Emergency Radiology Research Articles

Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution.

New-onset psychosis in the pediatric population poses many diagnostic challenges. Given the diversity of underlying causes, which fall under the purview of multiple medical specialties, a timely, targeted, yet thorough workup requires a systematic and coordinated approach. A committee of expert pediatric physicians from the divisions of emergency medicine, psychiatry, neurology, hospitalist medicine, and radiology convened to create and implement a novel clinical pathway and approach to the pediatric patient presenting with new-onset psychosis. Here we provide background and review the evidence supporting the investigations recommended in our pathway to screen for a comprehensive range of etiologies of pediatric psychosis.

Active upper aerodigestive tract hemorrhage in patients with head and neck cancers: the “dot-in-sludge” sign

Active extravasation into the upper aerodigestive tract is a dramatic and potentially life-threatening complication in patients with head and neck cancers. It prompts presentation to the emergency room and subsequent urgent imaging to identify the source of hemorrhage. Imaging of these patients may be complicated by treatment-altered anatomy, posing a challenge to the emergency radiologist who needs to rapidly identify the presence of active hemorrhage and the potential source vessel. This retrospective review summarizes the clinical and imaging findings of 6 oropharyngeal and oral cavity squamous cell cancer (SCC) patients with active upper aerodigestive tract hemorrhage. Most patients had advanced stage disease and prior radiation therapy. All CECT or CTA exams on presentation demonstrated the “dot-in-sludge” sign of active extravasation, as demonstrated by a “dot” of avidly enhancing extravasated contrast material layered against a background “sludge” of non-enhancing debris in the lumen of the upper aerodigestive tract. Common sources of hemorrhage included the lingual, facial, and superior thyroidal arteries. Familiarity with these findings will help radiologists increase their accuracy and confidence in interpreting these urgent, complex examinations.

Imaging of Intimate Partner Violence, From the AJR Special Series on Emergency Radiology.

Intimate partner violence (IPV) is a highly prevalent public health issue with multiple adverse health effects. Radiologists are well suited to assessing a patient's likelihood of IPV. Recognition of common IPV injury mechanisms and resulting target and defensive injury patterns on imaging and understanding of differences between patients who have experienced IPV and those who have not with respect to use of imaging will aid radiologists in accurate IPV diagnosis. Target injuries often involve the face and neck as a result of blunt trauma or strangulation; defensive injuries often involve an extremity. Awareness of differences in injury patterns resulting from IPV-related and accidental trauma can aid radiologists in detecting a mismatch between the provided clinical history and imaging findings to support suspicion of IPV. Radiologists should consider all available current and prior imaging in assessing the likelihood of IPV; this process may be aided by machine learning methods. Even if correctly suspecting IPV on the basis of imaging, radiologists face challenges in acting on that suspicion, including appropriately documenting the findings, without compromising the patient's confidentiality and safety. However, through a multidisciplinary approach with appropriate support mechanisms, radiologists may serve as effective frontline physicians for raising suspicion of IPV.

Structured reporting of computed tomography in the polytrauma patient assessment: a Delphi consensus proposal

ObjectivesTo develop a structured reporting (SR) template for whole-body CT examinations of polytrauma patients, based on the consensus of a panel of emergency radiology experts from the Italian Society of Medical and Interventional Radiology.MethodsA multi-round Delphi method was used to quantify inter-panelist agreement for all SR sections. Internal consistency for each section and quality analysis in terms of average inter-item correlation were evaluated by means of the Cronbach’s alpha (Cα) correlation coefficient.ResultsThe final SR form included 118 items (6 in the “Patient Clinical Data” section, 4 in the “Clinical Evaluation” section, 9 in the “Imaging Protocol” section, and 99 in the “Report” section). The experts’ overall mean score and sum of scores were 4.77 (range 1–5) and 257.56 (range 206–270) in the first Delphi round, and 4.96 (range 4–5) and 208.44 (range 200–210) in the second round, respectively.In the second Delphi round, the experts’ overall mean score was higher than in the first round, and standard deviation was lower (3.11 in the second round vs 19.71 in the first round), reflecting a higher expert agreement in the second round. Moreover, Cα was higher in the second round than in the first round (0.97 vs 0.87).ConclusionsOur SR template for whole-body CT examinations of polytrauma patients is based on a strong agreement among panel experts in emergency radiology and could improve communication between radiologists and the trauma team.

Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology.

Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short and long-term outcomes in many cases. Due to a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describing advantages and disadvantages of different imaging modalities, highlighting disorders that predispose children to infarct or hemorrhage, and presenting an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.

Current practice of emergency radiology in Turkey and future expectations: a survey study

The development of emergency radiology (ER) in Turkey has accelerated with the increase in the number of patients admitted to emergency departments. We aimed to present and discuss the responses to a survey distributed to radiologists in Turkey, which included questions about the current practice of ER and future expectations. A survey with 29 questions enquiring about the infrastructure of respondents' hospitals and radiology units, information about emergency services and ER (including patient volume), the number of staff and equipment, the ER working plan and reporting method, and training in the field of ER were distributed to members of the Turkish Radiological Society by email. The response rate was 21.97% (328/1.493). The presence of distinct ER units in radiology departments was confirmed by 40.55% of respondents, while for 34.25%, ER was located inside the emergency room. Of the respondents, 26.96% stated they believed that emergency cases should be reported by emergency radiologists, and the necessity for an ER subunit in the emergency room was agreed upon by 58.64% of contributors. The majority of respondents (69.54%) agreed with the opinion that residents should receive their ER training in an ER unit. Keeping abreast of current ER practices and radiologists' expectations may be helpful for improving national ER practices and academic studies.

Aneurisma de aorta abdominal roto, ¿qué necesitan el radiólogo intervencionista y el cirujano vascular de nuestro informe?

Abdominal aortic aneurysm is defined as a dilatation of the abdominal aorta greater than 3cm. Its prevalence is between 1 and 1.5 cases per 100 people, constituting an important cause of morbidity and mortality. Rare in women, its frequency increases with age and its most frequent location is between the renal arteries and the aorto-iliac bifurcation. Approximately 5% of cases will involve the visceral branches.It is a silent pathological process whose natural evolution is rupture, which often has a fatal outcome and whose diagnosis is part of the pathology that we will find in emergency radiology. The involvement of the radiologist and the preparation of an accurate diagnostic report, as soon as possible, is essential for decision-making by the team in charge of the patient's surgery.

Chest X-ray in Emergency Radiology: What Artificial Intelligence Applications Are Available?

Due to its widespread availability, low cost, feasibility at the patient's bedside and accessibility even in low-resource settings, chest X-ray is one of the most requested examinations in radiology departments. Whilst it provides essential information on thoracic pathology, it can be difficult to interpret and is prone to diagnostic errors, particularly in the emergency setting. The increasing availability of large chest X-ray datasets has allowed the development of reliable Artificial Intelligence (AI) tools to help radiologists in everyday clinical practice. AI integration into the diagnostic workflow would benefit patients, radiologists, and healthcare systems in terms of improved and standardized reporting accuracy, quicker diagnosis, more efficient management, and appropriateness of the therapy. This review article aims to provide an overview of the applications of AI for chest X-rays in the emergency setting, emphasizing the detection and evaluation of pneumothorax, pneumonia, heart failure, and pleural effusion.

Medical Students and the Informal Radiology Curriculum: Adopting the Emergency Radiology Triage Assistant Program (ER-TAP) Amid COVID-19

The Emergency Radiology Triage Assistant Program (ER-TAP) at the XXX was established in 2010 and has offered medical students paid employment to work as triage assistants in the emergency radiology reading room. ER-TAP is a radiology call assistant program which was modeled after the program first developed by the Yale Department of Radiology (1). Similar programs have been implemented at Dartmouth-Hitchcock Medical Center and the Hospital of the University of Pennsylvania (2,3). ER-TAP at XX offers medical students an opportunity to work weekdays and holidays from 6:00 pm to midnight.

Solid Organ Injury Grading in the Abdomen: A Primer for Emergency Radiology

The American Association for the Surgery of Trauma (AAST) established the Organ Injury Scale (OIS) in 1984, making an initial revision in 1994, and the most recent revision in 2018. This recent revision was made to better predict the need for operative or angiointervention management, considering active hemorrhage or other vascular complications. Diagnosis of hemodynamically stable patients is made by CT; however, hemodynamically unstable patients may be diagnosed via focused assessment with sonography in trauma (FAST) ultrasound or emergency laparotomy.1–3 In this article, we discuss in depth the different OIS gradings for renal, hepatic, and splenic trauma and demonstrate the necessary information that an emergency radiologist must know through a series of cases. This knowledge will allow radiologists to concisely communicate with referring teams and help them make the appropriate management decisions for each patient case.1 , 4

DETERMINATION OF POTENTIAL AREAS OF INFLUENCE ON THE ROMANIAN TERRITORY OF UKRAINIAN NUCLEAR POWER PLANTS IN THE CONTEXT OF THE CRISIS GENERATED BY THE RUSSIAN-UKRAINIAN CONFLICT

In the context of the crisis generated by the Russian-Ukrainian conflict, radiological situation forecasts were made within the National Institute of Research and Development for Physics and Nuclear Engineering "Horia Hulubei" (IFIN-HH) for all nuclear power plants in Ukraine. Therefore, the resident decision support software systems for radiological and nuclear emergencies were used, with the main purpose of identifying potential areas of influence on the territory of Romania generated by Ukrainian power plants, as consequence of military actions. In the absence of pertinent and confirmed information, two hypothetical scenarios were considered by which the radioactive material could be dispersed into the atmosphere, for which appropriate accident source terms were built, using methods validated and approved by the international organizations in the field. The monitoring of the radiological situation of the Ukrainian nuclear power plants was carried out over a period of several months starting from the first day of the conflict outbreak. In the paper are presented comparative results obtained with two software systems for a representative case at the Zaporozhe Nuclear Power Plant, the largest nuclear power plant in Europe, situated in the center of several disputes.

Occupational health and safety aspects in the handling of cryogenic materials in nuclear and radiological facilities

Cryogenic materials, widely used in industries and facilities associated with nuclear technology and science and radiological applications, pose occupational health and safety hazards owing to their unique properties. The major health hazards include cold burns, asphyxiation, hot burns, and major safety hazards are explosion, fire, and equipment failure. Risk assessment consistent with material safety data sheet and hazard analysis is essential to assess the potential dangers while using cryogenic materials. Safe handling of cryogenic materials in nuclear and radiological facilities requires special considerations to ensure the protection of personnel and the environment. Administrative measures such as access control, training, checklists, and engineering controls such as ventilation, gas detection systems, and purging techniques are applied to deal with cryogenic hazards. Many personal proactive equipments are available to protect users from cryogenic hazards. While some protective measures for cryogenic hazards could suffice for low radioactivity laboratories, additional personal protective equipments are required to protect workers from radiation exposure in workplaces with potentially significant radiation hazards. The formulation of preparedness plans for emergencies resulting from cryogenic hazards should essentially take into account the unique constraints and requirements of radiological facilities. Simultaneous occurrence of radiological and cryogenic emergencies presents complex challenges requiring special mitigative measures.

Centers for Disease Control and Prevention Participation in Cobalt Magnet National-Level Radiological Exercise.

Since September 11, 2001, the Centers for Disease Control and Prevention (CDC) has increased efforts to prepare the agency and public health partners for response to potential nuclear/radiological disasters. During the week of May 16-20, 2022, the CDC participated in a national-level radiological emergency exercise, Cobalt Magnet 22 (CM22). The exercise scenario consisted of a notional, failed search mission for a radiological dispersal device (RDD, "dirty bomb"), followed by its explosion during a public event in a large US city. Testing radioanalytical laboratory capabilities during a nuclear/radiological incident was an exercise objective, and developing clear messaging on low-dose exposure and long-term health concerns was a primary output of the exercise. The CDC practiced its activation protocols, exercised the establishment of its updated Incident Management System structure for radiation emergencies, and identified critical staffing needs for this type of response.

Assessment of a combined musculoskeletal and chest deep learning-based detection solution in an emergency setting

Rationale and objectivesTriage and diagnostic deep learning-based support solutions have started to take hold in everyday emergency radiology practice with the hope of alleviating workflows. Although previous works had proven that artificial intelligence (AI) may increase radiologist and/or emergency physician reading performances, they were restricted to finding, bodypart and/or age subgroups, without evaluating a routine emergency workflow composed of chest and musculoskeletal adult and pediatric cases. We aimed at evaluating a multiple musculoskeletal and chest radiographic findings deep learning-based commercial solution on an adult and pediatric emergency workflow, focusing on discrepancies between emergency and radiology physicians. Material and methodsThis retrospective, monocentric and observational study included 1772 patients who underwent an emergency radiograph between July and October 2020, excluding spine, skull and plain abdomen procedures. Emergency and radiology reports, obtained without AI as part of the clinical workflow, were collected and discordant cases were reviewed to obtain the radiology reference standard. Case-level AI outputs and emergency reports were compared to the reference standard. DeLong and Wald tests were used to compare ROC-AUC and Sensitivity/Specificity, respectively. ResultsResults showed an overall AI ROC-AUC of 0.954 with no difference across age or body part subgroups. Real-life emergency physicians’ sensitivity was 93.7 %, not significantly different to the AI model (P = 0.105), however in 172/1772 (9.7 %) cases misdiagnosed by emergency physicians. In this subset, AI accuracy was 90.1 %. ConclusionThis study highlighted that multiple findings AI solution for emergency radiographs is efficient and complementary to emergency physicians, and could help reduce misdiagnosis in the absence of immediate radiological expertize.

Artificial Intelligence in Emergency Radiology: Where Are We Going?

Emergency Radiology is a unique branch of imaging, as rapidity in the diagnosis and management of different pathologies is essential to saving patients' lives. Artificial Intelligence (AI) has many potential applications in emergency radiology: firstly, image acquisition can be facilitated by reducing acquisition times through automatic positioning and minimizing artifacts with AI-based reconstruction systems to optimize image quality, even in critical patients; secondly, it enables an efficient workflow (AI algorithms integrated with RIS-PACS workflow), by analyzing the characteristics and images of patients, detecting high-priority examinations and patients with emergent critical findings. Different machine and deep learning algorithms have been trained for the automated detection of different types of emergency disorders (e.g., intracranial hemorrhage, bone fractures, pneumonia), to help radiologists to detect relevant findings. AI-based smart reporting, summarizing patients' clinical data, and analyzing the grading of the imaging abnormalities, can provide an objective indicator of the disease's severity, resulting in quick and optimized treatment planning. In this review, we provide an overview of the different AI tools available in emergency radiology, to keep radiologists up to date on the current technological evolution in this field.

Application of Resuspension Data of Respirable Particles for Early Phase Inhalation Following Deposition Contamination in Radiological Emergencies.

Abstract In model experiments, wind resuspension rates, Rr, of respirable particles (<10 μm, aerodynamic diameter) and their time dependence after deposition on representatively contaminated urban surfaces were measured under real-life conditions, taking into account different weather conditions (wind velocities, precipitation) as well as countermeasures (fixation). For contamination by dry deposition of particles, short-term resuspension rates averaged over the first half hour, after exposure to wind with a friction velocity, u*, of 0.8 m s−1 ranged between 0.1% h−1 and 2% h−1 depending on the surface material, whereas after wet deposition, resuspension rates were two orders of magnitude lower. The time pattern of the resuspension rates followed a power law decrease, Rr ∝ t −μ , with values of μ close to 1. The measurements revealed a strong dependence on friction velocity, . For a larger area of 200 × 800 m2 contaminated with 106 Bq m−2 of particles in the respirable size range, applying a simple Gaussian dispersion model airborne activity concentration (Bq m−3) was calculated. On this basis, for an initial time of high windspeed, a cautious resuspension factor of Rf = 5 10−6 m−1 is derived for the first day, which diminishes inversely with time. The exposure of persons to external radiation and to inhaled airborne radioactivity is compared with examples for three radionuclides representing strong beta-, gamma- and alpha-radiation.

Factors Influencing the Choice of Radiology Subspecialty Among Radiology Trainees in Sudan.

Background and objective There are numerous reasons why radiologists would be interested in seeking additional fellowship training, some of which are personal, such as the possibility of bettering their career prospects, while others are work-related. This study aimed to identify whether the Sudanese radiology trainees wanted to pursue fellowshipand what were the motivating and restricting factors affecting their career choices. Methods This was a re-do research of a study from Saudi Arabia previously published in the Cureus journal in 2019. This wasa descriptive cross-sectional study conducted among the radiology registrarstraining under Sudan Medical Specialization Board (SMSB) in 2022 (n=90). By using convenient sampling, 74 of the 90 registrars were contacted, and aresponse rate of 81% (n=60) was achieved. Data were collected using a pre-tested self-administered online questionnaire. Data were analyzed usingIBMSPSS®Statistics version 25.0 (IBM Corp., Armonk, NY). A p-value ≤0.05 was considered statistically significant. Results The majority of the trainees in our study were females (61.7%, 37/60). More than 93% (n=56) of our participants were training in Khartoum, the capital of Sudan. The most commonly chosen subspecialties in our study were as follows: neuroradiology (33.3%, n=20) body imaging (26.7%, n=16), and interventional radiology (25%, n=15). In contrast, nuclear medicine (1.7%, n=1) and emergency radiology (3.3%, n=2)were among the least popular subspecialties.The top influencing factors among our trainees in choosing a subspecialty included "strong personal interest," "lifestyle," and "area of strongpersonal knowledge." The most common factors preventing trainees from opting for a fellowship were "financial restriction" (55%, n=33) and "family obligation" (28.3%, n=17). Of those with no plans to subspecialize, 75% (six out of eight) stated that the lack of a fellowship program in Sudan is a possible deterrent. A statistically significant association was found between genderand the choice of subspecialty in interventional radiology and women's/mammogram imaging. Our findings revealed that there are currently no trainees in the first year of radiology residency because the last selection exam had been conducted in 2019. Despite thecurrent unavailability of subspecialty training in Sudan, 75% (n=45) of trainees in our study were interested in joining a local program for fellowship training in the future. Conclusion Radiology trainees in Sudan share similar interests and influencing and restricting factors when pursuing subspecialty training, as reported in the literature. Unlike other countries, females predominate in the field of radiology training in Sudan at the moment. Radiologists from Sudan who are interested in subspecializing usually travel abroad for training; and once they find better prospects, many of them may not return. Programs offeringsubspecialization locally could mitigate the attrition of radiologists in Sudan. When designing subspecialty training programs in Sudan, stakeholders should use knowledge of influential factors and understanding of subspecialty decision trends among radiology trainees as a reference point. To the best of our knowledge, this study is the first of its kind to be conducted in this field in Sudan.

High-Throughput Determination of Ultratrace Actinides in Urine by In-Line Extraction Chromatography Combined with Quadrupole Inductively Coupled Plasma Mass Spectrometry (EC-ICP-MS).

Determining actinides in urine is vital for occupational exposure monitoring and radiological emergency response because of the toxicity and radiological dose effects of actinides on human health. Traditional radiochemistry analytical methods used to determine actinide concentrations in urine are time-consuming (sample analysis takes several days) and are hindered by a variety of technical and instrumentation-related obstacles. A high-throughput, fully automated, precise, and accurate in-line method was developed for determining five actinides (241Am, 239Pu, 237Np, 232Th, and 238U) at ng/L levels in urine using extraction chromatography combined with quadrupole inductively coupled plasma mass spectrometry (EC-ICP-MS). In this method, the five actinides were successfully separated with the required sensitivity, peak shape, and resolution using a simplified single Eichrom TRU column with a Dionex ICS-5000 system. The separated actinides were subsequently injected into an in-line PerkinElmer (PE) NexION 300D ICP-MS for quantitative determination. The sample-to-sample run time was 23 min for automatic chemical separation and quantification using only 0.5 mL of urine. The limits of detection (LOD) obtained using this method were 0.015, 0.022, 0.039, 4.5, and 2.4 ng/L for 241Am, 239Pu, 237Np, 232Th, and 238U, respectively. The method routinely had a chemical yield of >84% as well as a linearity (R2) coefficient of ≥0.999 for the calibrators. The method proved to be rapid, reliable, and effective for actinide quantification in urine and therefore is appropriate for radiological emergency response incidents.

Gamma Radioactivity Detection Limits and Associated Radionuclide Intakes Study in Artificial Human Urine Using Sodium-iodide and High-purity Germanium Detectors.

The performance of several gamma detectors was investigated for emergency urine bioassay screening of two radionuclides of concern: 131 I and 137 Cs. Unspiked artificial urine samples were measured for 10 min each on four different gamma detectors: 80% relative efficiency high-purity Ge detector in standard shielding, 102% low-background high-purity Ge detector equipped with top muon shield, 78% high-purity Ge well detector in standard shielding, and 4″ × 4″ NaI well detector in standard shielding. The measured gamma spectra were analyzed in two ways: (1) for the 364-keV peak region of 131 I and 662-keV peak region of 137 Cs and (2) for the total counts in the full energy spectrum (50-2,048 keV). The results were analyzed using the principles of signal detection theory according to the Currie's formalism extended by a complete uncertainty propagation. This enabled calculation of the detection capability in terms of detection limit (Bq L -1 ) of urine, the latter referred to as minimum detectable activity. The NaI well detector had the lowest minimum detectable activities for total spectra, whereas the high-purity Ge well detector had the lowest peak minimum detectable activity values. Minimum detectable inhalation and ingestion intakes from urine bioassay were calculated from the minimum detectable activity values for urine collection 1 d, 1 wk, and 1 mo past the initial intake. The calculated intakes were compared with annual limits on intake. The results are interpreted with respect to a large-scale radiological emergency response.

Novel optical technologies for emergency preparedness and response: Mapping contaminations with alpha-emitting radionuclides

Radiological emergencies involving an accidental or deliberate dispersion of alpha-emitting radionuclides in the environment can cause significant damage to humans and societies in general. Currently, there is a metrology gap in managing such emergencies due to the lack of detectors that can measure alpha particles at distances greater than their range in air: most conventional alpha detectors are only effective when placed just a few centimeters above the contaminated area. This paper presents the development and testing of lens based optical detection systems that utilize alpha particle-induced ultraviolet (UV) luminescence of air, known as alpha radioluminescence. Telescopes based on fused silica and Poly(methyl 2-methylpropenoate) (PMMA) Fresnel lenses were investigated for their usability in facilitating emergency management related to alpha-emitting radionuclides. Careful matching of the diameter and focal length of the receiving optics, the response of the photocathode, and the passband of the filter allows detection sensitivities as high as 34s−1MBq−1 at 2m source-to-detector distance and background count rate of about 3s−1 in the UV-C spectral region, and suppression of daylight background count rate down to 16s−1. By flushing the source with nitrogen (N2) containing trace amounts of nitric oxide (NO), a groundbreaking sensitivity of 1.3×105s−1MBq−1 has been achieved, allowing detection limits as low as 100Bq with room lighting on, and 70Bq in a dark environment. In the UV-A spectral region, a detection limit of 4kBq could be achieved in a dark environment. These optical detection systems are aimed to facilitate a rapid, coordinated, and effective response in emergency situations involving the release of alpha-emitting radionuclides by mounting them on a tripod or an unmanned aerial device (UAV).