1
|
Mumtaz ZUA, Desai SR, Padley SPG. Frequency of extracardiac findings on "negative" CT coronary angiography studies. Clin Radiol 2024; 79:e334-e343. [PMID: 38092649 DOI: 10.1016/j.crad.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 01/02/2024]
Abstract
AIM To evaluate the prevalence and nature of extracardiac findings identified on computed tomography (CT) coronary angiography (CTCA) in patients with chest pain but without evidence of coronary artery disease (CAD). MATERIALS AND METHODS CTCA studies in patients referred to the hospital between January 2017 to February 2021 with chest pain and a suspected diagnosis of CAD were reviewed retrospectively for the presence of extracardiac findings. Consensus review of CTCA studies was performed by two experienced thoracic radiologists. The presence and severity of extracardiac findings, together with the likelihood that chest pain might be attributed to these, was recorded. Patient records were reviewed to ascertain the recording of extracardiac findings on initial CTCA reports and, where applicable, the nature of the follow-up. RESULTS Extracardiac findings (n=210) were present in 110/180 patients (61%) with a mean of 1.9 findings per patient. Extracardiac findings were more prevalent in patients aged ≥65 years compared to those <65 years (p<0.001). At least one extracardiac finding with the potential to cause chest pain was present in 40 patients (22%): degenerative disc disease (n=23 [13%]) and hiatus hernia (n=6 [3.3%]) were the most common extracardiac findings. Only 37.6% (79) of all retrospectively identified findings had been initially reported and, of these, 12.7% (10) required further follow-up. CONCLUSION Extracardiac findings are common in patients with no evidence of CAD on CTCA. The entire dataset should be evaluated for the presence of extracardiac findings that could explain chest pain symptoms on wide field of view reconstructions.
Collapse
Affiliation(s)
- Z-U-A Mumtaz
- Faculty of Medicine, Imperial College School of Medicine, London, UK.
| | - S R Desai
- Department of Radiology, Royal Brompton and Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College, London, UK; Margaret Turner-Warwick Centre for Fibrosing Lung Diseases, Imperial College London, UK
| | - S P G Padley
- Department of Radiology, Royal Brompton and Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| |
Collapse
|
2
|
Walder JR, Faiz SA, Sandoval M. Lung cancer in the emergency department. EMERGENCY CANCER CARE 2023; 2:3. [PMID: 38799792 PMCID: PMC11116267 DOI: 10.1186/s44201-023-00018-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/13/2023] [Indexed: 05/29/2024]
Abstract
Background Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care. Findings Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers. Conclusion ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.
Collapse
Affiliation(s)
- Jeremy R. Walder
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, 6431 Fannin St., Ste. MSB 1.282, Houston, TX 77030 USA
| | - Saadia A. Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1462, Houston, TX 77030 USA
| | - Marcelo Sandoval
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1468, Houston, TX 77030 USA
| |
Collapse
|
3
|
Langenbach MC, Sandstede J, Sieren MM, Barkhausen J, Gutberlet M, Bamberg F, Lehmkuhl L, Maintz D, Naehle CP. German Radiological Society and the Professional Association of German Radiologists Position Paper on Coronary computed tomography: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome. ROFO-FORTSCHR RONTG 2023; 195:115-134. [PMID: 36634682 DOI: 10.1055/a-1973-9687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography. It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography. CITATION FORMAT: · Langenbach MC, Sandstede J, Sieren M et al. DRG and BDR Position Paper on Coronary CT: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome. Fortschr Röntgenstr 2023; 195: 115 - 133.
Collapse
Affiliation(s)
- Marcel C Langenbach
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Koln, Germany.,Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jörn Sandstede
- Radiologische Allianz, Hamburg, Germany.,Berufsverband der deutschen Radiologen e. V. (BDR), München, Deutschland
| | - Malte M Sieren
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein Campus Luebeck, Lübeck, Germany
| | - Jörg Barkhausen
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein Campus Luebeck, Lübeck, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Leipzig Heart Centre University Hospital, Leipzig, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Lehmkuhl
- Department for Diagnostic and Interventional Radiology, RHÖN Clinic, Campus Bad Neustadt, Germany
| | - David Maintz
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Koln, Germany
| | - Claas P Naehle
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Koln, Germany.,Radiologische Allianz, Hamburg, Germany
| |
Collapse
|
4
|
Langenbach MC, Sandstede J, Sieren MM, Barkhausen J, Gutberlet M, Bamberg F, Lehmkuhl L, Maintz D, Nähle CP. [German Radiological Society and the Professional Association of German Radiologists position paper on coronary computed tomography: clinical evidence and quality of patient care in chronic coronary syndrome]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:1-19. [PMID: 36633613 PMCID: PMC9838426 DOI: 10.1007/s00117-022-01096-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 01/13/2023]
Abstract
This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography (CT). It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography.
Collapse
Affiliation(s)
- M. C. Langenbach
- grid.411097.a0000 0000 8852 305XInstitut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Köln, Köln, Deutschland ,grid.32224.350000 0004 0386 9924Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
| | - J. Sandstede
- Radiologische Allianz, Hamburg, Deutschland ,Berufsverband der deutschen Radiologen e. V. (BDR), München, Deutschland
| | - M. M. Sieren
- grid.412468.d0000 0004 0646 2097Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - J. Barkhausen
- grid.412468.d0000 0004 0646 2097Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - M. Gutberlet
- grid.513819.70000 0004 0489 7230Abteilung für Diagnostische und Interventionelle Radiologie, Herzzentrum Leipzig – Universität Leipzig, Leipzig, Deutschland
| | - F. Bamberg
- grid.7708.80000 0000 9428 7911Medizinische Fakultät, Abteilung für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - L. Lehmkuhl
- Abteilung für Diagnostische und Interventionelle Radiologie, RHÖN Klinik, Campus Bad Neustadt, Bad Neustadt, Deutschland
| | - D. Maintz
- grid.411097.a0000 0000 8852 305XInstitut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Köln, Köln, Deutschland
| | - C. P. Nähle
- grid.411097.a0000 0000 8852 305XInstitut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Köln, Köln, Deutschland ,Radiologische Allianz, Hamburg, Deutschland
| |
Collapse
|
5
|
Evans CS, Arthur R, Kane M, Omofoye F, Chung AE, Moreton E, Moore C. Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis. Ann Emerg Med 2022; 80:243-256. [PMID: 35717273 DOI: 10.1016/j.annemergmed.2022.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 11/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Christopher S Evans
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Rodney Arthur
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael Kane
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Fola Omofoye
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Arlene E Chung
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Biostatistics & Bioinformatics, Duke School of Medicine, Durham, NC
| | - Elizabeth Moreton
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carlton Moore
- Clinical Informatics Fellowship Program, UNC Hospitals, Chapel Hill, NC; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
6
|
Azour L, Ko JP, Washer SL, Lanier A, Brusca-Augello G, Alpert JB, Moore WH. Incidental Lung Nodules on Cross-sectional Imaging: Current Reporting and Management. Radiol Clin North Am 2021; 59:535-549. [PMID: 34053604 DOI: 10.1016/j.rcl.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pulmonary nodules are the most common incidental finding in the chest, particularly on computed tomographs that include a portion or all of the chest, and may be encountered more frequently with increasing utilization of cross-sectional imaging. Established guidelines address the reporting and management of incidental pulmonary nodules, both solid and subsolid, synthesizing nodule and patient features to distinguish benign nodules from those of potential clinical consequence. Standard nodule assessment is essential for the accurate reporting of nodule size, attenuation, and morphology, all features with varying risk implications and thus management recommendations.
Collapse
Affiliation(s)
- Lea Azour
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA.
| | - Jane P Ko
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA
| | - Sophie L Washer
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA
| | - Amelia Lanier
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA
| | - Geraldine Brusca-Augello
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA
| | - Jeffrey B Alpert
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA
| | - William H Moore
- Department of Radiology, NYU Grossman School of Medicine, NYU Langone Health, Center for Biomedical Imaging, 660 First Avenue, New York, NY 10016, USA
| |
Collapse
|
7
|
Goldman LH, Lerer R, Shabrang C, Travin MI, Levsky JM. Clinical significance of incidental findings on coronary CT angiography: Insights from a randomized controlled trial. J Nucl Cardiol 2020; 27:2306-2315. [PMID: 30788757 DOI: 10.1007/s12350-019-01647-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The effect of incidental findings from coronary computed tomography angiography (CCTA) on management has not been rigorously investigated. This study uses a control group to explore this relationship. METHODS Analysis of data from a randomized controlled trial of acute chest pain patients admitted to telemetry was performed. Patients were randomized to undergo either CCTA (n = 200) or radionuclide myocardial perfusion imaging (MPI) (n = 200). Incidental findings were determined from imaging reports. Records were reviewed to determine subsequent management and imaging during and after hospitalization. Comparisons were performed using Fischer's exact tests. RESULTS 386 incidental findings were found among 187 CCTA studies. No extra-cardiac incidental findings were noted in the MPI arm, which served as an effective control group. There were significantly more non-coronary medical workups during admission in the CCTA group compared to the MPI group [20% (39) vs. 12% (23), P = 0.038]. CCTA patients underwent significantly more resting echocardiography during the inpatient workup compared to the MPI group [38% (75) vs. 18% (55), P = 0.042]. CCTA patients underwent significantly more non-contrast chest CT exams in the year following admission compared to MPI patients [14% (27) vs. 7% (13) P = 0.029]. CONCLUSIONS Incidental findings on inpatient CCTAs performed for chest pain have a significant impact on treatment and imaging during and following hospital admission.
Collapse
Affiliation(s)
- Lauren H Goldman
- Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA.
| | - Rikah Lerer
- Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Cyrus Shabrang
- Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Mark I Travin
- Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Jeffrey M Levsky
- Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| |
Collapse
|
8
|
Chang SH, Kent AJ. Commentary: Segmentectomies-The Minimally Invasive Sequel May Be Better Than the Original. Semin Thorac Cardiovasc Surg 2020; 33:545-546. [PMID: 33181291 DOI: 10.1053/j.semtcvs.2020.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/14/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Stephanie H Chang
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.
| | - Amie J Kent
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| |
Collapse
|
9
|
Beache GM, Mohammed TLH, Hurwitz Koweek LM, Ghoshhajra BB, Brown RKJ, Davis AM, Heitner J, Hsu JY, Johri AM, Khosa F, Kligerman SJ, Litmanovich D, Maroules CD, Meyersohn N, Tomaszewski CA, Villines TC, Wann S, Abbara S. ACR Appropriateness Criteria® Acute Nonspecific Chest Pain-Low Probability of Coronary Artery Disease. J Am Coll Radiol 2020; 17:S346-S354. [PMID: 33153548 DOI: 10.1016/j.jacr.2020.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022]
Abstract
Patients with acute nonspecific chest pain and low probability for coronary disease remain an important clinical management dilemma. We focus on evidence for imaging, in an integrated decision-making setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
- Garth M Beache
- University of Louisville School of Medicine, Louisville, Kentucky.
| | | | | | | | | | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians
| | - John Heitner
- New York Presbyterian Methodist Hospital, Brooklyn, New York; Society for Cardiovascular Magnetic Resonance
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | - Amer M Johri
- Queen's University, Kingston, Ontario; Canada, Cardiology expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic atherosclerotic plaque penetrating through the internal elastic lamina into the media. With the advances in imaging techniques, the differential diagnosis between PAU and other aortic ulcers remains a challenge. This review aims to summarize the latest insight into PAU, based on clinical context and the newest imaging characteristics, to aid treatment decision-making. RECENT FINDINGS Most PAUs are asymptomatic and do not require urgent invasive treatment. Nevertheless, when PAU leads to an acute aortic syndrome, emergency invasive therapy is recommended. A differential diagnosis with other lesions, such as ulcerated plaques or intimal disruptions within the context of an aortic intramural hematoma, is required as the risk of complications and management differ. Imaging technique plays a pivotal role in the correct diagnosis of aortic ulcers. SUMMARY The differential diagnosis of PAU with other aortic ulcers based on clinical and imaging technique information is mandatory as it may imply different prognosis and management. This diagnosis is particularly important when PAU is the cause of acute aortic syndromes as urgent invasive treatment should be recommended.
Collapse
|
11
|
Coronavirus disease 2019 (COVID-19) pneumonia incidentally detected on coronary CT angiogram: a do-not-miss diagnosis. Emerg Radiol 2020; 27:721-726. [PMID: 32519293 PMCID: PMC7280472 DOI: 10.1007/s10140-020-01802-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/25/2020] [Indexed: 01/08/2023]
Abstract
Coronary CT angiograms are commonly performed for the evaluation of coronary artery disease and coronary arterial anatomy. However, extracardiac findings are frequently detected on these examinations and often can explain patients’ underlying symptoms, having a significant impact on patient management. Here in, we discuss three cases of incidentally detected novel COVID-19-infected pneumonia (NCIP). This case series highlights the image findings in NCIP and emphasizes the importance of evaluating all organs in the field of view on coronary CT angiograms. In addition, with the ongoing outbreak of COVID-19 and exponentially increasing incidence throughout the world, this report stresses the need for including NCIP in the differential diagnosis of patients with typical image findings in at-risk populations, as early diagnosis is crucial for appropriate patient management and post-exposure recommendations.
Collapse
|
12
|
Evaluation of Hospitalizations Preventable with Idealized Outpatient Care and Continuity of Care. J Healthc Qual 2020; 43:145-152. [PMID: 32168121 DOI: 10.1097/jhq.0000000000000259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Unnecessary hospitalizations may pose the risk of iatrogenic complications, suboptimal patient experience, and increased cost. Administrative data lack granularity to understand the proportion and causes of hospitalizations preventable through optimizing care continuum (HPOCC). We aim to identify the incidence and causes of HPOCC through clinician-adjudicated chart review. METHODS A retrospective review was performed for inpatient admissions from the emergency department (ED) over 1 week. Each admission was reviewed by a clinician to determine whether it is an HPOCC defined as not requiring inpatient care with the assumption of idealized outpatient care and social support. RESULTS Of the 515 patients admitted from the ED, 31 (6.0%) patients were judged to have had an HPOCC. Causes of HPOCC include urgent diagnostics (9, 29.0%), unnecessary transfer from a long-term facility (7, 23.0%), needing IV therapy (5, 16.0%), benign incidental finding (5, 16.0%), diagnostic uncertainty in complex chronic illness (3, 10.0%), and lack of access to care for disposition (2, 6.0%). CONCLUSION Hospitalizations preventable through optimizing care continuum account for about 1 in every 15 hospitalizations in an urban academic medical center. The need for urgent diagnostics accounts for a plurality of HPOCC and could be an important target for quality improvement.
Collapse
|
13
|
A Secondary Analysis to Identify Patient-Centered Outcomes in the ACR’s Appropriateness Criteria. J Am Coll Radiol 2019; 16:1645-1655. [DOI: 10.1016/j.jacr.2019.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 11/20/2022]
|
14
|
Galetta D, Rampinelli C, Funicelli L, Casiraghi M, Grana C, Bellomi M, Spaggiari L. Computed Tomography-Guided Percutaneous Radiotracer Localization and Resection of Indistinct/Small Pulmonary Lesions. Ann Thorac Surg 2019; 108:852-858. [DOI: 10.1016/j.athoracsur.2019.03.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/19/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
|
15
|
Kay FU, Canan A, Abbara S. Common Incidental Findings on Cardiac CT: a Systematic Review. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9494-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
16
|
Radioguided lung lesion localization: introducing a fluoroscopy system in a SPECT/CT scan. Nucl Med Commun 2019; 40:597-603. [PMID: 30789851 DOI: 10.1097/mnm.0000000000000999] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose was to report our experience in the use of radiotracer localization and resection of small, indistinct, or nonpalpable pulmonary lesions. We developed an innovative technique implementing a fluoroscopy system on a single-photon emission computed tomography/computed tomography (SPECT/CT) scan that allowed to perform CT-guided injection of radiotracer directly on SPECT/CT. PATIENTS AND METHODS Patients were selected for the radiotracer procedure in presence of difficulties in locating nodules with video-assisted thoracoscopic surgery (VATS). Overall, 0.2 ml of technetium-99m macroaggregated albumin and 0.3 ml of nonionic iodinated contrast were injected under CT guidance. During the VATS procedure, an endoscopic gamma detecting probe was introduced to scan the lung surface. The area of major radioactivity, which matched with the area of the nodule, was resected. RESULTS Between January 2016 and October 2018, 37 patients underwent CT-guided radiotracer injection. The mean nodule size was 11 mm. CT nodule morphology characteristics were as follows: 15 nodules were ground glass, 12 were solid, and 10 were partly solid. No significant adverse events occurred. In one patient, the surgeons decided for an open thoracotomy after unsuccessfully VATS. Overall, lobectomy was performed in two patients, segmentectomy in one, and wedge resection in 33 patients. No mortality occurred. The pathological diagnosis was 15 (42%) primary lung cancer, eight (22%) metastases, and 13 (36%) benign lesions. CONCLUSION Radioguided pulmonary nodule localization is a reliable procedure with a high rate of success, minimal complications, and lower risk of failures, with no associated mortality or significant morbidity. Our SPECT/CT system is the first to benefit from the technological improvement with successfully implementation and application of fluoroscopy to SPECT/CT.
Collapse
|
17
|
Computed tomography coronary angiography in patients without known coronary artery disease can demonstrate possible non-cardiovascular causes of non-acute retrosternal chest pain. Insights Imaging 2018; 9:687-694. [PMID: 30276668 PMCID: PMC6206382 DOI: 10.1007/s13244-018-0654-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/21/2018] [Accepted: 08/07/2018] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES To assess the computed tomography coronary angiography (CTCA) accuracy for demonstrating possible non-cardiovascular causes of non-acute retrosternal chest pain in patients without known coronary artery disease (CAD) and to correlate CTCA results with the patient management and relief from pain. METHODS This prospective observational study was approved by the ethical committee. Consecutive patients suffering non-acute chest pain who underwent CTCA and with not known CAD were enrolled and classified as having coronary diseases (CD) or extracardiac diseases (ECD). Association between age, sex, body mass index (BMI), cardiovascular risk factors, and type of chest pain with CD or ECD was estimated. Correlation between BMI classes and each risk factor was also calculated. RESULTS A total of 106 patients (60 males; age 62 ± 14 years [mean ± standard deviation]; mean BMI 27) were enrolled. Hypertension was found in 71/106 (67%); smoking was significantly more frequent among males (p = 0.003) and hypercholesterolemia among females (p = 0.017); hypertension and hypercholesterolemia significantly correlated with age, and hypertension also with BMI. Pain was atypical in 70/106 (66%) patients. The kind of pain did not correlate with disease or gender. CTCA showed possible causes of chest pain in 69/106 (65%) patients; 32/69 (47%) having only CD, 23/69 (33%) only ECD, and 14/69 (20%) both CD and ECD. Prevalence was: hiatal hernia 35/106 (33%); significant CAD 24/106 (23%); myocardial bridging 22/106 (21%). At follow-up of 94/106 (89%) patients, 71/94 (76%) were pain-free, 14/17 (82%) significant CAD had been treated, and only one patient with non-significant CAD was treated after CTCA. CONCLUSION CTCA suggested possible causes of non-acute pain in 65% of patients. MAIN MESSAGES • CTCA can either rule in or rule out possible causes of chest pain alternative to CAD. • Clinically relevant findings were detected in 65% of patients with non-acute chest pain. • Non-cardiovascular diseases potentially explained symptoms in 35% of patients.
Collapse
|
18
|
Extracardiac findings on coronary computed tomography angiography in patients without significant coronary artery disease. Eur Radiol 2018; 29:1714-1723. [PMID: 30255246 DOI: 10.1007/s00330-018-5688-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/09/2018] [Accepted: 07/30/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To analyse extracardiac findings in patients without significant coronary artery disease (CAD) in general and in symptomatic patients in particular. METHODS We searched the Radiology Information System database for coronary computed tomography angiographies (CTA) performed from 2000-2014 and retrospectively enrolled 3,898 patients without significant CAD (coronary stenosis < 50%) in CTA. In 2,330 symptomatic patients, we analysed the spectrum of extracardiac findings and identified pathologies potentially explaining chest pain. Finally, we investigated variables affecting the number of extracardiac findings detected in CTA. RESULTS Overall extracardiac findings were found in 1,177 patients (30.2%; 95%CI, 28.8-31.7%). 94 patients (2.4%; 95%CI, 2.0-2.9%) had extracardiac findings with a recommendation for follow-up, sixteen patients (0.4%; 95%CI, 0.3-0.7%) had incidental urgent, and another three patients (0.1%; 95%CI, 0.1-0.2%) had incidental malignant extracardiac findings. 185 of 2,330 symptomatic patients (7.9%; 95%CI, 6.9-9.1%) revealed extracardiac findings potentially explaining chest pain after exclusion of significant CAD. The number of extracardiac findings increased significantly with patient age (p < 0.001) and the cumulative experience of the CT reader (p < 0.001). CONCLUSION 30.2% of patients undergoing CTA for exclusion of CAD had ECF, and 7.9% of symptomatic patients without significant CAD on their examination had findings that could potentially explain their symptoms. KEY POINTS • Of patients undergoing CTA, 2.8% have relevant incidental extracardiac findings. • CTA could identify the differential diagnosis of chest pain when excluding significant CAD. • Patient age and reader's professional experience influence the number of detected ECFs.
Collapse
|
19
|
Boldeanu I, Perreault Bishop J, Nepveu S, Stevens LM, Soulez G, Kieser TM, Lamy A, Noiseux N, Chartrand-Lefebvre C. Incidental findings in CT imaging of coronary artery bypass grafts: results from a Canadian multicenter prospective cohort. BMC Res Notes 2018; 11:72. [PMID: 29368660 PMCID: PMC5784672 DOI: 10.1186/s13104-018-3168-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/12/2018] [Indexed: 12/18/2022] Open
Abstract
Objective To assess the prevalence and clinical significance of incidental findings identified during computed tomography imaging of coronary artery bypass grafts. Results This prospective study includes 144 patients undergoing coronary graft patency assessment using computed tomography. Incidental findings were classified as significant if they were considered to need an immediate action or treatment, short-term work-up or follow-up, or minor. A total of 211 incidental findings were present in 109 (75.7%) patients. Seventy-one incidental findings (33.6%) were cardiac and 140 (66.4%) were extracardiac. Most common cardiac incidental findings were atrial dilatation [39 patients, 48 incidental findings (67.6%)] and aortic valve calcifications (7 patients, 9.9%). Among the 140 extracardiac incidental findings, the most common were lung nodules (51 patients, 54 nodules, 38.6%), and emphysema (21 patients, 15%). Thirty-six (25.7%) extracardiac incidental findings were significant and notably, 23 (63.9%) were lung nodules. Follow-up was recommended in 37 cases, among which all patients with significant lung nodules (23 patients, 62.2%). In conclusion, most common computed tomography incidental findings in patients with coronary grafts were lung nodules and emphysema. Electronic supplementary material The online version of this article (10.1186/s13104-018-3168-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- I Boldeanu
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1051 Sanguinet Street, Montreal, QC, H2X 0C1, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
| | - J Perreault Bishop
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1051 Sanguinet Street, Montreal, QC, H2X 0C1, Canada
| | - S Nepveu
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1051 Sanguinet Street, Montreal, QC, H2X 0C1, Canada
| | - L-M Stevens
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada.,Division of Cardiac Surgery, CHUM, Montreal, Canada
| | - G Soulez
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1051 Sanguinet Street, Montreal, QC, H2X 0C1, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
| | - T M Kieser
- Division of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - A Lamy
- Division of Cardiac Surgery, McMaster University and Population Health Research Institute, Hamilton, ON, Canada
| | - N Noiseux
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada.,Division of Cardiac Surgery, CHUM, Montreal, Canada
| | - C Chartrand-Lefebvre
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), 1051 Sanguinet Street, Montreal, QC, H2X 0C1, Canada. .,Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada.
| |
Collapse
|
20
|
Scholtz JE, Lu MT, Hedgire S, Meyersohn NM, Oliveira GR, Prabhakar AM, Gupta R, Kalra MK, Shepard JAO, Hoffmann U, Ghoshhajra BB. Incidental pulmonary nodules in emergent coronary CT angiography for suspected acute coronary syndrome: Impact of revised 2017 Fleischner Society Guidelines. J Cardiovasc Comput Tomogr 2017; 12:28-33. [PMID: 29195841 DOI: 10.1016/j.jcct.2017.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/05/2017] [Accepted: 11/12/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary nodules (PN) are frequently detected incidentally during coronary computed tomography angiography (CTA). We evaluated whether the 2017 Fleischner Society guidelines may result in a decrease of follow-up testing of incidental PN as compared to prior guidelines in patients undergoing coronary CTA. METHODS We conducted a retrospective study of a registry of emergency department patients who underwent coronary CTA for acute coronary syndrome assessment between 2012 and 2017. Based on guidelines, patients <35 years, history of cancer, or prior exams showing stability of PN were excluded. Patients >60 years, history of smoking, irregular/spiculated PN morphology, or PN size >20 mm were classified as high-risk for lung cancer. Radiological findings pertaining to PN were identified (PN size, morphology, quantity) through review of radiology reports. PN follow-up recommendations were established using 2017 Fleischner Society Guidelines and compared with prior guidelines for solid (2005) and subsolid (2013) PN. Data were analyzed with Student's t-test. RESULTS The registry included 2066 patients (female 45.1%, 52.9 ± 11.0 years), of which 578 (28.0%) reported PN. 438 of those (21.2%) were eligible for guideline-based follow-up evaluation. 205 (4 6.8%) were classified as high-risk for lung cancer. 2017 guidelines reduced the number of individuals requiring follow-up by 64.5%, from 264 (12.8%) to 94 patients (4.5%) when compared to prior guidelines (p < 0.001). The minimum number of follow-up chest CTs decreased by 55.8% from 430 to 190 (p < 0.001). CONCLUSION Application of the 2017 Fleischner Society Guidelines resulted in a significant decrease of follow-up testing for incidental PN in patients undergoing coronary CTA for suspected acute coronary syndrome.
Collapse
Affiliation(s)
- Jan-Erik Scholtz
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114-2750, USA; Department for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann-Wolfgang-Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany.
| | - Michael T Lu
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114-2750, USA
| | - Sandeep Hedgire
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114-2750, USA
| | - Nina M Meyersohn
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114-2750, USA
| | - George R Oliveira
- Department for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann-Wolfgang-Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany
| | - Anand M Prabhakar
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114-2750, USA
| | - Rajiv Gupta
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114-2750, USA
| | - Mannudeep K Kalra
- Department for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann-Wolfgang-Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany
| | - Jo-Anne O Shepard
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA 02114-2750, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114-2750, USA
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114-2750, USA
| |
Collapse
|
21
|
Safety of coronary CT angiography and functional testing for stable chest pain in the PROMISE trial: A randomized comparison of test complications, incidental findings, and radiation dose. J Cardiovasc Comput Tomogr 2017; 11:373-382. [PMID: 28838846 DOI: 10.1016/j.jcct.2017.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/25/2017] [Accepted: 08/12/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Coronary computed tomography angiography (CTA) and functional testing strategies for stable chest pain yield similar outcomes; one aspect that may guide test choice is safety. METHODS We compared test safety (test complications, incidental findings, and effective radiation dose) between CTA and functional testing as-tested in PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain). In the subgroup whose physicians intended nuclear stress over other functional tests if randomized to the functional arm, we compared radiation dose of CTA versus nuclear stress and identified characteristics associated with dose. RESULTS Of 9470 patients, none had major and <1% had minor complications (CTA: 0.8% [37/4633] vs. functional: 0.6% [27/4837]). CTA identified more incidental findings (11.6% [539/4633] vs. 0.7% [34/4837], p < 0.001), most commonly pulmonary nodules (9.4%, 437/4633). CTA had similar 90-day cumulative radiation dose to functional testing. However, in the subgroup whose physicians intended nuclear stress (CTA 3147; nuclear 3203), CTA had lower median index test (8.8 vs. 12.6 mSv, p < 0.001) and 90-day cumulative (11.6 vs. 13.1 mSv, p < 0.001) dose, independent of patient characteristics. The lowest nuclear doses employed 1-day Tc-99m protocols (12.2 mSv). The lowest CTA doses were at sites performing ≥500 CTAs/year (6.9 mSv) and with advanced (latest available) CT scanners (5.5 mSv). CONCLUSION Complications were negligibly rare for both CTA and functional testing. CTA detects more incidental findings. Compared to nuclear stress testing, CTA's lower radiation dose, independent of patient characteristics, makes it an attractive test choice. Radiation dose varies with imaging protocol, indicating opportunities to further reduce dose. (ClinicalTrials.gov number, NCT01174550).
Collapse
|
22
|
Thoracic Incidental Findings in Preoperative Computed Tomography Evaluation for Transcatheter Aortic Valve Implantation (TAVI). J Thorac Imaging 2017; 31:183-8. [PMID: 27082418 DOI: 10.1097/rti.0000000000000208] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many older patients with aortic stenosis are excluded from surgical intervention due to multiple comorbidities. For these patients, transcatheter aortic valve implantation (TAVI) is a viable treatment alternative. Cardiothoracic computed tomography (CT) provides detailed anatomic assessment of the aortic root structures for patient selection, preprocedural planning, and intraoperative decision-making; however, nonaortic incidental findings are frequently detected. The prevalence and clinical significance of these findings have not been well described. MATERIALS AND METHODS This retrospective study examined incidental findings in 209 consecutive patients (96 women and 113 men; mean age, 70 y) with aortic stenosis undergoing preoperative cardiothoracic CT evaluation for TAVI during a 3-year period. Incidental findings were recorded, and medical records were reviewed for follow-up diagnostic examinations. RESULTS Incidental findings, both significant and nonsignificant, were observed in 85.6% of patients (179/209). Noncalcified pulmonary nodules were the most common incidental finding occurring in 59/209 (28.2%) patients, followed by pleural effusion and emphysema both of which occurred in 34/209 (16.3%) patients, respectively. CONCLUSIONS Cardiothoracic CT obtained for evaluation before TAVI has a high frequency of incidental findings.
Collapse
|
23
|
Imaging of nontraumatic thoracic emergencies. Curr Opin Pulm Med 2016; 23:184-192. [PMID: 28009644 DOI: 10.1097/mcp.0000000000000355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Acute chest symptoms form an important incentive for imaging in the emergency setting. This review discusses the radiologic features of various vascular and pulmonary diseases leading to acute respiratory distress and recent developments on important emergency radiologic examinations. RECENT FINDINGS Recently, triple-rule-out computed tomography protocol was introduced in diagnosis of chest pain, and advancing computed tomography technology and knowledge have led to discussion on treatment of pulmonary embolism. Diffuse pulmonary opacities remain a diagnostic dilemma in the emergency setting and although imaging findings can often be nonspecific, they help in guiding toward accurate diagnosis and timely management. SUMMARY Though promising, triple-rule-out is not yet justified because of low incidence of additional findings compared with conventional computed tomography angiography in chest pain, but it might be suited for clinical practice in the near future. Relevance of isolated subsegmental pulmonary embolism is unknown and research on this topic is needed and on its way. We provided some key findings in differentiating diffuse pulmonary opacities and describe the additional value of chest ultrasound in this clinical dilemma. A brief sidestep to pneumothorax is made, as this is also a frequent finding in the acute dyspneic patient, as well as in patients with acute chest pain.
Collapse
|
24
|
Schoenhagen P, Ghoshhajra B, Achenbach S, Abbara S. Interpretation of ‘incidental’ cardiovascular findings in standard chest CTs impact of evolving scanner technology on educational requirements. J Cardiovasc Comput Tomogr 2016; 10:289-90. [DOI: 10.1016/j.jcct.2016.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/22/2016] [Indexed: 12/21/2022]
|
25
|
Showkathali R, Sen A, Brickham B, Dworakowski R, Wendler O, MacCarthy P. "Incidental findings" during TAVI work-up: more than just an inconvenience. EUROINTERVENTION 2016; 11:465-9. [PMID: 24970459 DOI: 10.4244/eijy14m06_04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To characterise the clinical course of patients who had incidental findings on the CT aortogram (CTA) done as a transcatheter aortic valve implantation (TAVI) work-up investigation. METHODS AND RESULTS All patients who underwent CTA as a work-up investigation for TAVI were retrospectively recruited (n=295, 83±6.7 years) to identify those with an incidental finding. A total of 323 incidental findings were identified in 201 (68.1%) patients. Of those with incidental findings, 87 (43.3%) had at least one of immediate clinical significance. Within this group, fewer (52.9%) eventually had TAVI compared to those without incidental findings (63%). In patients going on to have TAVI, the time between CTA and TAVI was longer in those with incidental findings (median 96 vs. 81 days). At follow-up, overall mortality in those with incidental findings was higher than in those without (49.4% vs. 37.5%). In patients who underwent TAVI, there was a trend to increased mortality in those with incidental findings (34.8% vs. 21.4%, p=0.07). CONCLUSIONS Incidental findings were associated with a longer time to TAVI procedure, lower chance of eventually receiving TAVI as definitive therapy and a worse overall outcome. Such findings are clearly important and should be taken into account when delivering a contemporary TAVI service.
Collapse
Affiliation(s)
- Refai Showkathali
- Department of Cardiology, King's College Hospital, Denmark Hill, London, United Kingdom
| | | | | | | | | | | |
Collapse
|
26
|
Mahani MG, Morani AC, Lu JC, Dehkordy SF, Jeph S, Dorfman AL, Agarwal PP. Non-cardiovascular findings in clinical cardiovascular magnetic resonance imaging in children. Pediatr Radiol 2016; 46:473-82. [PMID: 26754539 DOI: 10.1007/s00247-015-3512-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/15/2015] [Accepted: 11/13/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND With increasing use of pediatric cardiovascular MRI, it is important for all imagers to become familiar with the spectrum of non-cardiovascular imaging findings that can be encountered. OBJECTIVE This study aims to ascertain the prevalence and nature of these findings in pediatric cardiovascular MRIs performed at our institution. MATERIALS AND METHODS We retrospectively evaluated reports of all cardiovascular MRI studies performed at our institute from January 2008 to October 2012 in patients younger than18 years. Most studies (98%) were jointly interpreted by a pediatric cardiologist and a radiologist. We reviewed the electronic medical records of all cases with non-cardiovascular findings, defined as any imaging finding outside the cardiovascular system. Non-cardiovascular findings were classified into significant and non-significant, based on whether they were known at the time of imaging or they required additional workup or a change in management. RESULTS In 849 consecutive studies (mean age 9.7 ± 6.3 years), 145 non-cardiovascular findings were found in 140 studies (16.5% of total studies). Overall, 51.0% (74/145) of non-cardiovascular findings were in the abdomen, 30.3% (44/145) were in the chest, and 18.6% (27/145) were in the spine. A total of 19 significant non-cardiovascular findings were observed in 19 studies in individual patients (2.2% of total studies, 47% male, mean age 5.9 ± 6.7 years). Significant non-cardiovascular findings included hepatic adenoma, arterially enhancing focal liver lesions, asplenia, solitary kidney, pelvicaliectasis, renal cystic diseases, gastric distention, adrenal hemorrhage, lung hypoplasia, air space disease, bronchial narrowing, pneumomediastinum and retained surgical sponge. CONCLUSION Non-cardiovascular findings were seen in 16.5% of cardiovascular MRI studies in children, of which 2.2% were clinically significant findings. Prevalence and nature of these non-cardiovascular findings are different from those reported in adults. Attention to these findings is important during interpretation.
Collapse
Affiliation(s)
- Maryam Ghadimi Mahani
- Department of Radiology, Section of Pediatric Radiology, University of Michigan Health System, C.S. Mott Children's Hospital, 1540 E. Hospital Drive, SPC 4252, Ann Arbor, MI, 48019-4252, USA.
| | - Ajaykumar C Morani
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jimmy C Lu
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Soudabeh Fazeli Dehkordy
- Department of Radiology, Section of Pediatric Radiology, University of Michigan Health System, C.S. Mott Children's Hospital, 1540 E. Hospital Drive, SPC 4252, Ann Arbor, MI, 48019-4252, USA.,Department of Graduate Medical Education, Providence Hospital and Medical Centers, Southfield, MI, USA
| | - Sunil Jeph
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Radiology, Geisinger Medical Center, Danville, PA, USA
| | - Adam L Dorfman
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Prachi P Agarwal
- Department of Radiology, Division of Cardiothoracic Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| |
Collapse
|
27
|
Karkhanis S, Patil S, Hoey ET, Ganeshan A. The prevalence and significance of thoracic findings in patients undergoing extended coverage computed tomography for assessment of abdominal aortic aneurysms. Br J Radiol 2016; 89:20150723. [PMID: 26987373 DOI: 10.1259/bjr.20150723] [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 Many major vascular centres, including ours, incorporate coverage of the thoracic aorta in CT scans evaluating abdominal aortic aneurysms (AAAs) (extended coverage contrast-enhanced CT (EC-CECT) scan]. We sought to determine the prevalence of thoracic pathology in a large consecutive series of patients with AAA undergoing EC-CECT. METHODS All patients who underwent EC-CECT for AAA between April 2013 and 2014 were identified from our radiology information system. Reports were retrospectively reviewed and for each study, sex, age and reported thoracic aortic and other non-vascular findings were extracted. Findings were initially categorized into "major" or "minor" depending on if they were mentioned in the report impression/conclusion. Any major thoracic pathology was termed "significant" if there was a new diagnosis/patient intervention/investigation and a change in patient management. RESULTS Of the 150 scans included in the study, 97 (65%) had at least one thoracic finding. These findings included 24 scans (16%) with major findings and 73 scans (48%) with minor findings. In 13 scans (9%), the findings were significant and resulted in a delay (n = 11) or cancellation (n = 2) of AAA repair. CONCLUSION Pre-procedural EC-CECT helps to identify significant intrathoracic findings in patients with AAA, which can have a major impact on AAA repair. This study supports the routine use of pre-procedural EC-CECT in planning AAA repair. ADVANCES IN KNOWLEDGE This study describes the prevalence of significant thoracic pathology, which can impact on AAA repair. This information could potentially change the pre-procedure imaging protocol for patients with AAA.
Collapse
Affiliation(s)
- Salil Karkhanis
- 1 Radiology Department, New Queen Elizabeth Hospital, Birmingham, UK
| | - Shahbaz Patil
- 1 Radiology Department, New Queen Elizabeth Hospital, Birmingham, UK
| | - Edward Td Hoey
- 2 Radiology Department, Birmingham Heartland Hospital, Birmingham, UK
| | - Arul Ganeshan
- 2 Radiology Department, Birmingham Heartland Hospital, Birmingham, UK
| |
Collapse
|
28
|
Incidental findings in emergency imaging: frequency, recommendations, and compliance with consensus guidelines. Emerg Radiol 2016; 23:169-74. [DOI: 10.1007/s10140-016-1378-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 01/14/2016] [Indexed: 12/13/2022]
|
29
|
Population imaging in neuroepidemiology. Neuroepidemiology 2016. [DOI: 10.1016/b978-0-12-802973-2.00005-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
|
30
|
ACR Appropriateness Criteria Acute Nonspecific Chest Pain—Low Probability of Coronary Artery Disease. J Am Coll Radiol 2015; 12:1266-71. [DOI: 10.1016/j.jacr.2015.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/24/2022]
|
31
|
|
32
|
Value of “large FOV” calcium score as a screening method for detection of extracardiac incidental findings. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2015. [DOI: 10.1016/j.ejrnm.2015.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
33
|
Shahir K, McCrea JM, Lozano LAS, Goodman LR. Reduced z-axis technique for CT Pulmonary angiography in pregnancy—validation for practical use and dose reduction. Emerg Radiol 2015; 22:651-6. [DOI: 10.1007/s10140-015-1340-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/13/2015] [Indexed: 12/21/2022]
|
34
|
Callister MEJ, Baldwin DR, Akram AR, Barnard S, Cane P, Draffan J, Franks K, Gleeson F, Graham R, Malhotra P, Prokop M, Rodger K, Subesinghe M, Waller D, Woolhouse I. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 2015; 70 Suppl 2:ii1-ii54. [PMID: 26082159 DOI: 10.1136/thoraxjnl-2015-207168] [Citation(s) in RCA: 560] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- M E J Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - D R Baldwin
- Nottingham University Hospitals, Nottingham, UK
| | - A R Akram
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S Barnard
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle, UK
| | - P Cane
- Department of Histopathology, St Thomas' Hospital, London, UK
| | - J Draffan
- University Hospital of North Tees, Stockton on Tees, UK
| | - K Franks
- Clinical Oncology, St James's Institute of Oncology, Leeds, UK
| | - F Gleeson
- Department of Radiology, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - P Malhotra
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - M Prokop
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - K Rodger
- Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - M Subesinghe
- Department of Radiology, Churchill Hospital, Oxford, UK
| | - D Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - I Woolhouse
- Department of Respiratory Medicine, University Hospitals of Birmingham, Birmingham, UK
| | | | | |
Collapse
|
35
|
Maroules CD, Ghoshhajra BB, Malguria N, Landay M, Hummel J, Ferencik M, Abbara S. Noncardiac Incidental Findings on Cardiac CT: A Step-by-Step Approach. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9283-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
36
|
Goehler A, McMahon PM, Lumish HS, Wu CC, Munshi V, Gilmore M, Chung JH, Ghoshhajra BB, Mark D, Truong QA, Gazelle GS, Hoffmann U. Cost-effectiveness of follow-up of pulmonary nodules incidentally detected on cardiac computed tomographic angiography in patients with suspected coronary artery disease. Circulation 2014; 130:668-75. [PMID: 25015342 DOI: 10.1161/circulationaha.113.007306] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary nodules (PNs) are often detected incidentally during coronary computed tomographic (CT) angiography, which is increasingly being used to evaluate patients with chest pain symptoms. However, the efficiency of following up on incidentally detected PN is unknown. METHODS AND RESULTS We determined demographic and clinical characteristics of stable symptomatic patients referred for coronary CT angiography in whom incidentally detected PNs warranted follow-up. A validated lung cancer simulation model was populated with data from these patients, and clinical and economic consequences of follow-up per Fleischner guidelines versus no follow-up were simulated. Of the 3665 patients referred for coronary CT angiography, 591 (16%) had PNs requiring follow-up. The mean age of patients with PNs was 59±10 years; 66% were male; 67% had ever smoked; and 21% had obstructive coronary artery disease. The projected overall lung cancer incidence was 5.8% in these patients, but the majority died of coronary artery disease (38%) and other causes (57%). Follow-up of PNs was associated with a 4.6% relative reduction in cumulative lung cancer mortality (absolute mortality: follow-up, 4.33% versus non-follow-up, 4.54%), more downstream testing (follow-up, 2.34 CTs per patient versus non-follow-up, 1.01 CTs per patient), and an average increase in quality-adjusted life of 7 days. Costs per quality-adjusted life-year gained were $154 700 to follow up the entire cohort and $129 800 per quality-adjusted life-year when only smokers were included. CONCLUSIONS Follow-up of PNs incidentally detected in patients undergoing coronary CT angiography for chest pain evaluation is associated with a small reduction in lung cancer mortality. However, significant downstream testing contributes to limited efficiency, as demonstrated by a high cost per quality-adjusted life-year, especially in nonsmokers.
Collapse
Affiliation(s)
- Alexander Goehler
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.).
| | - Pamela M McMahon
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Heidi S Lumish
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Carol C Wu
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Vidit Munshi
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Michael Gilmore
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Jonathan H Chung
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Brian B Ghoshhajra
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Daniel Mark
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Quynh A Truong
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - G Scott Gazelle
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| | - Udo Hoffmann
- From the Department of Radiology, Yale University, New Haven, CT (A.G.); Cardiac MR, PET CT Program, Department of Radiology (A.G., H.S.L., B.B.G., Q.A.T., U.H.), Institute for Technology Assessment (A.G., P.M.M., V.M., M.G., G.S.G.), and Department of Cardiology (Q.A.T.), Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA (A.G., P.M.M., C.C.W., B.B.G., Q.A.T., G.S.G., U.H.); Division of Thoracic Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (C.C.W.); Department of Radiology, National Jewish Health, Denver, CO (J.H.C.); Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.M.); and Department of Health Management and Policy, Harvard School of Public Health, Boston, MA (G.S.G.)
| |
Collapse
|
37
|
Raff GL, Chinnaiyan KM, Cury RC, Garcia MT, Hecht HS, Hollander JE, O'Neil B, Taylor AJ, Hoffmann U. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 2014; 8:254-71. [DOI: 10.1016/j.jcct.2014.06.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 02/06/2023]
|
38
|
Erol C, Koplay M, Seker M, Paksoy Y. The prevalence and clinical importance of incidentally detected noncoronary cardiovascular findings with coronary multidetector CT angiography. Wien Klin Wochenschr 2014; 126:460-7. [PMID: 24970312 DOI: 10.1007/s00508-014-0556-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/17/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the prevalence and clinical importance of incidental findings of noncoronary cardiac structures and mediastinal great vessels in patients who underwent coronary computed tomography angiography (CCTA). METHODS The study included 2,096 consecutive patients (1,472 men and 624 women, with a mean age of 55 years). Cardiovascular findings were categorized into three groups according to the clinical importance: group 1 included findings necessitating immediate treatment or intervention; group 2 included findings requiring clinical awareness, follow-up, or further clinical and/or radiological investigations; and group 3 included findings not requiring any follow-up or further tests. We also evaluated whether there was any previous diagnosis of cardiovascular findings. RESULTS A total of 174 abnormalities (8.3 %) were detected in 170 patients. Of these abnormalities, 21 findings (12 %) were considered as group 1, 121 (69.5 %) as group 2, and 32 (18.5 %) as group 3. The majority of cardiovascular findings (140 of 174, 80.5 %) were unknown by the reporter during the interpretation of CCTA examinations and regarded as incidental findings. CONCLUSION Noncoronary incidental cardiovascular findings in patients who underwent CCTA are common. It is important to be aware of these findings necessitating immediate treatment or intervention, and follow-up or further investigations, and careful attention must be paid to all the structures included in the images.
Collapse
Affiliation(s)
- Cengiz Erol
- Department of Radiology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | | | | | | |
Collapse
|
39
|
Dzsinich C, Vaszily M, Vallus G, Berek P, Barta L, Dzsinich M, Darabos G, Nyiri G, Szentpétery L, Pataki T, Nagy G. [Penetrating atheromatous ulcer of the thoracic aorta. Treatment options]. Orv Hetil 2014; 155:461-8. [PMID: 24631934 DOI: 10.1556/oh.2014.29846] [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: 11/19/2022]
Abstract
INTRODUCTIONS Atherosclerosis is a generalized degenerative disease of arteries. A rare manifestation of that is the penetrating atheromatous aortic ulceration of the aortic wall which may be complicated by subintimal hematoma, dissection, false aneurysm and rupture (acute aortic syndrome). AIM The aim of the authors was to analyse their experience with this rare disease. METHOD In the department of the authors 10,212 patients underwent surgery for cardiovascular diseases. Among these, 18 patients were diagnosed with penetrating atheromatous aortic ulceration located in the thoracic aorta (ascending aorta 2, aortic arch 8, descending aorta 6 and thoracoabdominal aorta 2 patients). Severe comorbidities were present in the majority of patients. RESULTS Depending on the localisation the authors used various treatment options such as open surgery (4 patients), hybrid techniques (7 patients) and pure endografting (7 patients). One patient died on postoperative day 3. Two patients had late complications due to endoleaks treated successfully by open surgery. CONCLUSIONS The authors conclude that when this dangerous condition detected in time, a wide variety of open, hybrid and endovascular methods can be applied with good results.
Collapse
Affiliation(s)
- Csaba Dzsinich
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Miklós Vaszily
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gábor Vallus
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Péter Berek
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - László Barta
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Máté Dzsinich
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gábor Darabos
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gabriella Nyiri
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - László Szentpétery
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Tibor Pataki
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gabriella Nagy
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| |
Collapse
|
40
|
Karius P, Schuetz GM, Schlattmann P, Dewey M. Extracardiac findings on coronary CT angiography: A systematic review. J Cardiovasc Comput Tomogr 2014; 8:174-82.e1-6. [DOI: 10.1016/j.jcct.2014.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/03/2014] [Accepted: 04/09/2014] [Indexed: 12/21/2022]
|
41
|
Incidentally detected lung nodules: clinical predictors of adherence to Fleischner Society surveillance guidelines. J Comput Assist Tomogr 2014; 38:89-95. [PMID: 24424558 DOI: 10.1097/rct.0b013e3182a939a5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective of this study was to determine adherence to incidentally detected lung nodule computed tomographic (CT) surveillance recommendations and identify demographic and clinical factors that increase the likelihood of CT surveillance. MATERIALS AND METHODS A total of 419 patients with incidentally detected lung nodules were included. Recorded data included patient demographic, radiologic, and clinical characteristics and outcomes at a 4-year follow-up. Multivariate logistic regression models determined the factors associated with likelihood of recommended CT surveillance. RESULTS At least 1 recommended surveillance chest CT was performed on 48% of the patients (148/310). Computed tomographic result communication to the patient (odds ratio [OR], 2.2; P = 0.006; confidence interval [CI], 1.3-4.0) or to the referring physician (OR, 2.8; P = 0.001; CI, 1.7-4.5) and recommendation of a specific surveillance time interval (OR, 1.7; P = 0.023; CI, 1.08-2.72) increased the likelihood of surveillance. Other demographic, radiologic, and clinical factors did not influence surveillance. CONCLUSIONS Documented physician and patient result communication as well as the recommendation of a specific surveillance time interval increased the likelihood of CT surveillance of incidentally detected lung nodules.
Collapse
|
42
|
Malignant incidental extracardiac findings on cardiac CT: systematic review and meta-analysis. AJR Am J Roentgenol 2013; 201:555-64. [PMID: 23971446 DOI: 10.2214/ajr.12.10306] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective of our study was to systematically review the evidence on incidental extracardiac findings on cardiac CT with a focus on previously unknown malignancies. MATERIALS AND METHODS A systematic search was performed (PubMed, EMBASE, Cochrane databases) for studies reporting incidental extracardiac findings on cardiac CT. Among 1099 articles initially found, 15 studies met the inclusion criteria. The references of those articles were hand-searched and 14 additional studies were identified. After review of the full text, 10 articles were excluded. Nineteen studies including 15,877 patients (64% male) were analyzed. A three-level analysis was performed to determine the prevalence of patients with incidental extracardiac findings, the prevalence of patients with major incidental extracardiac findings, and the prevalence of patients with a proven cancer. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% CI were calculated. RESULTS The prevalence of both incidental extracardiac findings and major incidental extracardiac findings showed a high heterogeneity (I2>95%): The pooled prevalence was 44% (95% CI, 35-54%) and 16% (95% CI, 14-20%), respectively. No significant explanatory variables were found for using or not using contrast material, the size of the FOV, and study design (I2>85%). The pooled cancer prevalence for 10 studies including 5082 patients was 0.7% (95% CI, 0.5-1.0%), with an almost perfect homogeneity (I2<0.1%). Of 29 reported malignancies, 21 (72%) were lung cancers; three, thyroid cancers; two, breast cancers; two, liver cancers; and one, mediastinal lymphoma. CONCLUSION Although the prevalence of reported incidental extracardiac finding at cardiac CT was highly variable, a homogeneous prevalence of previously unknown malignancies was reported across the studies, for a pooled estimate of 0.7%; more than 70% of these previously unknown malignancies were lung cancers. Extracardiac findings on cardiac CT require careful evaluation and reporting.
Collapse
|
43
|
Noncardiac findings in clinical cardiac magnetic resonance: prevalence in 300 examinations after blind reassessment. J Comput Assist Tomogr 2013; 37:382-6. [PMID: 23674009 DOI: 10.1097/rct.0b013e3182845bdb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE To assess the prevalence of noncardiac findings (NCFs) in a consecutive series of 300 cardiac magnetic resonance (CMR) studies. METHODS We retrospectively evaluated CMRs of 192 males and 108 females (42 ± 22 years), comparing findings included in reports to those detected after focused reassessment of CMR images. Noncardiac findings were classified as relevant if additional workup was required. RESULTS We found 19 NCFs, 14 (4.7%) tagged as nonrelevant and 5 (1.7%) as relevant. Images' reassessment presented 45 NCFs, 26 (8.7%) nonrelevant and 16 (5.3%) relevant (P < 0.003). CONCLUSIONS Cardiac magnetic resonance involves the study of areas larger than the heart alone, and NCFs are found in 1 of 7 patients; more than a half of them are not included in the initial CMR report. A small part is relevant, but detection can be unnecessarily stressful and harmful for patients and could increase costs. Risks of overdiagnosis or underreporting are to be taken into account.
Collapse
|
44
|
Dorbala S, Di Carli MF, Delbeke D, Abbara S, DePuey EG, Dilsizian V, Forrester J, Janowitz W, Kaufmann PA, Mahmarian J, Moore SC, Stabin MG, Shreve P. SNMMI/ASNC/SCCT guideline for cardiac SPECT/CT and PET/CT 1.0. J Nucl Med 2013; 54:1485-507. [PMID: 23781013 DOI: 10.2967/jnumed.112.105155] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
|
45
|
Hoffmann U, Venkatesh V, White RD, Woodard PK, Carr JJ, Dorbala S, Earls JP, Jacobs JE, Mammen L, Martin ET, Ryan T, White CS. ACR Appropriateness Criteria(®) acute nonspecific chest pain-low probability of coronary artery disease. J Am Coll Radiol 2013; 9:745-50. [PMID: 23025871 DOI: 10.1016/j.jacr.2012.06.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 06/28/2012] [Indexed: 11/28/2022]
Abstract
This document outlines the usefulness of available diagnostic imaging for patients without known coronary artery disease and at low probability for having coronary artery disease who do not present with classic signs, symptoms, or electrocardiographic abnormalities indicating acute coronary syndrome but rather with nonspecific chest pain leading to a differential diagnosis, including pulmonary, gastrointestinal, or musculoskeletal pathologies. A number of imaging modalities are available to evaluate the broad spectrum of possible pathologies in these patients, such as chest radiography, multidetector CT, MRI, ventilation-perfusion scans, cardiac perfusion scintigraphy, transesophageal and transthoracic echocardiography, PET, spine and rib radiography, barium esophageal and upper gastrointestinal studies, and abdominal ultrasound. It is considered appropriate to start the assessment of these patients with a low-cost, low-risk diagnostic test such as a chest x-ray. Contrast-enhanced gated cardiac and ungated thoracic multidetector CT as well as transthoracic echocardiography are also usually considered as appropriate in the evaluation of these patients as a second step if necessary. A number of rest and stress single-photon emission CT myocardial perfusion imaging, ventilation-perfusion scanning, aortic and chest MR angiographic, and more specific x-ray and abdominal examinations may be appropriate as a third layer of testing, whereas MRI of the heart or coronary arteries and invasive testing such as transesophageal echocardiography or selective coronary angiography are not considered appropriate in these patients. Given the low risk of these patients, it is mandated to minimize radiation exposure as much as possible using advanced and appropriate testing protocols. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Collapse
Affiliation(s)
- Udo Hoffmann
- Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Foster TA, Shapiro MD. The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done, and If So, How? CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9152-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
47
|
Teague SD, Rissing S, Mahenthiran J, Achenbach S. Learning to interpret the extracardiac findings on coronary CT angiography examinations. J Cardiovasc Comput Tomogr 2012; 6:232-45. [DOI: 10.1016/j.jcct.2012.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Revised: 02/04/2012] [Accepted: 02/27/2012] [Indexed: 12/21/2022]
|
48
|
Lee SY, Landis MS, Ross IG, Goela A, Leung AE. Extraspinal Findings at Lumbar Spine CT Examinations: Prevalence and Clinical Importance. Radiology 2012; 263:502-9. [DOI: 10.1148/radiol.12112152] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
49
|
Buckens CF, Verkooijen HM, Gondrie MJ, Jairam P, Mali WP, van der Graaf Y. Unrequested findings on cardiac computed tomography: looking beyond the heart. PLoS One 2012; 7:e32184. [PMID: 22536315 PMCID: PMC3334960 DOI: 10.1371/journal.pone.0032184] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 01/23/2012] [Indexed: 12/21/2022] Open
Abstract
Objectives To determine the prevalence of clinically relevant unrequested extra-cardiac imaging findings on cardiac Computed Tomography (CT) and explanatory factors thereof. Methods A systematic review of studies drawn from online electronic databases followed by meta-analysis with meta-regression was performed. The prevalence of clinically relevant unrequested findings and potentially explanatory variables were extracted (proportion of smokers, mean age of patients, use of full FOV, proportion of men, years since publication). Results Nineteen radiological studies comprising 12922 patients met the inclusion criteria. The pooled prevalence of clinically relevant unrequested findings was 13% (95% confidence interval 9–18, range: 3–39%). The large differences in prevalence observed were not explained by the predefined (potentially explanatory) variables. Conclusions Clinically relevant extra-cardiac findings are common in patients undergoing routine cardiac CT, and their prevalence differs substantially between studies. These differences may be due to unreported factors such as different definitions of clinical relevance and differences between populations. We present suggestions for basic reporting which may improve the interpretability and comparability of future research.
Collapse
|
50
|
Christiaens L, Duchat F, Boudiaf M, Tasu JP, Fargeaudou Y, Ledref O, Soyer P, Sirol M. Impact of 64-slice coronary CT on the management of patients presenting with acute chest pain: results of a prospective two-centre study. Eur Radiol 2011; 22:1050-8. [DOI: 10.1007/s00330-011-2354-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 11/09/2011] [Accepted: 11/12/2011] [Indexed: 01/05/2023]
|