A review of full-body radiography in nontraumatic emergency medicine

Identification of ureteral stones at reduced radiation exposure: a pilot study comparing conventional versus digital low-dosage linear slot scanning (Lodox®) radiography

PURPOSE

Digital low-dosage, linear slot scanning radiography (Lodox^®) is an imaging modality that can emit down to one-tenth the radiation of conventional X-ray systems. We prospectively evaluated Lodox^® as a diagnostic imaging modality in patients with ureterolithiasis.

METHODS

Conventional kidney-ureter-bladder (KUB) X-ray and Lodox^® were performed in 41 patients presenting with acute flank pain due to unilateral ureteral stone confirmed by computed tomography. KUB X-ray and Lodox^® images were then reviewed by four blinded readers (urology expert/resident, radiology expert/resident). Identification rates were compared using Pearson's Chi square test. The impact of different parameters on stone identification by Lodox^® was evaluated using logistic regression and generalized linear mixed models. Inter-reader agreement was tested using Cohen's kappa coefficient.

RESULTS

Median stone size was 5 mm (range 2-12), median stone density was 800 HU (range 200-1500). The identification rates of the urology expert were 68% for KUB X-ray and 90% for Lodox^® (p = 0.014), and for all four readers 61% for KUB X-ray and 62% for Lodox^® (p = 0.8). Radiation exposure for KUB X-ray and Lodox^® was 0.45 mSv (SD ± 0.64) and 0.027 mSv (SD ± 0.038), respectively. Multivariable analyses showed an association between stone identification by Lodox^® and stone size (p < 0.001), stone density (p = 0.005), lower body mass index (p = 0.005), and reader (p < 0.001).

CONCLUSIONS

The high identification rates and low radiation doses of Lodox^® make it a promising imaging modality for the diagnosis of ureteral stones. Further validation in larger cohorts, including performance evaluation for renal stones, is warranted.

TRIAL REGISTRATION

http://www.controlled-trails.com/ISRCTN12915426.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Death of a Female Prostitute Due to Intestinal Obstruction by an Unknown Substance

A young adult black female, known to be a prostitute and suspected of smuggling narcotics, was found dead in her apartment in a state of early decomposition. Oval-shaped gray-white masses of exogenous origin protruded from the anus. The autopsy showed dilatation of the folds of the large intestine, which were almost completely filled with these oval-shaped gray-white masses of foreign material. The uterus was enlarged with multiple large leiomyomas. Toxicological tests of blood and the foreign material revealed no toxicologically relevant substances. Kaolin was detected in a sample of the foreign material from the large intestine. The immediate cause of death was intestinal obstruction due to the formation of a kaolin bezoar with simultaneous compression of the large intestine by the enlarged myomatous uterus. Subsequent revelation of a habit the deceased had brought from her native country led to the conclusion that this exotic custom was responsible for her death.

Use of a full-body digital X-ray imaging system in acute medical emergencies: a systematic review

BACKGROUND

To evaluate the available evidence for the clinical effectiveness and biohazard safety of a full-body digital X-ray imaging system (Lodox) in acute medical emergencies.

METHODS

Electronic databases (including PubMed, Embase and the Cochrane Library; up to January 2014) and reference lists of articles were searched. The quality of the included studies was determined, and a narrative assessment was undertaken.

RESULTS

A total of 256 articles were reviewed. Fifteen clinical studies and eight case series met the eligibility criteria. All 23 studies reporting use of a full-body X-ray imaging system in acute medical emergencies on Lodox. Based on figures in six studies comprising various evaluation methods, image quality of Lodox was mostly comparable to that of conventional X-rays and the radiation dose was considerably lower. Lodox demonstrated a sensitivity ranging from 62% to 73%, and a specificity ranging from 99% to 100% compared with CT for the evaluation of emergency patients with polytrauma, which is similar to that of conventional X-rays. Examination time using Lodox ranged from 3.5  to 13.9 min compared with 8 to 25.7 min using conventional X-rays. However, there was no evidence it significantly shortened resuscitation time or emergency department length of stay. Publication bias might have occurred; some published studies might have been influenced by conflicts of interest.

CONCLUSIONS

The Lodox machine is capable of rapidly scanning the entire body and offers an equivalent diagnostic assessment tool compared with conventional X-rays. It seems to have the potential to reduce cumulative radiation dosage for emergency patients compared with conventional X-rays. Application of Lodox might be helpful to reduce resource use and simplify care in lower-resourced areas.