Emergency Radiology Research Articles

Rapid determination of ultra-trace plutonium in large volume of urine samples by tandem quadrupole inductively coupled plasma-mass spectrometry

Rapid bioassay method for plutonium in urine samples are employed to assess the possible internal dose resulting from exposure to plutonium in the event of a radiological and nuclear emergency. In this work, a rapid method for the determination of plutonium isotopes (239Pu and 240Pu) in large volume of urine samples was developed using tandem quadrupole ICP-MS combined with a high-efficiency sample introduction system (APEX-Ω). The mixture gases of NH3 and He was employed to effectively eliminate the tailing of 238U and the uranium hydride ions (238U1H+and 238U1H2+) and significantly improve the measurement sensitivity of plutonium. The method was validated by analyzing urine samples spiked with known amounts of 239Pu and 240Pu ranging from 1 to 60 fg. The detection limits for the method were estimated to be 0.83 fg for 239Pu, 0.14 fg for 240Pu in 1 L of urine.

Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow.

Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

Diagnostic Errors in Neuroradiology: A Message to Emergency Radiologists and Trainees.

Diagnostic errors in neuroradiology are inevitable, yet potentially avoidable. Through extensive literature search, we present an up-to-date review of the psychology of human decision making and how such complex process can lead to radiologic errors. Our focus is on neuroradiology, so we augmented our review with multiple explanatory figures to show how different errors can reflect on real-life clinical practice. We propose a new thematic categorization of perceptual and cognitive biases in this article to simplify message delivery to our target audience: emergency/general radiologists and trainees. Additionally, we highlight individual and organizational remedy strategies to decrease error rate and potential harm.

Developing an instrument to measure household radiological emergency preparedness using the Community Assessment for Public Health Emergency Response (CASPER) methodology: An evidence-informed approach.

Community assessments to measure emergency preparedness can inform policies, planning, and communication to the public to improve readiness and response if an emergency was to occur. Public health and emergency management officials need an effective assessment tool to measure community preparedness for a radiological emergency. The authors created a survey instrument to collect data on household radiological emergency preparedness that could be implemented using the Community Assessment for Public Health Emergency Response (CASPER) methodology, developed by the U.S. Centers for Disease Control and Prevention. To inform the development of the tool, the authors examined existing CASPER surveys, focusing on identifying best practices for creating a survey instrument, as well as analyzing the results of a survey of radiation preparedness experts and state/local health and emergency management officials. The developed survey tool includes 32 questions covering four domains: communication in an emergency, preparedness planning, physical/behavioral health, and demographics. The instrument captures information related to identified barriers in communicating in a radiological emergency as well as self-reported behaviors that could potentially be influenced through awareness and education. Using the proposed survey instrument and following the existing rapid assessment methodology provided by CASPER, public health and emergency management agencies can collect valuable information on the radiation preparedness needs of their communities, which can then be used to improve household readiness for an emergency.

Criteria of medical response to radiological emergencies in the Republic of Belarus

The Republican Research Center for Radiation Medicine and Human Ecology in the Internal and External Emergency Plans of the Belarusian nuclear power plant is specified as an institution that provides specialized treatment for personnel, as well as persons from the population living in the emergency zone of the station. The plant is the first facility in the Republic that used nuclear energy. There is no experience in treating radiation injuries in Belarus. This is the first time that the National Health Service has been assigned the task of ensuring readiness for the reception and specialized treatment of people who have been exposed to emergency or unplanned radiation. The purpose of the work is to establish criteria for radiation exposure for use in a Belarusian specialized medical institution in case of medical response to radiological accidents. As a result of the analysis of publications of international organizations, the criteria of radiation exposure that can be applied in the conditions of Belarusian specialized medical institutions were selected. Assessment of the criteria was made taking into account existing national technical regulations and the available capabilities of emergency response participants. To account for the quality of radiation in relation to deterministic effects “Gy-equivalent” is used. The criteria include both dosimetric values for cases of external and internal accidental and unplanned exposure, and levels of radioactive substances with unknown physical and chemical properties entering the body that require urgent medical intervention. Criteria for cases of surface contamination of skin and wounds require separate consideration.

System and capability of public health response to nuclear or radiological emergencies in China.

In order to respond to nuclear or radiological emergencies effectively and protect the physical and mental health of the public, the national-, provincial-, municipal- and county-level public health response systems for nuclear or radiological emergencies had been established in China by the end of twentieth century. The health administrative departments at all levels have established professional emergency response teams, continue to improve their own level of emergency response systems and operating mechanisms, enhance the capabilities of radiation injury treatment, radiation monitoring and protection through training and exercises and also pay attention to the logistical support for emergency response. In this article the organizations, management system and capabilities of public health response to nuclear or radiological emergencies in China are briefly introduced. We try to strengthen information exchange and cooperation with foreign counterparts in this field in the future, so as to jointly promote the development of preparedness and response for nuclear or radiological emergencies.

Protection measures against SARS-CoV-2 infection for cytopathology and histopathology laboratories personnel: practical recommendations.

In the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, healthcare workers are at high risk to be infected with this new coronavirus, particularly when they handle not only patients, but also their body fluids. In Romania, even though the protective measures to be used by medical staff in emergency departments, clinical departments, radiology departments, clinical laboratories and morgues services are well known, there is little information about the protection of medical staff in the laboratories of cytopathology and histopathology. In this article, we will discuss the transmission routes of the new coronavirus, the surfaces it could contaminate in a hospital, as well as the modalities of its inactivation. We will present some guidelines for preparing the pathology departments to face the pandemic situation like the present one. Also, we will point out some possible recommendations/suggestions for protective measures to be taken by laboratory staff during the cytological and histopathological procedures when they manipulate body fluids or surgical samples of patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Laboratory personnel should be aware that any body fluid or surgical specimen that arrives in the laboratory may contain SARS-CoV-2 and, as such, they should act after new working procedures. We recommend restraint from performing extemporaneous examination (smear and frozen section) and cytopathological examination in laboratories that do not have adequate condition for handling and processing Hazard Group 3 (HG3) pathogens, as SARS-CoV-2. Also, laboratory personnel should pay attention to instruments, technical equipment, or environmental surfaces as these also can be contaminated with the new coronavirus.

Ultra-low-dose cone-beam CT compared to standard dose in the assessment for acute fractures.

Multi-detector computed tomography (MDCT) is superior in fracture detection than conventional radiography; however, dose is increased. Cone-beam computed tomography (CBCT) offers higher spatial resolution and lower dose than MDCT. Manufacturers offer an ultra-low-dose algorithm. This study compares the diagnostic accuracy of the ultra-low-dose CBCT (ULDCBCT) with that of the standard-dose CBCT (SDCBCT). In total, 64 patients were scanned with both the SDCBCT and the ULDCBCT protocols. Both studies were reported by two consultant radiologists with fellowship training in emergency radiology separated in time. The reporter recorded a diagnosis of fracture or normal and diagnostic confidence using a 5-point Likert scale. The gold standard was taken as the SDCBCT. Reporters were blinded to the indication and the SDCBCT report. Cases of discrepancy were resolved by consensus. There were 34 fractures and 30 cases had no fracture. Several fractures were missed using the UDCBCT, and there were also several cases of overdiagnosis. ULD was inferior to SD for fracture diagnosis (p < 0.00001). The diagnostic accuracy of ULDCBCT was 82.8% (75.1-88.9 CI). The diagnostic accuracy of plain radiograph was 64% (55.1-75.7% CI). Diagnostic confidence was reduced; the mean confidence for SDCBCT was 4.68 vs 4.12 for ULDCBCT (p < 0.001). The Kappa for interobserver agreement was 0.6. ULDCBCT is inferior to SDCBCT in fracture detection and confidence is reduced. For diagnostic studies, the standard dose should be used.

Complications of cholecystitis: a comprehensive contemporary imaging review.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Allium cepa used as a dosimetry system in nuclear and radiological emergencies

Allium cepa used as a dosimetry system in nuclear and radiological emergencies

EURADOS STRATEGIC RESEARCH AGENDA 2020: VISION FOR THE DOSIMETRY OF IONISING RADIATION.

Since 2012, the European Radiation Dosimetry Group (EURADOS) has developed its Strategic Research Agenda (SRA), which contributes to the identification of future research needs in radiation dosimetry in Europe. Continued scientific developments in this field necessitate regular updates and, consequently, this paper summarises the latest revision of the SRA, with input regarding the state of the art and vision for the future contributed by EURADOS Working Groups and through a stakeholder workshop. Five visions define key issues in dosimetry research that are considered important over at least the next decade. They include scientific objectives and developments in (i) updated fundamental dose concepts and quantities, (ii) improved radiation risk estimates deduced from epidemiological cohorts, (iii) efficient dose assessment for radiological emergencies, (iv) integrated personalised dosimetry in medical applications and (v) improved radiation protection of workers and the public. This SRA will be used as a guideline for future activities of EURADOS Working Groups but can also be used as guidance for research in radiation dosimetry by the wider community. It will also be used as input for a general European research roadmap for radiation protection, following similar previous contributions to the European Joint Programme for the Integration of Radiation Protection Research, under the Horizon 2020 programme (CONCERT). The full version of the SRA is available as a EURADOS report (www.eurados.org).

Beware of the bicycle! An increase in paediatric bicycle related injuries during the COVID-19 period in Western Australia.

In Western Australia, the media has reported on an increase in the purchasing, repairs and use of bicycles during the COVID-19 period. The study aimed to investigate for a relationship in bicycle related injuries in the paediatric population during the time of COVID-19 restrictions. A retrospective study of the incident of motorized and non-motorized bicycle related injuries and trauma presentations during the COVID-19 'shutdown' period from March to June 2020. Data were collected from the Emergency Department Information System, discharge summaries, operation and radiology reports. The data presented is from Perth Children's Hospital, the only tertiary paediatric hospital and the only referral centre for childhood trauma in the state of Western Australia. Participants were children aged 15 years and younger attending the emergency department (ED) at Perth Children's Hospital during the designated time period. The primary outcomes included total ED presentations, bicycle related presentations and bicycle related admissions during the COVID-19 period. Bicycle related presentations to the ED increased by 42.7% over the COVID-19 period from 1.4% to 3.0% of all children attending the ED. Children admitted to the hospital with bicycle related injuries or trauma increased by 48.7% from 76 to 113 children in comparison to the same period in 2019. During the period of COVID-19 restrictions, paediatric ED presentations decreased dramatically, but bicycle related injuries and trauma increased substantially. Safety equipment including helmets and protective gear should be worn for all children riding bicycles, and social distancing should be maintained.

Pediatric Emergency Imaging Studies in Academic Radiology Departments: A Nationwide Survey of Staffing Practices.

Particularly for pediatric patients presenting with acute conditions or challenging diagnoses, identifying variation in emergency radiology staffing models is essential in establishing a standard of care. We conducted a cross-sectional survey among radiology departments at academic pediatric hospitals to evaluate staffing models for providing imaging interpretation for emergency department imaging requests. We conducted an anonymous telephone survey of academic pediatric hospitals affiliated with an accredited radiology residency program across the United States. We queried the timing, location, and experience of reporting radiologists for initial and final interpretations of emergency department imaging studies, during weekday, overnight, and weekend hours. We compared weekday with overnight, and weekday with weekend, using Fisher's exact test and an α of 0.05. Surveying 42 of 47 freestanding academic pediatric hospitals (89%), we found statistically significant differences for initial reporting radiologist, final reporting radiologist, and final report timing between weekday and overnight. We found statistically significant differences for initial reporting radiologist and final report timing between weekday and weekend. Attending radiologist involvement in initial reports was 100% during daytime, but only 33.3% and 69.0% during overnight and weekends. For initial interpretation during overnight and weekend, 38.1% and 28.6% use resident radiologists without attending radiologists, and 28.6% and 2.4% use teleradiology. All finalized reports as soon as possible during weekdays, but only 52.4% and 78.6% during overnight and weekend. A minority of hospitals use 24-hour in-house radiology attending radiologist coverage. During overnight periods, the majority of academic pediatric emergency departments rely on resident radiologists without attending radiologist supervision or outside teleradiology services to provide initial reports. During weekend periods, over a quarter rely on resident radiologists without attending radiologist supervision for initial reporting. This demonstrates significant variation in staffing practices at academic pediatric hospitals. Future studies should look to determine whether this variation has any impact on standard of care.

Container CT scanner: a solution for modular emergency radiology department during the COVID-19 pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic period, container computed tomography (CT) scanners were developed and used for the first time in China to perform CT examinations for patients with clinically mild to moderate COVID-19 who did not need to be hospitalized for comprehensive treatment, but needed to be isolated in Fangcang shelter hospitals (also known as makeshift hospitals) to receive some supportive treatment. The container CT is a multidetector CT scanner installed within a radiation-protected stand-alone container (a detachable lead shielding room) that is deployed outside the makeshift hospital buildings. The container CT approach provided various medical institutions with the solution not only for rapid CT installation and high adaptability to site environments, but also for significantly minimizing the risk of cross-infection between radiological personnel and patients during CT examination in the pandemic. In this article, we described the typical setup of a container CT and how it worked for chest CT examinations in Wuhan city, the epicenter of COVID-19 outbreak.

The importance of trustworthy sources of scientific information in risk communication with the public.

ABSTRACTIn the event of a nuclear accident or radiological emergency, effective communication with the public on radiation risks is important in order to contain and rein in damage to physical and mental health, and social and economic consequences. The purpose of this paper is to summarize features of trustworthy sources of scientific information, and to convey their importance in radiation risk communication by recalling other aspects influencing the effectiveness of that communication. This will draw on key references in the literature, augmented with some experience and insight gleaned from a professional career of more than 35 years at the national and international level, including contributing to the International Atomic Energy Agency’s (IAEA) work on the consequences of the Chernobyl accident (1990–1995), heading its incident and emergency centre (1996–2005), and as the secretary (2005–2018) of the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), which conducts scientific reviews on the levels and effects of radiation exposure. The paper highlights the necessity of sound science and trustworthy sources, and recapitulates the main elements needed both to ensure solid conclusions on radiation epidemiology and to foster trust. The paper concludes that, while sound science and trustworthy sources are necessary, they are in themselves to a greater or lesser degree insufficient to ensure fully effective risk communication. Some of the major problems in communicating this science are highlighted to help others charged with preparing for and conducting this onerous task in the future.

The impact of COVID-19 quarantine efforts on emergency radiology and trauma cases

ObjectiveAmidst COVID-19 pandemic, many states have issued stay at home advisories and non-essential business closures to limit public exposure. During this “quarantine” period, it is important to understand the volume and types of emergency/trauma radiology cases to better prepare for the continuing and future pandemics. This study demonstrates new trends in pathologies and an overall increase in positive exams. MethodsA retrospective review of emergency department's imaging during the initial two weeks of this state's quarantine period, 3/23/2020–4/5/2020 was compared to similar dates of the previous year (“pre-quarantine” period), 3/25/2019–4/7/2019. One thousand emergency radiology and 991 trauma cases were evaluated. Of the emergency radiology cases 500 studies from each period were assessed, and from the trauma cases, 783 cases from pre-quarantine and 315 from the quarantine period were examined. Chi-square analysis was performed to assess for statistical significance. ResultsOverall there were 43.0% fewer emergency radiology studies performed during the quarantine period (n = 4530) compared to pre-quarantine period (n = 2585). Additionally, the number of positive cases was significantly higher (P = 0.0001) during the quarantine period (43.0%) compared to the pre-quarantine period (30.2%). Several trends in types of trauma were observed, including a significant increase in domestic violence during the quarantine period (P = 0.0081). DiscussionDifferent volumes and types of emergency/trauma imaging cases were observed during the recent quarantine period. Findings may assist emergency radiology departments to plan for future pandemics or COVID-19 resurgences by offering evidence of the types and volume of emergency radiology cases one might expect.

Update on establishing and managing an overnight emergency radiology division

Emergency department (ED) radiology divisions that serve to provide overnight attending coverage have become an increasingly common feature of radiology departments. The purpose of this article is to review the common ED radiology coverage models, describe desirable traits of emergency radiologists, and discuss workflow in the ED radiology setting. ED radiologists may be trained as ED radiologists or may develop the necessary skills and adopt the subspecialty. Choosing radiologists with the correct traits such as being a “night owl” and remaining calm under pressure and implementing an acceptable work schedule such as shift length of 9–10 h and a “one week on, two weeks off” schedule contribute to sustainability of the position. Strategies to address the unique stressors and workflow challenges of overnight emergency radiology coverage are also presented. Workflow facilitators including trainees, PAs, radiology assistants, and clerks all have roles to play in managing high case volumes and in making sure that the service is well staffed. Usage of artificial intelligence software is the latest technique to streamline workflow by identifying cases which should be prioritized on a busy worklist. Implementing such strategies will maintain quality of care for patients regardless of time of day as well as sustainability and quality of life for overnight emergency radiologists.

Effects of multiphase versus single-phase CT angiography for the detection of distal cerebral vessel occlusion.

The goal of this study was to determine whether the benefits of multiphase CTA (mCTA) over single-phase CTA (sCTA) for the detection of proximal cerebrovascular occlusions similarly extend to the distal cerebral vasculature. Four attending radiologists, two neuroradiologists and two emergency radiologists, contributed as readers to this retrospective study. For each reader, two sessions were conducted, one using sCTA and one using mCTA. During each session, the reader interpreted the studies of 104 patients who underwent imaging for suspicion of acute ischemic stroke, resulting in a total of 832 interpretations. Changes in diagnostic accuracy, time to render final decision, and reported levels of reader confidence were quantitatively assessed. Further analysis comparing the effects for neuroradiologists versus emergency radiologists was additionally conducted. Using mCTA resulted in a significant 5.0% absolute increase in sensitivity (91.6% vs. 96.6%, p = .004) and an insignificant increase in specificity (99.5% vs. 99.7%, p = .39). A significant reduction in reading time (66.7s vs. 59.6s, p = .001) and an increase in diagnostic confidence (2.26 vs. 2.58, p < .001) were observed. Using sCTA, higher sensitivity was achieved by neuroradiologists than emergency radiologists (96.0% vs. 86.9%, p = .002); using mCTA resulted in an absolute increase in sensitivity of 0.9% (97.4%, p = .44) for neuroradiologists and 9.6% (96.5%, p < .001) for emergency radiologists, eliminating significant differences between the groups (p = 0.57). The use of mCTA results in increased sensitivity and negative predictive value, decreased reading time, increased diagnostic confidence, and the elimination of differences in accuracy between neuroradiologists and emergency radiologists.

Knowing the unknowns: Uncertainties during radiological emergencies

Emergency management implies making decisions under uncertainty. Though this is a truism, uncertainties faced by different actors during radiological emergencies have not been investigated as intensively as other emergencies and lack a systematic analysis during realistic conditions. Hence, the goal of this study is to identify and analyse the uncertainties that may appear during radiological emergencies. Furthermore, this research explores among which actors and at which stages of decision-making process these uncertainties appear.For this purpose, non-participatory observation has been used during 11 nuclear or radiological emergency exercises in the period of 2017–2018 at 29 observation points in 6 countries and 1 international exercise. The observers recorded actual behavior of different actors (participants of the observed exercises) under live conditions.Results provide valuable insights into the complex decision-making process related to actions taken for the protection of individuals and society at large during realistic exercises of a radiological emergency. Most uncertainties synthesized from our observations are related to the practical implementation of emergency actions, e.g. the potential for unexpected failure of communication tools or channels, or the inadequacy of emergency plans to cope with the real situation. A high number of uncertainties were also associated to knowledge gaps, e.g. related to the consistency of radiological assessments or the insufficient familiarity of emergency actors with the rules and procedures. The findings of this study can inspire emergency planners and other stakeholders to strengthen radiological emergency management, advance emergency response practices, and improve communication and collaboration between different actors in emergency situations.

Salty Crackers as Fortuitous Dosimeters: A Novel PSL Method for Rapid Radiation Triage

When a radiological and nuclear (R/N) emergency occurs, the categorization of individuals into those who are unaffected and those requiring medical intervention is a high priority. At times, a professional dosimeter is not available and therefore some common belongings may be used as fortuitous dosimeters. The preparation of these objects for the measurement should be such as to give the most accurate and precise results. This paper focused on the Photo-Stimulated Luminescence (PSL) response of salty crackers confronts the problem of sample preparation (mass, grain size), dose response and signal stability. The dose response was determined for doses up to 5 Gy, which allowed the calculation of the limit of detection. Additionally, the signal stability was investigated for samples irradiated with 0.3 and 3 Gy. The observed decrease of the signal does not prevent the detection in the dose range typical for R/N emergency. The main dosimetric characteristics were investigated by using two different models of PSL readers equipped with single (infrared) or double (infrared, blue light) stimulation. The results indicated that the limit of detection can be improved by applying blue light stimulation. Moreover, strong correlation of the measurements performed in the two different instruments, as well as the rapidity of the analysis and the simplicity of the operations, suggest that this method can be suitable for a rapid radiation triage of a large number of civilians in a mass casualty event. The study was simultaneously conducted by two laboratories (Ruder Bošković Institute, RBI, Croatia and Istituto Superiore di Sanità, ISS, Italy) involved in the BioPhyMeTRE project (grant No. G5684) supported by NATO Science for Peace and Security Programme.