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Robinson JD, Kessler R, Vrablik ME, Vrablik MC, Hippe DS, Hall MK, Mitchell SH, Linnau KF. Transfer Patient Imaging: Assessment of the Impact of Discrepancies Identified by Emergency Radiologists. J Am Coll Radiol 2022; 19:1244-1252. [PMID: 35973650 PMCID: PMC10695447 DOI: 10.1016/j.jacr.2022.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Advanced imaging examinations of emergently transferred patients (ETPs) are overread to various degrees by receiving institutions. The practical clinical impact of these second opinions has not been studied in the past. The purpose of this study is to determine if emergency radiology overreads change emergency medicine decision making on ETPs in the emergency department (ED). METHODS All CT and MRI examinations on patients transferred to a level I trauma center during calendar year 2018 were routinely overread by emergency radiologists and discrepancies with the outside report electronically flagged. All discrepant reports compared with the outside interpretations were reviewed by one of four emergency medicine physicians. Comparing the original and final reports, reviewers identified changes in patient management that could be attributed to the additional information contained in the final report. Changes in patient care were categorized as affecting ED management, disposition, follow-up, or consulting services. RESULTS Over a 12-month period, 5,834 patients were accepted in transfer. Among 5,631 CT or MRI examinations with outside reports available, 669 examinations (12%) had at least one discrepancy in the corresponding outside report. In 219 examinations (33%), ED management was changed by discrepancies noted on the final report; patient disposition was affected in 84 (13%), outpatient follow-up in 54 (8%), and selection of consulting services in 411 (61%), and ED stay was extended in 544 (81%). Discrepant findings affected decision making in 613 of 669 of examinations (92%). CONCLUSION Emergency radiology overreading of transferred patients' advanced imaging examinations provided actionable additional information to emergency medicine physicians in the care of 613 of 669 (92%) examinations with discrepant findings. This added value is worth the effort to design workflows to routinely overread CT and MRI examinations of ETPs.
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Affiliation(s)
| | - Ross Kessler
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Michael E Vrablik
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Marie C Vrablik
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Clinical Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - M Kennedy Hall
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Steven H Mitchell
- Department of Emergency Medicine, University of Washington, Seattle, Washington; Medical Director, Emergency Services, Harborview Medical Center, Seattle, Washington
| | - Ken F Linnau
- Department of Radiology, University of Washington, Seattle, Washington; Assistant Chief of Service, Department of Radiology, Harborview Medical Center, Seattle, Washington
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Miller JP, Ivanics C, Zalewski K, Mody SS, Kannikeswaran N. Rates and clinical impact of discordant X-ray and CT imaging in transfers to a pediatric emergency department. Am J Emerg Med 2021; 49:166-171. [PMID: 34126562 DOI: 10.1016/j.ajem.2021.05.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/13/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Children are often transferred to a Pediatric Emergency Department (PED) for definitive care after completion of diagnostic imaging. There is a paucity of data on the concordance rates of interpretation of imaging studies between referral and PED. Our objective is to describe the rates and clinical impact of discordant interpretation of X-rays and CT in children transferred to a PED. METHODS This was a retrospective cohort study of patients over a 12-month period from 12/1/2017-11/30/2018 with X-ray (XR) and CT performed prior to transfer to our PED. We compared referral radiology interpretations to those of pediatric radiologists to determine concordance. Encounters with discordant imaging interpretations were further evaluated for clinical impact (none, minor or major) based on need for additional laboratory workup, consultation, and changes in management and disposition. RESULTS We analyzed 899 patient encounters. There were high rates of concordance in both XR and CT interpretation (668/743; 89.9%, 95% CI 0.87-0.91 and 205/235; 87.2%, 95% CI 0.82-0.91, respectively). XR discordance resulted in minor clinical impact in 34 patients (45%, 95% CI 0.35-0.57) and a major clinical impact in 28 patients (37%, 95% CI 0.27-0.49). CT discordance resulted in minor clinical impact in 10 patients (33%, 95% CI 0.19-0.51) of patients and major clinical impact in 15 patients (50%, 95% CI 0.33-0.67). The most common discordances with major clinical impact were related to pneumonia on XR chest and appendicitis or inflammatory bowel disease on CT abdomen. CONCLUSIONS In patients transferred to the PED, concordance of XR and CT interpretations was high. A majority of discordant interpretations led to clinical impact meaningful to the patient and emergency medicine (EM) physician. Referring EM physicians might consider the benefit of pediatric radiology consultation upon transfer, especially for imaging diagnoses related to pneumonia, appendicitis, or inflammatory bowel disease.
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Affiliation(s)
- Jason P Miller
- Children's Hospital of Michigan, Division of Emergency Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, United States; Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States; Central Michigan University School of Medicine, 1280 East Campus Dr, Mt Pleasant, MI 48858, United States.
| | - Ciara Ivanics
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States
| | - Kristina Zalewski
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States
| | - Swati S Mody
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States; Children's Hospital of Michigan, Department of Radiology, 3901 Beaubien Blvd, Detroit, MI 48201, United States
| | - Nirupama Kannikeswaran
- Children's Hospital of Michigan, Division of Emergency Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, United States; Central Michigan University School of Medicine, 1280 East Campus Dr, Mt Pleasant, MI 48858, United States
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Impact of a statewide computed tomography scan educational campaign on radiation dose and repeat CT scan rates for transferred injured children. J Clin Transl Sci 2021; 5:e129. [PMID: 34367674 PMCID: PMC8327550 DOI: 10.1017/cts.2021.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign's impact on injured children received radiation dose. Methods All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. Results Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). Conclusion A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.
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Filev PD, Little BP, Duong PAT. Second-Opinion Reads in Interstitial Lung Disease Imaging: Added Value of Subspecialty Interpretation. J Am Coll Radiol 2020; 17:786-790. [PMID: 31930981 DOI: 10.1016/j.jacr.2019.12.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to determine how often a second-opinion interpretation of interstitial lung disease (ILD) by an academic cardiothoracic radiologist is discordant with the initial interpretation by a nonacademic radiologists and how often the clinical diagnosis determined by multidisciplinary consensus agrees with the initial and second-opinion interpretations. METHODS This retrospective study included 364 consecutive second-opinion CT examination reports of imaging from nonacademic radiology practices from July 2014 to May 2016. The second-opinion interpretations, provided by seven fellowship-trained cardiothoracic radiologists, were compared with the initial interpretations and the clinical diagnoses determined by multidisciplinary consensus. RESULTS Two hundred ninety-six consecutive reports met the inclusion criteria, and two hundred had findings of ILD. The initial interpretations lacked specific diagnoses in 41% of reports, but the second-opinion reports lacked specific diagnoses in only 7%. When a diagnosis was provided, the second-opinion diagnosis disagreed with the initial interpretation in 25% of cases. The clinical-consensus diagnosis was concordant with that of the academic radiologists 85% of the time but concordant with the initial interpretation only 44% of the time. The academic radiologists' diagnostic sensitivity was higher than that of the initial radiologists for the four most common diagnoses: usual interstitial pneumonitis (0.91 versus 0.4), sarcoidosis (0.94 versus 0.60), hypersensitivity pneumonitis (0.79 versus 0.17), and nonspecific interstitial pneumonitis (0.72 versus 0.14). CONCLUSIONS Academic cardiothoracic radiologists were more likely to provide specific diagnoses for ILD, and these diagnoses were more likely to be concordant with the multidisciplinary consensus.
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Affiliation(s)
- Peter D Filev
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia
| | - Brent P Little
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Phuong-Anh T Duong
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah.
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Hassan N, Butler C, DeCou J, Crumb T, Flohr S, Reischman D, Junewick J. Pediatric cervical spine injuries on CT: difference in accuracy of interpretations by pediatric versus non-pediatric radiologists. Emerg Radiol 2019; 27:185-190. [PMID: 31820269 DOI: 10.1007/s10140-019-01743-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 11/01/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To retrospectively compare the accuracy of interpretation of initial cervical computerized tomography (CCT) by a non-pediatric radiologist (NPR) versus a pediatric radiologist (PR). METHODS IRB approval and consent waiver were granted to review all injured children from 2010 to 2014 in the trauma registry with CT and magnetic resonance imaging (MRI) of the cervical spine. Patients with negative CCT who subsequently had positive MRI from a single institution comprised the study group. Patients with negative CCT and MRI, matched by age, gender, and severity scores, comprised the control group. The CCTs from both groups were initially interpreted at the time of service by a NPR. Subsequently, a single PR with 20 years of experience blinded to clinical/imaging data reinterpreted these CCT examinations. CT interpretations were then compared with MRI results and evaluated for statistical significance using SSPS software. The data analysis utilized summary statistics, two-tailed binomial test, and univariate χ2 test. Significance for all comparisons was assessed at P < 0.05. RESULTS The study group was comprised of the 21 patients with negative CCT and positive MRI. Of the cohort included, 76% (16) were male and 24% (5) were female. The age range was 1 month-17 years, with a mean age of 9.7 years. CCT interpretation by NPR had a specificity of 91.7% (sensitivity 71.2%, positive predictive value 81.3%, and negative predictive value 86.3%) compared with results of MRI. Six of the 21 negative CCTs were interpreted by the PR as positive, mainly craniocervical junction injuries, and confirmed by MRI (28.6%, P < .001 compared with the NPR); no control CCT was interpreted by the PR as positive (sensitivity 100%, positive predictive value 100%, and negative predictive value 58.3%). CONCLUSION In our retrospective study, a pediatric radiologist has improved recognition of pediatric cervical spine injuries on CT compared with non-pediatric radiologist.
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Affiliation(s)
- Nabil Hassan
- Division of Pediatric Critical Care, OSF Healthcare Children's Hospital of Illinois, 530 NE Glen Oak Ave, Peoria, IL, 61637, USA
| | - Chloe Butler
- Mercy Medical Center, P.O. Box 14584, Des Moines, IA, 50306-3584, USA
| | - James DeCou
- Department of Surgery, Helen DeVos Children's Hospital, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
| | - Teri Crumb
- Department of Surgery, Helen DeVos Children's Hospital, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
| | - Stephanie Flohr
- Department of Surgery, Helen DeVos Children's Hospital, 100 Michigan St. NE, Grand Rapids, MI, 49503, USA
| | - Diann Reischman
- Department of Epidemiology, Grand Valley State University, A-1-178 Mackinac Hall, Allendale, MI, 49401, USA
| | - Joseph Junewick
- Advanced Radiology Services PC, Grand Rapids, MI, USA. .,Michigan State University College of Human Medicine, Grand Rapids, MI, USA. .,Department of Radiology, Helen DeVos Children's Hospital, 100 Michigan Street, Grand Rapids, MI, 49503, USA.
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Mahalingam S, Bhalla NM, Mezrich JL. Curbside consults: Practices, pitfalls and legal issues. Clin Imaging 2019; 57:83-86. [DOI: 10.1016/j.clinimag.2019.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/28/2019] [Accepted: 05/20/2019] [Indexed: 11/25/2022]
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Glavis-Bloom J, Yang U, Nahl D, Goodarzian F, Sura A. Ensuring Appropriateness of Pediatric Second Opinion Consultations. Curr Probl Diagn Radiol 2019; 49:82-84. [PMID: 31147095 DOI: 10.1067/j.cpradiol.2019.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/10/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE We sought to evaluate discrepancy rates between outside interpretations, radiology trainee preliminary reports, and subspecialist attending final interpretations for pediatric second opinion consultations on plain film and computed tomography imaging and to evaluate the impact of a process improvement for second opinion consultations. METHODS Of a total of 572 requests for second opinion consultations during 1-year preintervention period, we utilized RADPEER to score concurrence of 158 requests which occurred overnight and included outside radiologist interpretations and resident preliminary reports. In consultation with clinician committees, we developed new guidelines for requesting second opinion consultations. We evaluated the impact on the number of consultations for the 1-year period following implementation of this process improvement. RESULTS There was concurrence between the outside interpretation and pediatric subspecialist second opinion in 146 of 158 cases (92%). There was concurrence between the radiology resident and pediatric subspecialist second opinion in 145 of 158 cases (92%). During the 1-year period following our process improvement implementation, the total number of second opinion consultations decreased to 185 (from 572, a decrease of 68%) and the number of overnight requests for resident preliminary reports decreased to 11 (from 158, a decrease of 93%). CONCLUSIONS There was a high degree of concurrence between interpretations provided by outside radiologists, overnight radiology residents, and attending pediatric radiologists at our institution. Analyzing institutional-specific discrepancy rates is a valuable first step in partnering with clinicians to develop appropriate guidelines for second opinion consultations.
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Affiliation(s)
- Justin Glavis-Bloom
- Department of Radiological Sciences, University of California Irvine, Orange, CA
| | - Unikora Yang
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Daniel Nahl
- Department of Diagnostic Imaging, Children's Hospital of Orange County, Orange, CA
| | - Fariba Goodarzian
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA
| | - Amit Sura
- Department of Radiology, Children's Hospital Los Angeles, Los Angeles, CA.
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JOURNAL CLUB: Hepatopancreaticobiliary Imaging Second-Opinion Consultations: Is There Value in the Second Reading? AJR Am J Roentgenol 2018; 211:1264-1272. [DOI: 10.2214/ajr.17.19452] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rosenkrantz AB, Duszak R, Babb JS, Glover M, Kang SK. Discrepancy Rates and Clinical Impact of Imaging Secondary Interpretations: A Systematic Review and Meta-Analysis. J Am Coll Radiol 2018; 15:1222-1231. [DOI: 10.1016/j.jacr.2018.05.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/26/2018] [Accepted: 05/31/2018] [Indexed: 12/27/2022]
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Added value of double reading in diagnostic radiology,a systematic review. Insights Imaging 2018; 9:287-301. [PMID: 29594850 PMCID: PMC5990995 DOI: 10.1007/s13244-018-0599-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/10/2018] [Accepted: 01/15/2018] [Indexed: 01/10/2023] Open
Abstract
Objectives Double reading in diagnostic radiology can find discrepancies in the original report, but a systematic program of double reading is resource consuming. There are conflicting opinions on the value of double reading. The purpose of the current study was to perform a systematic review on the value of double reading. Methods A systematic review was performed to find studies calculating the rate of misses and overcalls with the aim of establishing the added value of double reading by human observers. Results The literature search resulted in 1610 hits. After abstract and full-text reading, 46 articles were selected for analysis. The rate of discrepancy varied from 0.4 to 22% depending on study setting. Double reading by a sub-specialist, in general, led to high rates of changed reports. Conclusions The systematic review found rather low discrepancy rates. The benefit of double reading must be balanced by the considerable number of working hours a systematic double-reading scheme requires. A more profitable scheme might be to use systematic double reading for selected, high-risk examination types. A second conclusion is that there seems to be a value of sub-specialisation for increased report quality. A consequent implementation of this would have far-reaching organisational effects. Key Points • In double reading, two or more radiologists read the same images. • A systematic literature review was performed. • The discrepancy rates varied from 0.4 to 22% in various studies. • Double reading by sub-specialists found high discrepancy rates. Electronic supplementary material The online version of this article (10.1007/s13244-018-0599-0) contains supplementary material, which is available to authorised users.
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Diagnostic Accuracy of MRI Versus CT for the Evaluation of Acute Appendicitis in Children and Young Adults. AJR Am J Roentgenol 2017; 209:911-919. [PMID: 28796552 DOI: 10.2214/ajr.16.17413] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Appendicitis is frequently diagnosed in the emergency department, most commonly using CT. The purpose of this study was to compare the diagnostic accuracy of contrast-enhanced MRI with that of contrast-enhanced CT for the diagnosis of appendicitis in adolescents when interpreted by abdominal radiologists and pediatric radiologists. SUBJECTS AND METHODS Our study included a prospectively enrolled cohort of 48 patients (12-20 years old) with nontraumatic abdominal pain who underwent CT and MRI. Fellowship-trained abdominal and pediatric radiologists reviewed all CT and MRI studies in randomized order, blinded to patient outcome. Likelihood for appendicitis was rated on a 5-point scale (1, definitely not appendicitis; 5, definitely appendicitis) for CT, the unenhanced portion of the MRI, and the entire contrast-enhanced MRI study. ROC curves were generated and AUC compared for each scan type for all six readers and then stratified by radiologist type. Image test characteristics, interrater reliability, and reading times were compared. RESULTS Sensitivity and specificity were 85.9% (95% CI, 76.2-92.7%) and 93.8% (95% CI, 89.7-96.7%) for unenhanced MRI, 93.6% (95% CI, 85.6-97.9%) and 94.3% (95% CI, 90.2-97%) for contrast-enhanced MRI, and 93.6% (95% CI, 85.6-97.9%) and 94.3% (95% CI, 90.2-97%) for CT. No difference was found in the diagnostic accuracy or interpretation time when comparing abdominal radiologists to pediatric radiologists (CT, 3.0 min vs 2.8 min; contrast-enhanced MRI, 2.4 min vs 1.8 min; unenhanced MRI, 1.5 min vs 2.3 min). Substantial agreement between abdominal and pediatric radiologists was seen for all methods (κ = 0.72-0.83). CONCLUSION The diagnostic accuracy of MRI to diagnose appendicitis was very similar to CT. No statistically significant difference in accuracy was observed between imaging modality or radiologist subspecialty.
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Peng N, Wang X, Zhang Z, Fu S, Fan J, Zhang Y. Diagnosis value of multi-slice spiral CT in renal trauma. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2016; 24:649-655. [PMID: 27392829 DOI: 10.3233/xst-160585] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Computed tomography (CT) is most commonly used as a noninvasive approach in diagnosis of internal organ injures. Use of multi-slice spiral CT becomes more popular in diagnosis of trauma because of its ability to generate 3D volumetric information. This study evaluated the diagnostic value of multi-slice spiral computed tomography (MSCT) with enhanced scanning in renal trauma. In total, 126 patients with kidney injury underwent MSCT scanning from a single hospital in the southern of China between January 2012 and February 2016. According to kidney injury grading standards of American Association for the Surgery of Trauma (AAST), 30 were diagnosed and classified in level I, 26 in level II, 42 in level III, 17 in level IV, 11 in level V. The outcomes of MSCT enhanced scanning achieve a 100% diagnostic accuracy rate, which was confirmed by surgical findings. We concluded that the enhanced MSCT scan permits reliable detection of renal trauma and the associated organ or tissue injuries, providing important clinical value for the diagnosis and classification of renal trauma or internal organ injures.
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Affiliation(s)
- Naixiong Peng
- Department of Urology, Shenzhen Longhua New District Central hospital, Shenzhen, Guangdong, China
| | - Xisheng Wang
- Department of Urology, Shenzhen Longhua New District Central hospital, Shenzhen, Guangdong, China
| | - Zejian Zhang
- Department of Urology, Shenzhen Longhua New District Central hospital, Shenzhen, Guangdong, China
| | - Shui Fu
- Department of Urology, Shenzhen Longhua New District Central hospital, Shenzhen, Guangdong, China
| | - Jiqing Fan
- Department of Urology, Shenzhen Longhua New District Central hospital, Shenzhen, Guangdong, China
| | - Yuanyuan Zhang
- Wake Forest Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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