Advanced Diagnostic Imaging Research Articles

Undiagnosed fatal malignancy in adult autopsies: a 10-year retrospective study

Autopsies reveal undiagnosed malignancies even in this era of modern diagnostic imaging and ancillary laboratory studies. The incidence of clinically undiagnosed malignancies related to primary cause of death in a university hospital setting has rarely been studied. Our objective was to determine the incidence of clinically undiagnosed fatal malignancies in an urban teaching hospital and to assess whether this incidence was influenced by the duration of hospital stay. We performed a retrospective analysis of consecutive adult hospital autopsies in which the primary cause of death was related to undiagnosed malignancy. The detailed autopsy report, clinical records, and relevant laboratory results from laboratory and hospital databases were reviewed. Eight hundred twenty-one adult autopsies were performed over 10 years. Sixty-nine clinically undiagnosed malignant neoplasms were found in 66 cases (8%). In 26 of these 66 cases, the undiagnosed malignant neoplasm was related to the primary cause of death (3.1%). The duration of hospital stay was less than 24 hours in 8 cases (30.7%), 2 to 7 days in 9 cases (34.6%), and greater than 7 days in 9 cases (34.6%). In 10 of these 26 cases (1.2%), there was suspicion of malignancy without definitive tissue diagnosis, and the average hospital stay was 4.9 days. In 16 (1.9%) of these 26 cases, malignancy was not clinically suspected, and the average hospital stay was 9.9 days. We conclude that despite the recent advances in diagnostic imaging and laboratory techniques, a subset of adult autopsies (3.1%) performed in an urban university hospital have clinically undiagnosed malignancy related to the primary cause of death. Malignancy was not clinically suspected in 1.9% of these cases. There is a need to conduct comprehensive "root cause" analysis in these cases for improvement of clinical care.

Percutaneous treatment of liver metastases

Early detection of metastatic disease within the liver by advanced diagnostic imaging has driven the rise of image-guided intervention for hepatic metastases. In this talk, we will explore the rationale, indications, technique and post procedure imaging findings of percutaneous treatments of liver metastases. Curative intent ablative therapies, such as radiofrequency ablation, microwave ablation, cryoablation, and irreversible electroporation will be discussed, including the common pitfalls of reading post ablative imaging studies. In addition, bridging and palliative therapies embolotherapies for liver dominant metastatic disease, such as hepatic artery embolization, transarterial chemoembolization, drug eluting beads, and yttrium-90 selective internal radiation therapy, will be reviewed.

Use of Computed Tomography in Children Is on the Decline

Computed tomography (CT) was a significant advancement in diagnostic imaging when it was developed more than 30 years ago. However, CT use in pediatrics might be declining, largely due to concerns overexposing children to the typical dosages of ionizing radiation. To examine recent shifts in the use of CT in children and to determine whether changes were associated with shifts to alternate …

Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis.

Advanced diagnostic imaging is commonly used in the evaluation of suspected appendicitis in children. Despite its inferior diagnostic performance, ultrasonography (US) is now preferred to computed tomography (CT) owing to concerns about ionizing radiation exposure. With changes in imaging modalities, the influence on outcomes should be assessed. To review trends in the use of US and CT for children with appendicitis and to investigate simultaneous changes in the proportions of negative appendectomy, appendiceal perforation, and emergency department (ED) revisits. We reviewed the Pediatric Health Information System administrative database for children who presented to the ED with the diagnosis of appendicitis or who underwent an appendectomy in 35 US pediatric institutions from January 1, 2010, through December 31, 2013. We studied the use of US and CT for trends and their association with negative appendectomy, appendiceal perforation, and 3-day ED revisits. Our investigation included 52,153 children with appendicitis. Use of US increased 46% (from 24.0% in 2010 to 35.3% in 2013; absolute difference, 11.3%; adjusted test for linear trend, P = .02), whereas use of CT decreased 48% (from 21.4% in 2010 to 11.6% in 2013; absolute difference, -9.8%; adjusted test for linear trend, P < .001). The proportion of negative appendectomy declined during the 4-year study period from 4.7% in 2010 to 3.6% in 2013 (test for linear trend, P = .002), whereas the proportion of perforations (32.3% in 2010 to 31.9% in 2013) and ED revisits (5.6% in 2010 and 2013) did not change (adjusted tests for linear trend, P = .64 and P = .84, respectively). Among children with suspected appendicitis, the use of US imaging has increased substantially as the use of CT has declined. Despite the increased reliance on the diagnostically inferior US, important condition-specific quality measures, including the frequency of appendiceal perforation and ED revisits, remained stable, and the proportion of negative appendectomy declined slightly.

Appropriateness of advanced diagnostic imaging ordering before and after implementation of clinical decision support systems.

Appropriateness of advanced diagnostic imaging ordering before and after implementation of clinical decision support systems.

Effects of fully accessible magnetic resonance imaging in the emergency department.

The Joint Commission Comprehensive Stroke Center certification requires that magnetic resonance imaging (MRI) be available on site, 24hours a day, 7days a week for evaluation of stroke in emergency department (ED) patients. Increased access to advanced diagnostic imaging has been shown to increase utilization, ED length of stay (LOS), and health care costs. EDs nationwide face decisions to pursue certification and increase MRI access. Understanding changes in utilization and the downstream effects may inform these decisions. The objective was to determine changes in emergency MRI utilization following placement of a 24/7 accessible MRI in the ED and its effects on resource utilization for rule-out stroke and neurology consult patients. This was a retrospective cohort study comparing MRI use during the 32months before and 26months after MRI acquisition period in the ED of a Level I trauma and stroke center. An interrupted time-series design was used to account for changes in clinical practice patterns following MRI acquisition. Time-series plots and segmented regression analyses are presented to compare utilization patterns pre- and post-MRI and to understand potential confounding due to secular trends. Statistical hypothesis testing was used to determine differences in utilization, demographics, and clinical characteristics for cohorts pre- and post-MRI. MRI utilization in the ED increased 38.4% for rule-out stroke and 51.4% for neurology consult patients after MRI acquisition. The proportion of rule-out stroke patients receiving MRI increased from 32.5% pre-MRI to 45.0% post-MRI (p<0.001). The proportion of neurology consult patients increased from 32.6% pre-MRI to 49.4% post-MRI (p<0.001). Considering baseline increases in MRI utilization rates for both cohorts over time, segmented regression models detected more substantial and significant changes in utilization after MRI acquisition for the larger neurology cohort (p<0.001) compared to the rule-out stroke cohort (p=0.095). However, hospital admission rates declined 16.7% for rule-out stroke patients (68.2% pre, 56.8% post; p<0.001) and remained constant for neurology patients (56.5% pre, 57.5% post; p=0.414). Patients who obtained MRI in the ED had increased ED LOS, but decreased hospital LOS (admitted patients), compared to those with no MRI for pre and post cohorts. Emergency MRI utilization increased substantially after placement of a fully accessible MRI in the ED. Patients receiving emergency MRI had increased ED LOS, decreased admission rates for some patients (rule-out stroke), and reduced hospital LOS for those admitted. Potential changes in ED patient resource utilization should be considered when determining whether to acquire an MRI for Comprehensive Stroke Center certification.

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial.

BackgroundMissed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge.Methods/DesignWe propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality.DiscussionThe findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders.Trial registrationANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-0733-y) contains supplementary material, which is available to authorized users.

Traumatic odontoid process synchondrosis fracture with atlantoaxial instability in a calf: clinical presentation and imaging findings.

A 6-week-old female Simmental calf was evaluated for acute non-ambulatory tetraparesis. Physical and laboratory examinations revealed no clinically relevant abnormalities. Neurological findings were consistent with acute, progressive and painful cervical myelopathy. Radiographs displayed a fractured odontoid process (dens axis) and vertebral step misalignment at the fracture site. A traumatic origin was suspected. Advanced diagnostic imaging was considered to allow better planning of potential surgical stabilisation and to exclude any additional lesions of the cervical vertebral column. However, during trailer transportation to the advanced diagnostic imaging and surgery site, the calf deteriorated neurologically and was humanely euthanised. Magnetic resonance imaging (MRI) and computed tomography (CT) were performed immediately post-mortem for scientific reasons. The MRI examination reflected the radiographic findings and confirmed severe spinal cord compression at the fracture site. In addition, a T2W-hyperintense signal change within the paravertebral soft tissue dorsal to the fracture site was indicative of a traumatic event. CT identified the fracture site at the synchondrosis between the odontoid process and the body of the axis, and this finding was confirmed by post-mortem examination. Advanced diagnostic imaging and post-mortem examination did not identify any other cervical lesion. In summary, this calf was diagnosed with a traumatic odontoid process synchondrosis fracture, which has not been reported previously in calves but presents a challenging and well-known fracture type in young children. This case report indicates that the odontoid process synchondrosis is a potential predisposed injury site and that traumatic odontoid process synchondrosis fractures should be considered as a potential differential in calves with acute cervical pain and/or signs of a cervical myelopathy.

Emergency physician perceptions of shared decision-making.

Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated. As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM. A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose." Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.

Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.

The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice. As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented. In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.

Imaging of congenital lung malformations

Congenital lung malformations are a heterogeneous group of anomalies that involve the lungs and tracheobronchial tree (congenital airway pulmonary malformation, bronchial atresia, bronchogenic cyst, congenital lobar overinflation, pulmonary cyst, hamartoma, pulmonary isomerism and azygous lobe), vascular abnormalities (arteriovenous malformations, anomalous pulmonary venous return, pulmonary artery sling, interrupted pulmonary artery, pulmonary varix, pulmonary vein stenosis and pulmonary lymphangiectasia), or frequently both entities (pulmonary sequestration, pulmonary maldevelopment and scimitar syndrome). Advances in diagnostic imaging (including sonography, multi-detector computer tomography, magnetic resonance imaging and angiography) have increased their detection during both antenatal and postnatal periods, and radiological characterisation, which in turn influence patient counselling and management stratification. An educational illustration of the clinical application in characterisation of these malformations is presented.

Abstract W MP15: Use of Multimodal Imaging for Thrombolysis-Eligible Stroke Patients Presenting to Hospitals in a Large Urban Region

Introduction: Advances in diagnostic imaging of stroke include the use of multimodal techniques, including noninvasive angiography to evaluate the intracranial and cervical vasculature as well as perfusion imaging. Despite increased adoption of these imaging techniques in academic medical centers, the current practice of multimodal imaging utilization among stroke patients in the community has remained largely uncharacterized. Methods: We quantified neuroimaging utilization in the ED among 1700 hyperacute stroke patients participating in the NIH Field Administration of Stroke Therapy Magnesium (FAST-MAG) study throughout Los Angeles and Orange Counties. Subjects were enrolled in the field &lt;2 hours from symptom onset and transported to their usual care hospital, one of 58 centers throughout a single urban region. There was no recommendation as to what type of imaging should be utilized. Results: Of 1700 cases 1699 were imaged a median (IQR) of 92 (74-120) minutes after last known well time and 28 (19-40.75) minutes after ED arrival. The mean age was 71 (SD13) years old and the final diagnosis was cerebral ischemia in 73%, intracerebral hemorrhage in 23%, and mimic in 4%. Initial imaging scanner used in the ED was CT in a preponderance of cases (N=1612, 95%), with MRI in 88 cases (5%). Parenchymal CT scan was almost always performed without contrast and most commonly as the only study. However, CT angiography was obtained in 192 (11%) and perfusion CT in 91 (5.4%) cases in the first 24 hours. MRI imaging was universally obtained using diffusion-weighted images, 60% with MR angiography and 33% included perfusion imaging. Rates of multimodal (CTA and/or CTP) CT imaging utilization increased in the later years of the study from 4% in 2005-2006, 2% in 2007-2008, 8% in 2009-2010 and 26% in 2011-2012 (p for trend &lt;0.001). There was no change in rates of multimodal MRI imaging as one academic medical center accounted for &gt;80% of all studies. Conclusions: Among acute stroke patients presenting in the time window for TPA use, noncontrast CT was the most common initial imaging strategy in clinical practice in the 2005-2012 time period, though use of concomitant CTA grew to one-quarter of cases.

Vascular myelopathies.

Vascular myelopathies include several diagnoses that are often misdiagnosed or undertreated. Some represent neurologic emergencies, such as spinal cord infarction, and others can be disabling if they remain unrecognized, such as spinal dural arteriovenous fistulas. This review describes the clinical characteristics and current therapeutic strategies for the most common vascular myelopathies and emphasizes practical concepts for the clinician. Although none of the vascular myelopathies have been studied in large prospective studies and their treatments have not been tested in randomized controlled trials, recent years have brought advances in diagnostic imaging and treatment alternatives as well as useful information regarding prognosis. Refinement in MRI technique now allows precise, noninvasive diagnoses of most vascular myelopathies and is crucial for the exclusion of differential diagnoses. Surgical and endovascular therapies are highly effective in treating spinal vascular malformations. Longitudinal studies have shown that the prognosis of spinal cord infarction is more favorable than previously conceived, and even patients with severe deficits can achieve meaningful recovery. Clinicians should be keenly aware of the clinical and radiologic features of the various vascular causes for acute or progressive myelopathy. Optimal management of patients with vascular myelopathies requires close collaboration with neuroradiologists, neurointerventionalists, and vascular neurosurgeons. Prognosis should be estimated with caution because functional outcomes over time may be better than initially expected. Vascular myelopathies are infrequent, but their consequences to the patient's functional capacity can be devastating. Because of their relative rarity, these disorders are often initially misdiagnosed, and, in some cases, this delay in arriving at the correct diagnosis can prove very detrimental. This article reviews the essential concepts of diagnosis and management of vascular diseases of the spinal cord, both ischemic and hemorrhagic, beginning with a basic summary of the vascular anatomy of the cord, as this knowledge is crucial for an understanding of the pathologies.

Caudal lumbar disc disease presenting as ‘praying position’-like posture and gait

A 10-year-old Border collie and a five-year-old Domestic shorthaired cat are reported with a ‘praying’-like posture as clinical presentation for caudal lumbar disc disease. Neurological examination localised to L6-S3 spinal...

Performance Quality Improvement Projects: Suggestions for the Body Imager

Body imaging constitutes a significant portion of diagnostic imaging and incorporates multiple modalities, including CT, MRI, radiography, and ultrasound. The more heavily used modalities in body imaging (ie, CT and MRI) often require specific protocols and techniques to improve diagnostic accuracy for the specified indication. Optimizing the performance of these advanced diagnostic imaging examinations can significantly improve patient safety, quality, workflow efficiency, and patient satisfaction. The scope, frequency, and complexity of body imaging present numerous potential opportunities for performance improvements that may be undertaken.

Cellular uptake and biocompatibility of bismuth ferrite harmonic advanced nanoparticles

Bismuth Ferrite (BFO) nanoparticles (BFO-NP) display interesting optical (nonlinear response) and magnetic properties which make them amenable for bio-oriented diagnostic applications as intra- and extra membrane contrast agents. Due to the relatively recent availability of this material in well dispersed nanometric form, its biocompatibility was not known to date. In this study, we present a thorough assessment of the effects of in vitro exposure of human adenocarcinoma (A549), lung squamous carcinoma (NCI-H520), and acute monocytic leukemia (THP-1) cell lines to uncoated and poly(ethylene glycol)-coated BFO-NP in the form of cytotoxicity, haemolytic response and biocompatibility. Our results support the attractiveness of the functional-BFO towards biomedical applications focused on advanced diagnostic imaging. From the Clinical EditorBismuth Ferrite nanoparticles (BFO-NP) have been recently successfully introduced as photodynamic tools and imaging probes. However, how these nanoparticles interact with various cells at the cellular level remains poorly understood. In this study, the authors performed in vitro experiments to assess the effects of uncoated and PEG-coated BFO-NP in the form of cytotoxicity, haemolytic response and biocompatibility.

Cone Beam Computed Tomography-A Third Eye in Interpreting TMJ Disorders-A Case Report

Imaging is an important diagnostic adjunct for clinical assessment of Dental Patients. Rapid advances in diagnostic imaging and computer technology have major impact in dental radiology. Cone Beam Computed Tomography Technique presents an innovation of tomographic imaging system and subsequent volumetric image reconstruction for dentistry. Here we present a case of 28 year old female patient with chief complaint of pain in the right & left preauricular region since 6months. Pain was intense, dull in nature. Pain was aggravated while chewing food. Patient gave history of clicking sound while opening & closing the mouth from the past 5months & now from past 2months no clicking sound present but pain still persists with limited mouth opening. With the above clinical findings provisional diagnosis of Internal Derangement was given. CBCT scan was performed which revealed Early to mild right TMJ Degenerative changes & Chronic mild Left TMJ degenerative changes.

心臓サルコイドーシスを巡る最近の画像診断の進歩

心臓サルコイドーシスを巡る最近の画像診断の進歩

Advanced diagnostic imaging for neoplastic processes in the head

Advanced diagnostic imaging for neoplastic processes in the head

Florbetaben for PET Imaging of Beta-Amyloid Plaques in the Brain.

Alzheimer’s disease (AD) is a devastating neurodegenerative disorder affecting the elderly. Current clinical diagnostic tools are often ineffective in accurately diagnosing AD. However, new advances in diagnostic imaging, particularly positron emission tomography (PET) amyloid imaging, have shown increased sensitivity and specificity, as well as high inter-reader agreement. The most commonly studied tracer, PiB-C11, has shown high affinity binding to amyloid, but is limited in its use outside of research due to its short half-life. Instead, development of other PET ligands with increased half-life, such as fluorine-18-labeled (18F) tracers, allows for more widespread use of PET in clinical settings. In particular, recent phase II and III trials of 18F-florbetaben have demonstrated the high accuracy of this PET tracer in identifying amyloid accumulation. This paper will examine the techniques of amyloid imaging, focusing particularly on the recently approved 18F-florbetaben.Electronic supplementary materialThe online version of this article (doi:10.1007/s40120-014-0022-9) contains supplementary material, which is available to authorized users.