receive low-value imaging while NHB patients more frequently receive low-value medications for bronchiolitis. Our study demonstrates the differences in care across race and ethnicity extend to many services, including those of low value. These findings highlight the importance of greater understanding of the complex interaction of race and ethnicity with clinical practice.

[Incidental and "leave me alone" findings of the GI tract-part 2 : Intestinal wall and mesentery]

Due to the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) asymptomatic incidental findings of the gastrointestinal (GI) tract are increasingly being recognized. Incidental findings are frequently not part of the primary inquiry from referring physicians but it is obligatory to make a diagnosis and to stipulate the need for further clarification. A multitude of incidental findings in the intestinal lumen, in the intestinal wall and in the adjacent mesentery or subperitoneal space are shown in CT and MRI of the GI tract. The last part of the two-part review addresses the gastrointestinal incidental findings in the intestinal wall and the adjacent sections. Extramural incidental findings occur as mesenteric inflammation, tumors and cysts. Many of the findings can be classified as benign and as "leave me alone lesions" do not necessitate any further clarification but in contrast others need a definitive clarification. The most important incidental findings in the GI tract are systematically classified, illustrated and evaluated with respect to the clinical relevance, depending on the localization (e.g. stomach, small and large intestines).

Lipoma of the Pancreas: A Rare Incidental Tumor

Recent studies have shown a significant increase in the utilization of computed tomography (CT) scans in the emergency department for a broad spectrum of conditions. This had a significant impact on the identification of patients with serious pathologies in a timely manner. However, the overutilization of computed tomography scans leads to increased identification of incidental findings. For example, pancreatic lesions are not uncommon findings that can be identified in imaging studies performed for other indications. Here, we report the case of a 55-year-old male with a history of urinary stone disease who presented with right flank pain and dysuria. The urinalysis findings revealed numerous red blood cells and leukocytes. Non-contrast computed tomography scan of the abdomen was performed to detect urinary stones, but no hyperdense stones were noted, suggesting the possibility of spontaneous passage of the stone. However, a lesion in the pancreatic tail was observed. This exhibited fat attenuation with no solid component in the pancreatic tail representing a pancreatic lipoma. No surgical intervention was made considering the benign nature of the incidentally detected tumor. Pancreatic lipoma is a very rare benign mesenchymal tumor of the pancreas. Recognition of the classic radiological feature of pancreatic lipoma is essential to avoid unnecessary investigation and procedures.

Endoscopic Evaluation of Radiologic Distal Esophageal Thickening

GOALS

We aim to determine the incidence of esophagogastroduodenoscopies (EGDs) primarily performed for imaging findings of distal esophageal thickening (DET). We also aim to determine if patients with imaging findings of DET have a higher incidence of cancer, and to evaluate the risk factors associated with findings of malignancy.

BACKGROUND

The growth of diagnostic imaging has led to an increase in incidental findings of DET. This nonspecific finding frequently prompts an EGD for evaluation-many of which demonstrate benign conditions. There may be a misuse of valuable resources.

STUDY

We performed a retrospective chart review of 1080 EGDs from January 2016 to July 2018 at the Veterans Affairs Medical Center, comparing EGDs for the indication of imaging report of DET with EGDs for other indications. Patient demographics, clinical history, imaging, procedure, and pathology reports were collected. Descriptive analysis and biostatistical analysis with χ2, Fisher exact, Wilcoxon rank sum, and Kruskal-Wallis tests were utilized in analyzing the data.

RESULTS

Of the 1080 total endoscopies, 8.2% (n=88) were done specifically because of the imaging findings of DET. Those who had EGDs performed because of DET had a higher percentage of abnormal esophageal findings and of cancer. A history of Barrett's esophagus, tobacco use, and having gastrointestinal symptoms were not significant predictors of abnormal findings or of cancer for EGDs done for DET.

CONCLUSIONS

There may be a role for EGDs performed for radiologic findings of DET. Even those without risk factors for malignancy should have EGDs performed for DET. Radiologists should consider reporting the DET size in order to determine if significant endoscopic findings correlate with wall thickness.

Postmenopausal virilization secondary to a large ovarian cystadenoma with stromal hyperthecosis

Ovarian cystadenomas may present in a functional manner. Biochemical workup of seemingly benign ovarian lesions should be considered in the appropriate clinical context.

Spectrum and Relevance of Incidental Bowel Findings on Computed Tomography

A wide spectrum of incidental bowel findings can be seen on CT, including but not limited to, pneumatosis intestinalis, diverticular disease, non-obstructive bowel dilatation, transient small bowel intussusception, and submucosal fat. Radiologists should be aware that such findings are almost always benign and of little clinical significance in the absence of associated symptoms. Conversely, vigilance must be maintained when evaluating the bowel, because malignant neoplasms occasionally come to clinical attention as incidental imaging findings. When suspicious incidental bowel wall thickening is detected, the radiologist can alert the clinical team to the finding prior to the patient becoming symptomatic, potentially leading to definitive management at an early, more curable stage.

What are the clinical effects of the different emergency department imaging options for suspected renal colic? A scoping review

OBJECTIVES

Clinicians have minimal guidance regarding the clinical consequences of each radiologic imaging option for suspected renal colic in the emergency department (ED), particularly in relation to patient-centered outcomes. In this scoping review, we sought to identify studies addressing the impact of imaging options on patient-centered aspects of ED renal colic care to help clinicians engage in informed shared decision making. Specifically, we sought to answer questions regarding the effect of obtaining computed tomography (CT; compared with an ultrasound or delayed imaging) on safety outcomes, accuracy, prognosis, and cost (financial and length of stay [LOS]).

METHODS

We conducted a comprehensive search using Pubmed, EMBASE, Web of Science conference proceedings index, and Google Scholar, identifying studies pertaining to renal colic, urolithiasis, and ureterolithiasis. In a prior qualitative study, stakeholders identified 14 key questions regarding renal colic care in the domains of safety, accuracy, prognosis, and cost. We systematically screened studies and reviewed the full text of articles based on their ability to address the 14 key questions.

RESULTS

Our search yielded 2570 titles, and 68 met the inclusion criteria. Substantial evidence informed questions regarding test accuracy and radiation exposure, but less evidence was available regarding the effect of imaging modality on patient-oriented outcomes such as cost and prognosis (admissions, ED revisits, and procedures). Reviewed studies demonstrated that both standard renal protocol CT and low-dose CT are highly accurate, with ultrasound having lower accuracy. Several studies found that ureterolithiasis diagnosed by ultrasound was associated with overall reduced radiation exposure. Existing studies did not suggest choice of imaging influences prognosis. Several studies found no substantial differences in monetary cost, but LOS was found to be shorter if a diagnosis was made with point-of-care ultrasound.

CONCLUSION

There is a plethora of data related to imaging accuracy. However, there is minimal data regarding the effect of CT on many patient-centered outcomes. Further research could improve the patient-centeredness of ED care.

Towards a benchmark of abdominal CT use during duty shifts: 15-year sample from the Netherlands

Purpose

To investigate temporal changes in the utilization and patient impact of abdominal CT during duty shifts in the past 15 years.

Methods

This study included a random sample of 1761 abdominal CT scans that were made during evening and night duty shifts in a tertiary care center between 2005 and 2019.

Results

The number of CT scans significantly increased (almost threefold) between 2005 and 2019 (Mann–Kendall tau of 0.829, P < 0.001). The proportion of negative CT scans (i.e., the absence of findings related to the reason that the CT scan was made and no disease deterioration or other new and clinically relevant findings compared to a previous imaging examination when available) was 40.0% (700/1749) in the entire 15-year study frame and did not significantly change over time (Mann–Kendall tau of − 0.219, P = 0.276). The overall frequency of same-day hospital discharge after negative CT was 20.6% (150/729) in the past 15 years and showed a significant increase over time (Mann–Kendall tau of 0.505, P = 0.010). The overall proportion of CT scans with incidental findings was 3.4% (60/1761) and remained statistically stable over the past 15 years (Mann–Kendall tau of − 0.057, P = 0.804).

Conclusion

Over the past 15 years, the number of CT scans and the frequency of same-day hospital discharge after negative CT have increased, while the proportions of negative CT scans and incidental findings have remained stable in our tertiary care center. The data from this study can be used for interinstitutional benchmarking to define, monitor, and improve the appropriateness of imaging utilization.

Implementation of Ultrasound in Anatomy Education

The use of different ways to view the body has always been associated with anatomy. With advancing technology, the use of ultrasound has become more portable and accessible as a way for students to learn anatomy. Moreover, ultrasound's direct clinical context makes it an important skill that students need to acquire and be competent in, not only after graduation but on clinical placements as a student. There does appear to be a learned skill in being able to interpret ultrasound images and to be able to relate the anatomy seen to existing anatomical knowledge. In addition, there is a learned skill in being able to correctly hold the ultrasound probe and gain clear images. Because ultrasound use and interpretation is a skill it therefore needs to be taught as part of undergraduate medical and allied health care professional education. A key to successful training is regular teaching sessions distributed longitudinally throughout the curriculum with active, hands-on learning time being the focus of any teaching session.

Delayed Presentation of Basal Cell Carcinoma: A Case Report

Basal cell carcinoma (BCC) is the most common skin cancer in the United States. Although BCC has a low metastatic potential, it can be locally invasive and destructive, especially when there is a delay in diagnosis or treatment. This can affect not only the surrounding skin, but deeper tissues including muscle, cartilage, and even bone. Primary care physicians often serve as the first line of defense in the recognition, diagnosis, and even treatment of skin lesions suspicious for BCC. Most low-risk BCC can be treated in the primary care office with electro-desiccation and curettage or surgical excision. We present a case of locally invasive BCC with significant soft tissue destruction of the neck, which was incidentally identified during an emergency department presentation for a myocardial infarction. It is the responsibility of primary care physicians to recognize the appearance of skin lesions suspicious for BCC and initiate or arrange for subsequent definitive diagnosis and treatment. Our intent in presenting this case is to illustrate a missed opportunity for earlier recognition and treatment because of lack of access to primary care, as well as to demonstrate the destructive nature of BCC when neglected over time. Comprehensive approaches to diagnosis and treatment are described elsewhere.

The effects of incidental findings from whole-body MRI on the frequency of biopsies and detected malignancies or benign conditions in a general population cohort study

Magnetic resonance imaging (MRI) yields numerous tumor-related incidental findings (IFs) which may trigger diagnostics such as biopsies. To clarify these effects, we studied how whole-body MRI IF disclosure in a population-based cohort affected biopsy frequency and the detection of malignancies. Laboratory disclosures were also assessed. Data from 6753 participants in the Study of Health in Pomerania (SHIP) examined between 2008 and 2012 were utilized. All underwent laboratory examinations and 3371 (49.9%) a whole-body MRI. Electronic biopsy reports from 2002 to 2017 were linked to participants and assigned to outcome categories. Biopsy frequency 2 years pre- and post-SHIP was investigated using generalized estimating equations with a negative-binomial distribution. Overall 8208 IFs (laboratory findings outside reference limits: 6839; MRI: 1369) were disclosed to 4707 participants; 2271 biopsy reports belonged to 1200 participants (17.8%). Of these, 938 biopsies occurred pre-SHIP; 1333 post-SHIP (event rate/100 observation years = 6.9 [95% CI 6.5; 7.4]; 9.9 [9.3; 10.4]). Age, cancer history, recent hospitalization, female sex, and IF disclosure were associated with higher biopsy rates. Nonmalignant biopsy results increased more in participants with disclosures (post-/pre-SHIP rate ratio 1.39 [95% CI 1.22; 1.58]) than without (1.09 [95% CI 0.85; 1.38]). Malignant biopsy results were more frequent post-SHIP (rate ratio 1.74 [95% CI 1.27; 2.42]). Biopsies increased after participation in a population-based cohort study with MRI and laboratory IF disclosure. Most biopsies resulted in no findings and few malignancies were diagnosed, indicating potential overtesting and overdiagnosis. A more restrictive policy regarding IF disclosure from research findings is required.

Should Radiologists Comment on Incidental Findings of Vascular Calcifications Found on Abdominal/Pelvic CT in Patients Less Than 50 Years of Age?

RATIONALE AND OBJECTIVES

To evaluate if incidental abdominopelvic calcified atherosclerosis (ACA) in patients under 50 years of age correlates with cardiovascular disease (CVD) risk factors. Most studies evaluating calcific atherosclerosis and associated increased risk of CVD have concentrated on middle age and older populations.

MATERIALS AND METHODS

A retrospective review of 519 emergency department patients, aged 25-50 years, receiving computed tomography (CT) was performed and ACA correlated with lipid panels obtained via chart review. Those with calcified atherosclerosis were subdivided by vessel location and calcification burden (mild, moderate, or severe). Patients were followed for six years. Normality, Wilcoxon-Mann-Whitney, Kruskal-Wallis, and chi-square tests were performed.

RESULTS

Two hundred and sixty-nine patients with incidental ACA on CT and 250 without ACA were studied. Atherosclerotic calcifications had a statistically significant correlation with elevated triglyceride (128 mg/dL vs 105 mg/dL; p = 0.0003) and decreased high-density lipoprotein (38 mg/dL vs 41 mg/dL; p = 0.0032) as compared to the control. Patients with ACA were at higher risk of stroke, heart attack, and death (p < 0.0001) during a six-year follow-up period.

CONCLUSION

Incidental atherosclerotic calcification on abdominopelvic CT in patients under 50 years of age correlated with elevated triglycerides and decreased high-density lipoprotein as well as higher risk of cardiovascular events. Since radiologists may be the first to identify this finding and CVD is the leading cause of US deaths, proper recognition and reporting of calcification is valuable.

Bowel wall thickening on computed tomography scan: Inter-observer agreement and correlation with endoscopic findings

BACKGROUND AND STUDY AIMS

Bowel wall thickening (BWT) on computed tomography (CT) has been frequently reported by radiologists. There are no clear guidelines regarding the level of thickening that is correlated with definite pathology. Radiologists usually rely on their overall subjective impression, and studies on inter-observer agreement (IOA) are lacking. This study evaluated IOA concerning BWT found on abdominal CT and identified the corresponding findings on endoscopy.

PATIENTS AND METHODS

Reports of abdominal CTs performed between January 2000 and December 2015 containing the term 'thickening' were retrieved from the radiology department database. Corresponding patients who later underwent endoscopy were included. IOA concerning BWT was evaluated using a randomly mixed sample of 80 patients with normal findings or pathological BWT on endoscopy. A search for predictive factors for the subsequent finding of malignancy on endoscopy was performed using multivariate analysis.

RESULTS

During the study period, 6142 CT scans described thickening, equivalent to a BWT prevalence of 13.7%. Ninety-one patients (mean age, 58 years) were included in the analysis. Thickening was found most commonly in the stomach (38.5%), followed by the rectum (22%) and small intestine (14%). Twenty-seven patients (29.7%) exhibited diffuse BWT, whereas 64 patients showed localised BWT (70.3%). Biopsy was performed for 64 of 91 patients with endoscopies. Among these patients, 8.8% exhibited normal findings, whereas inflammation and malignancy were discovered in 25 and 51.6% of patients, respectively, with a positive predictive value for malignancy of 0.36. The IOA concerning CT for predicting significantly pathological BWT was moderate (mean κ = 0.6). A strong association was evident between the presence of lymph nodes on CT and the presence of neoplastic lesions.

CONCLUSION

Our study strongly recommends endoscopic follow-up of patients exhibiting BWT irrespective of the thickening location, especially if it is associated with lymphadenopathy. IOA between radiologists was moderate.

Incidental findings on emergency CT scans: Predictive factors and medico-economic impact

PURPOSE

The main objective was to evaluate types and predictive factors of incidental findings (IFs) on multidetector computed tomographies (MDCTs) performed for an emergency department (ED). The secondary aim was to analyze additional investigations, their benefits, side effects, costs and the final diagnoses.

METHOD

One thousand consecutive patients over 18 years old who underwent an MDCT in the ED of our institution from January 2011 to November 2011 were retrospectively included, accounting for 300 head MDCTs and 700 other MDCTs. The following criteria were collected in patient electronic medical records: IFs (divided into low and high clinical significance), body areas covered, availability of a prior imaging, radiologist's experience and subspecialty, additional investigations, their outcomes and costs.

RESULTS

Among the 1000 included patients, 232 had at least one IF and 122 had at least one IF of high clinical significance (IFCS). There were 340 IFs and 150 IFCSs. A significant association with the presence of at least one IF was noted for older patients, less-experienced radiologists, no subspecialty of the radiologist, the abdominopelvic area, and the absence of prior imaging. Eighteen IFs generated additional investigations in our institution, including five invasive samplings and three surgical operations, with two diagnoses of malignancy (a gastrointestinal stromal tumor and a Bosniak IV cystic renal lesion). One benign iatrogenic complication occurred. Total cost of these investigations was €41,247 (with an average of €2292 per IF investigated).

CONCLUSION

IFs on emergency MDCTs were frequent, rarely severe, rarely iatrogenic and relatively expensive.

Incidental findings on CT angiography of the head and neck in stroke patients. Evaluation of frequency and detection rate

OBJECTIVE

A comprehensive CT algorithm in suspected ischemic stroke consists of a native CT scan, CT perfusion imaging of the brain and a CT angiography from the aortic arch to the vertex. Besides core findings of the brain and targeted vessels, various other findings may be identified. We analyzed a large patient sample and estimated the frequency of incidental findings (IFs) and whether these findings were correctly mentioned in the radiological reports.

PATIENTS AND METHODS

In the time period between 01/16 and 02/19 the radiological database of one hospital containing 1625 patients admitted for stroke suspicion were retrospectively evaluated. In total 1175 patients with ischemic stroke CTs were included. IFs were classified according to Lumbreras et al. for their clinical relevance. The primary radiological report was used to classify, whether the finding was reported initially or not.

RESULTS

Overall, 1988 IFs were identified in 1175 patients (mean 1.7 findings per patient). The most frequent finding were thyroid incidentalomas with n = 461 (23.2 % of all findings), followed by signs of mucosal swelling and/or opacification of the nasal sinus (n = 391, 19.7 %). Regarding clinical relevance, 181 findings were of major relevance (9.1 % of all findings), 902 were of moderate relevance (45.4 %) and 905 were of minor relevance (45.5 %). Overall, 772 findings (38.8 %) were not reported and 1216 (61.2 %) were sufficiently reported by the radiologist.

CONCLUSION

The present study corroborates that incidental findings are frequent in patients undergoing ischemic stroke CT, which are about half of moderate and major relevance. About 40 % of these findings were not mentioned in the primary radiology report, including findings of high clinical relevance. The radiologist should be aware of these findings.

Evaluation of an AI-Based Detection Software for Acute Findings in Abdominal Computed Tomography Scans: Toward an Automated Work List Prioritization of Routine CT Examinations

OBJECTIVE

The aim of this study was to test the diagnostic performance of a deep learning-based triage system for the detection of acute findings in abdominal computed tomography (CT) examinations.

MATERIALS AND METHODS

Using a RIS/PACS (Radiology Information System/Picture Archiving and Communication System) search engine, we obtained 100 consecutive abdominal CTs with at least one of the following findings: free-gas, free-fluid, or fat-stranding and 100 control cases with absence of these findings. The CT data were analyzed using a convolutional neural network algorithm previously trained for detection of these findings on an independent sample. The validation of the results was performed on a Web-based feedback system by a radiologist with 1 year of experience in abdominal imaging without prior knowledge of image findings through both visual confirmation and comparison with the clinically approved, written report as the standard of reference. All cases were included in the final analysis, except those in which the whole dataset could not be processed by the detection software. Measures of diagnostic accuracy were then calculated.

RESULTS

A total of 194 cases were included in the analysis, 6 excluded because of technical problems during the extraction of the DICOM datasets from the local PACS. Overall, the algorithm achieved a 93% sensitivity (91/98, 7 false-negative) and 97% specificity (93/96, 3 false-positive) in the detection of acute abdominal findings. Intra-abdominal free gas was detected with a 92% sensitivity (54/59) and 93% specificity (39/42), free fluid with a 85% sensitivity (68/80) and 95% specificity (20/21), and fat stranding with a 81% sensitivity (42/50) and 98% specificity (48/49). False-positive results were due to streak artifacts, partial volume effects, and a misidentification of a diverticulum (each n = 1).

CONCLUSIONS

The algorithm's autonomous detection of acute pathological abdominal findings demonstrated a high diagnostic performance, enabling guidance of the radiology workflow toward prioritization of abdominal CT examinations with acute conditions.

Referral Patterns for the Evaluation of Asymptomatic Microscopic Hematuria in Women in a Single Health Care System: Room for Improvement

OBJECTIVE

To identify patterns of care for women referred for asymptomatic microhematuria in a single, hospital-based health care system and estimate the cost of unindicated evaluation.

METHODS

We conducted a retrospective study of 100 women with a diagnosis of asymptomatic microhematuria referred to a tertiary female pelvic medicine and reconstructive surgery practice. Our analysis focused on referral patterns by obstetrician-gynecologists and primary care physicians. Data analyzed included whether asymptomatic microhematuria was documented using urine microscopy (vs urine dipstick) and whether the urine microscopy correctly identified asymptomatic microhematuria with three red blood cells (RBCs).

RESULTS

Forty-six patients were referred who met the American Urological Association's guidelines for asymptomatic microhematuria with a workup estimated at $8,298 per patient. Fifty-four were referred to a female pelvic medicine and reconstructive surgery specialist despite clearly not meeting the American Urological Association's definition of asymptomatic microhematuria. Of these, 33 patients were referred based on dipstick-positive results only, 11 were referred based on microscopic urinalysis demonstrating fewer than three RBCs per high-power field (HPF), and the remaining 10 patients were referred with urine microscopy demonstrating at least 3 RBC/HPF but in the setting of a clearly benign cause, such as infection or menstruation. The total estimated cost of the unnecessary asymptomatic microhematuria workup in patients who did not meet American Urological Association criteria for referral was $1,213 per patient.

CONCLUSION

Fewer than half of the referrals for asymptomatic microhematuria were appropriate, leading to wasted and entirely preventable health care expenditures. This study highlights the need for education of health care providers making these referrals.

Adnexal lesions detected on CT in postmenopausal females with non-ovarian malignancy: do simple cysts need follow-up?

PURPOSE

To assess whether CT morphology of adnexal lesions in postmenopausal women with history of non-ovarian cancer could be used to discriminate benign and malignant lesions, particularly focusing on applicability of the ACR criteria.

MATERIALS AND METHODS

This was an IRB-approved HIPAA-compliant retrospective review of contrast-enhanced CTs of 199 women, 55 years and older. Lesions were classified as simple cystic, complex cystic, solid-cystic, or solid based on CT morphology, and were diagnosed as benign, indeterminate, or malignant on follow-up imaging or pathology. Associated metastatic disease was noted, if present. Findings were analyzed to correlate CT morphology, primary tumor pathology, and metastatic disease pattern with eventual lesion diagnosis.

RESULTS

There were 223 adnexal lesions, including 123 (55%) simple cystic, 48 (22%) complex cystic, 40 (18%) solid-cystic, and 12 (5%) solid lesions. 186/223 (83%) lesions were benign, and 37/223 (17%) were malignant. Primary colorectal cancer was significantly associated with an increased likelihood of malignant adnexal lesions (OR 10.2, p < 0.001) compared to patients with other cancers. Adnexal malignancy was significantly associated with the presence of non-ovarian peritoneal metastases (p < 0.001). None of the simple cysts (including 85 cysts between 1-3 cm and 38 cysts > 3 cm) were found to be malignant (malignancy rate: 0.0%, 95% CI 0.0-3.0%). Complex cysts were more likely to be malignant than simple cysts (p = 0.002) and solid-cystic lesions were more likely to be malignant than complex cysts (p < 0.001).

CONCLUSION

Simple adnexal lesions on CT in this cohort were unlikely to be malignant, supporting the ACR guidelines. A higher size threshold of 3 cm (vs. 1 cm) may be preferred in all cases of simple cysts for recommending further follow-up. However, more complex-appearing cysts need further evaluation as the risk of malignancy is increased. Peritoneal metastases have a significant correlation with malignant adnexal involvement.

Extravascular findings during upper limb computed tomographic angiography focusing on undiagnosed malignancy

BACKGROUND

Computer tomography angiography (CTA) has been an established method for diagnostic vascular disease of lower limbs. Recently, the method is widely used for diagnosis of vascular pathologies in the upper limbs too. It also has increased the possibilities of this scans being reviewed by no specially trained radiologists. This increases the risk of incidental non vascular findings to be missed or misinterpreted. The study is focusing in the frequency of extravascular incidental finding (EVIF) and highlights the importance for both the reporting radiologist and the referring physician recognizing the frequency of EVIFs.

AIM

To analyse the frequency of EVIF identified on computed angiography (CT) of the upper limb.

METHODS

A total of 1383 CT angiographic studies of the peripheral arterial system were performed between August 2015 and August 2017. All upper limb CTAs (n = 79) were retrospectively reviewed for the presence of non-vascular incidental findings within the chest, abdomen/pelvis, musculoskeletal system or head and neck. These EVIFs were subsequently grouped into 3 categories based on clinical significance. EVIFs of immediate clinical relevance were included in category A, findings considered indeterminate but most likely benign were placed in category B, while incidental findings of no clinical significance were included in category C.

RESULTS

Complete imaging datasets were available in 74/79 (93.7%). Patient demographics included 39 (52.7%) females and 35 (47.2%) males with a mean age of 59 ± 19.5 years (range 19-93 years). A total of 153 EVIFs were reported in 52 patients (70.3%). Of these, 44 EVIFs (28.7%) were found in the chest, 83 (54.2%) in the abdomen, 14 (9.2%) in the musculoskeletal system and 9 (5.8%) in the head and neck. Thirteen EVIFs (8.4%) identified in 11 patients were noted to be of immediate clinical significance (Category A), 50 EVIFs (32.3%) were identified in 20 patients and were considered indeterminate but most likely benign, while the remaining 91 EVIFs (59.5%) identified in 21 patients were determined to be of no clinical significance (Category C). One index case of malignancy (1.3%) and four cases of new disseminated metastatic disease (5.4%) were identified.

CONCLUSION

Our study of upper limb CTA examinations demonstrated a frequency of 8.4% for extravascular incidental findings of immediate clinical significance. We highlight the importance for both the reporting radiologist and the referring physician of the need to recognize the frequency with which EVIFs are identified in the upper limb peripheral arterial system and of the necessity for further clinical and imaging work-up.

Blunt Thoracolumbar-Spine Trauma Evaluation in the Emergency Department: A Meta-Analysis of Diagnostic Accuracy for History, Physical Examination, and Imaging

BACKGROUND

Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging.

OBJECTIVE

Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients.

METHODS

A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios.

RESULTS

In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I² = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I² = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I² = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I² = 23%; p = 0.26).

CONCLUSIONS

CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures.

Evaluation of image quality and radiation dose of abdominal dual-energy CT

Background Dual-energy computed tomography (DECT) has conceptually been known since the late 1970s and commercially available as dual-source CT (DSCT) systems since 2006; however, the technique has not yet seen widespread implementation in routine protocols. Part of the cause for this is likely due to misconceptions about radiation dose and/or image quality when using DECT. Purpose To compare image quality and radiation dose of single-energy CT (SECT) and DECT abdominal examinations obtained in clinical practice on a second generation DSCT. Material and Methods A total of 495 included patients (mean age = 70.9 years) were retrospectively analyzed after undergoing either SECT (120 kVp and age-based mAs) or DECT examinations (80/Sn140 kVp and age-based mAs). The patients were divided into two groups based on examination type (247 SECT, 248 DECT), which were then subdivided into two groups, each based on age. Image noise was measured in the liver and image quality was subjectively assessed in 100 randomly selected patients. Results Noise levels were significantly lower in DECT (13.9 HU) compared with SECT (14.7 HU) ( P < 0.05). No significant differences in subjective image quality were found between DECT and SECT, except for one criterion in the 50-74-year age group. The mean dose-length product (DLP) (376 mGy-cm) and effective dose (6.1 mSv) of DECT were significantly lower than the DLP (513 mGy-cm) and effective dose (8.4 mSv) of SECT ( P < 0.05). Conclusion DECT can be implemented in routine clinical use without negatively impacting image quality while lowering radiation dose to the patient.

Access to primary care and computed tomography use in the emergency department

Background

The decision to obtain a computed tomography CT scan in the emergency department (ED) is complex, including a consideration of the risk posed by the test itself weighed against the importance of obtaining the result. In patients with limited access to primary care follow up the consequences of not making a diagnosis may be greater than for patients with ready access to primary care, impacting diagnostic reasoning. We set out to determine if there is an association between CT utilization in the ED and patient access to primary care.

Methods

We performed a cross-sectional study of all ED visits in which a CT scan was obtained between 2003 and 2012 at an academic, tertiary-care center. Data were abstracted from the electronic medical record and administrative databases and included type of CT obtained, demographics, comorbidities, and access to a local primary care provider (PCP). CT utilization rates were determined per 1000 patients.

Results

A total of 595,895 ED visits, including 98,001 visits in which a CT was obtained (16.4%) were included. Patients with an assigned PCP accounted for 55% of all visits. Overall, CT use per 1000 ED visits increased from 142.0 in 2003 to 169.2 in 2012 (p < 0.001), while the number of annual ED visits remained stable. CT use per 1000 ED visits increased from 169.4 to 205.8 over the 10-year period for patients without a PCP and from 118.9 to 142.0 for patients with a PCP. Patients without a PCP were more likely to have a CT performed compared to those with a PCP (OR 1.57, 95%CI 1.54 to 1.58; p < 0.001). After adjusting for age, gender, year of visit and number of comorbidities, patients without a PCP were more likely to have a CT performed (OR 1.20, 95% CI 1.18 to 1.21, p < 0.001).

Conclusions

The overall rate of CT utilization in the ED increased over the past 10 years. CT utilization was significantly higher among patients without a PCP. Increased availability of primary care, particularly for follow-up from the ED, could reduce CT utilization and therefore decrease costs, ED lengths of stay, and radiation exposure.

Incidental findings on brain magnetic resonance imaging in the elderly:the PROOF study

To prospectively evaluate the prevalence of incidental findings on standardized brain MRI scans in a cohort of elderly subjects. All participants provided written informed consent to participate in this prospective study, which was approved by the institutional review board and was HIPAA compliant. There were 503 subjects (75.3 ± 0.9 years of age, 58 % women) who received brain MRIs on a 1.5-T scanner using a standard acquisition protocol. All scans were reviewed by an experienced neuroradiologist. Incidental findings were stratified as follows: 1, no incidental findings; 2, incidental findings without clinical significance; 3, incidental findings with clinical significance or requiring clinical follow-up. Incidental findings were identified in 77.9 % of subjects. Among 392 scans that exhibited incidental findings, 494 abnormalities were identified. The most common findings in our study were cysts (45.9 % of subjects) and ear, nose, and throat (ENT) lesions (24.8 %) followed by stroke lesions (6.6 %) and neoplasms (3.8 %). There were 472 incidental findings that lacked clinical significance (group 2), and 22 incidental findings that required follow-up evaluation (group 3). Incidental findings on brain MRIs were commonly observed in this cohort of elderly subjects, but clinical follow-up was rarely indicated.

Incidental Findings on Pediatric Abdominal Computed Tomography At A Pediatric Trauma Center

BACKGROUND

The increasing availability and use of computed tomography (CT) in pediatric abdominal trauma has increased the detection of incidental findings. While some of these findings are benign, others may require further evaluation for possible clinical importance.

OBJECTIVES

This study aimed to identify the frequency and type of incidental findings and their need for follow-up on abdominal CT in patients at a pediatric trauma center.

METHODS

This was a retrospective, observational study on trauma patients ≤21 years of age who presented to the emergency department between January 1, 2004 and July 31, 2016 and underwent CT scans of the abdomen and pelvis. Findings were classified as benign anatomic variants, benign pathologic lesions, and pathologic lesions requiring additional work-up.

RESULTS

There were 1073 patients included in the study population, with a mean age of 15.5 years; 707 (66%) were males. A total of 418 incidental findings were identified in 345 patients. Of these, 290 (69%) were benign and 60 (14%) were likely benign pathologic that required possible outpatient monitoring. Of those requiring additional evaluation, 5 (1%) patients warranted further evaluation before discharge.

CONCLUSIONS

Nearly one-third of patients had at least one radiographic finding unrelated to their injury. Of these, more than two-thirds did not require additional evaluation, but nearly one-third of patients required some form of further work-up.

Increased Computed Tomography Utilization in the Emergency Department and Its Association with Hospital Admission

Introduction

Our goal was to investigate trends in computed tomography (CT) utilization in emergency departments (EDs) and its association with hospitalization.

Methods

We conducted an analysis of an administrative claims database of U.S. privately insured and Medicare Advantage enrollees. We identified ED visits from 2005 through 2013 and assessed for CT use, associated factors, and hospitalization after CT, along with patient demographics. We used both descriptive methods and regression models adjusted for year, age, sex, race, geographic region, and Hwang comorbidity score to explore associations among CT use, year, demographic characteristics, and hospitalization.

Results

We identified 33,144,233 ED visits; 5,901,603 (17.8%) involved CT. Over time, CT use during ED visits increased 59.9%. CT use increased in all age groups but decreased in children since 2010. In propensity-matching analysis, odds of hospitalization increased with age, comorbidities, male sex, and CT use (odds ratio, 2.38). Odds of hospitalization over time decreased more quickly for patients with CT.

Conclusion

CT utilization in the ED has increased significantly from 2005 through 2013. For children, CT use after 2010 decreased, indicating caution about CT use. Male sex, older age, and higher number of comorbidities were predictors of CT in the ED. Over time, odds of hospitalization decreased more quickly for patients with CT.

Introduction of a new imaging guideline for suspected renal colic in the ED reduces CT urography utilisation

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.