Inadequate Visualization Research Articles

The Changing Paradigm in the Treatment of Structural Heart Disease and the Need for the Interventional Imaging Specialist.

Percutaneous interventions in structural heart diseases are emerging rapidly. The variety of novel percutaneous treatment approaches and the increasing complexity of interventional procedures are associated with new challenges and demands on the imaging specialist. Standard catheterisation laboratory imaging modalities such as fluoroscopy and contrast ventriculography provide inadequate visualisation of the soft tissue or three-dimensional delineation of the heart. Consequently, additional advanced imaging technology is needed to diagnose and precisely identify structural heart diseases, to properly select patients for specific interventions and to support fluoroscopy in guiding procedures. As imaging expertise constitutes a key factor in the decision-making process and in the management of patients with structural heart disease, the sub-speciality of interventional imaging will likely develop out of an increased need for high-quality imaging.

Magnetic Resonance Imaging Following Spine Trauma.

Magnetic resonance imaging (MRI) provides high-resolution images without ionizing radiation. It has substantially improved our diagnostic capability following spine trauma, especially for assessing soft-tissue structures. Strong, changing magnetic fields are used to generate cross-sectional images on the basis of the anatomy and chemical composition of the tissues. Nevertheless, compared with radiographs and computed tomography (CT) scans, MRI has several disadvantages, including inadequate visualization of bones, the considerable amount of time required for the procedure (rendering this method impractical in emergency situations), logistical considerations (including the availability of infrastructure and skilled technicians and the necessity for patient transfer), and high cost. Moreover, MRI is routinely performed with the patient in the supine position and therefore may not detect instability associated with loading (upright) positions. Finally, MRI is contraindicated for patients …

Multicenter, randomized, tandem evaluation of EndoRings colonoscopy--results of the CLEVER study.

Adenoma miss rate during colonoscopy has become a widely acknowledged proxy measure for post-colonoscopy colorectal cancer. Among other reasons, this can happen because of inadequate visualization of the proximal aspects of colonic folds and flexures. EndoRings (EndoAid Ltd., Caesarea, Israel) is a silicone-rubber device that is fitted onto the distal end of the colonoscope. Its flexible circular rings engage and mechanically stretch colonic folds during withdrawal. The primary aim of this study was to compare adenoma miss rates between standard colonoscopy and colonoscopy using EndoRings. In this multicenter, randomized, tandem colonoscopy study, we performed same-day, back-to-back colonoscopies with EndoRings followed by standard colonoscopy, or vice versa. After exclusion of 10 patients for protocol violations, 116 patients (38.8% female; mean age 58.7) remained for analysis. The adenoma miss rate of EndoRings colonoscopy (7/67; 10.4%) was significantly lower (P<0.001) compared with standard colonoscopy (28/58; 48.3%). Similar results were found for polyp miss rates: EndoRings (9.1%) and standard colonoscopy (52.8%; P<0.001). Mean cecal intubation times (9.3 vs. 8.4 minutes; P=0.142) and withdrawal times (7.4 vs. 7.2 minutes; P=0.286), respectively, were not significantly different between EndoRings and standard colonoscopy. Mean total procedure time was longer with EndoRings than with standard colonoscopy (21.6 vs. 18.5 minutes, P=0.001) as more polyps were removed. This study demonstrates that colonoscopy with EndoRings has lower adenoma and polyp miss rates than standard colonoscopy, which may improve the efficacy particularly of screening and surveillance colonoscopies. ClinicalTrials.gov NCT01955122.

Vaginal Misoprostol for Overcoming Inadequate Colposcopies: A Meta-analysis of Randomized Controlled Trials.

Inadequate colposcopic results due to inadequate visualization of the cervical transformation zone is a diagnostic problem that is encountered in approximately 10% to 15% of these procedures. The objective of the present systematic review and meta-analysis was to investigate whether misoprostol effectively converts inadequate colposcopic examinations to adequate. We searched MEDLINE (1966-2014), Scopus (2004-2014), Popline (1974-2014), ClinicalTrials.gov (2008-2014), CENTRAL (1999-2014), and Google Scholar (2004-2014) search engines along with reference lists of all electronically retrieved articles. For the meta-analysis of selected indices, we used the RevMan 5.2 program. Treatment with misoprostol significantly increases the rates of adequate colposcopic examinations (odds ratio [OR] = 6.78, 95% confidence interval [CI] = 2.94-15.61). Its principal adverse effect is abdominal pain (OR = 10.19, 95% CI = 2.19-47.45). Neither nausea (105 women, random effects model [REM], OR = 4.99, 95% CI = 0.54-45.71) nor fever (111 women, REM, OR = 3.90, 95% CI = 0.59-25.56) or diarrhea (111 women, REM, OR = 2.21, 95% CI = 0.49-10.00) was found increased among women receiving misoprostol. The conversion rates toward an adequate examination ranged between 55.5% and 78.9% in the misoprostol group. According to our meta-analysis, misoprostol seems to improve the conversion rates from inadequate colposcopic examinations to adequate diagnoses. However, firm results to generalize our findings among specific populations, such as those already having a previous conization, are precluded by the small number of enrolled studies. Thus, future research in the field becomes necessary.

Characterising ‘near miss’ events in complex laparoscopic surgery through video analysis

BackgroundRoot cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical...

Minimally invasive primary aortic valve surgery: the OLV Aalst experience.

The purpose of this study was to evaluate our in-hospital outcomes with primary J-sternotomy aortic valve surgery since the initiation of our program in 1997. Between October 1(st) 1997 and August 31(st) 2014, 768 patients (mean age: 69.1±11.2 years, 46.6% females, 15.6% aged greater than 80 years) underwent primary JS-AVS. Additional risk factors included diabetes mellitus (n=98, 12.2%), peripheral vascular disease (n=42, 5.5%) and body mass index greater than 30 (n=144, 18.8%). The mean logistical EuroSCORE I was 5.46%±4.5%. Aortic valve replacement and repair were performed in 758 (98.7%) and 10 (1.3%) patients respectively, for isolated valve stenosis (n=472, 61.8%), incompetence (n=56, 7.3%) and mixed valve disease (n=236, 30.9%). Valve pathology included sclerosis (n=516, 67.2%), rheumatic disease (n=110, 14.3%) and endocarditis (n=10, 1.3%). Reasons for conversion to full sternotomy (n=23, 3.0%) included porcelain ascending aorta (n=3, 0.4%), inadequate visualization (n=2, 0.3%) and intra-operative complications (n=18, 2.3%). Mean length of hospital stay was 11.0±7.4 days. Morbidity included stroke (n=15, 2.0%), revision or re-exploration (n=52, 6.8%), atrial fibrillation (n=201, 26.2%) and sternitis (n=5, 0.7%). In-hospital mortality was 1.6% (n=12). Overall survival at 30 days was 98.0%. JS-AVS is safe and is our routine approach for isolated aortic valve disease. Procedure related mortality is lower than predicted, conversion rates limited and significant morbidity minimal.

Evaluation of the use of freehand SPECT for sentinel node biopsy in early stage oral carcinoma

Inadequate intraoperative visualization of the sentinel node can hamper its harvest. Freehand SPECT is a 3D tomographic imaging modality based on the concepts of SPECT, which can be used for intraoperative visualization and navigation towards the sentinel node in order to improve its localization and removal during surgery. The use of freehand SPECT was evaluated during 66 sentinel node biopsy procedures in early stage oral cancer patients. Intraoperative detection of sentinel nodes was compared with preoperative identified sentinel nodes on lymphoscinitigraphic examination. Additional value of freehand SPECT was subjectively scored by the surgeon directly following the biopsy procedure. Freehand SPECT was able to detect 94% of sentinel nodes intraoperatively. Most sentinel nodes not detected (7 out of 9) were located in level I of the neck. Freehand SPECT appeared to be of additional value for facilitating the intraoperative detection of the sentinel node in 24% of procedures. The use of the freehand SPECT system is feasible in the intraoperative detection of sentinel nodes in early stage oral cancer. Freehand SPECT provides helpful information facilitating the SN biopsy procedure in a quarter of cases. However, freehand SPECT cannot detect all SNs which are located in the vicinity of the injection site.

Analysis of a Grading System to Assess Quality of Small Bowel Preparation for Capsule Endoscopy: In Search of the Holy Grail

Introduction: Capsule endoscopy (CE) diagnostic yield is vulnerable to inadequate visualization related to residual bile or chyme remaining in the lumen despite intestinal lavage. There remains no consensus on the reliability of qualitative, quantitative, or computer-derived quality assessments for CE. This study evaluates the intra-observer and inter-observer agreement of a previously validated scale. Methods: The digital images of 34 patients who underwent CE were independently reviewed by 2 blinded physicians according to a previously validated grading scale. One of the physicians reviewed and graded the patients a second time, also in blinded fashion. The luminal bowel preparation quality was assessed using a qualitative parameter (fluid transparency) and a more quantitative one (mucosal invisibility) for each of 3 small intestinal segments. An overall small bowel score for each parameter was assigned as well. A weighted kappa coefficient was used to calculate the intra-observer (Observer 1A and 1B) and inter-observer (Observer 1A and Observer 2) agreement. A kappa of 0.60 or more suggests strong agreement, 0.40 to 0.60 moderate agreement, and less than 0.40 is indicative of low agreement. Results: The intra-observer weighted kappa index was 0.52 for both fluid transparency and mucosal visibility, which is consistent with moderate agreement. The inter-observer weighted kappa indices were 0.29 and 0.42 for fluid transparency and mucosal visibility, respectively, demonstrating suboptimal interobserver agreement. Individual segment inter-observer kappa indices were better for mucosal visibility (0.52, 0.39, and 0.47 for small bowel segments 1, 2 and 3, respectively) as compared to fluid transparency (0.18, 0.38 and 0.31). Conclusion: The proposed grading scale for assessment of CE preparation quality has inadequate interobserver and intra-observer agreement. Capsule endoscopy preparation grading scales which focus more on quantitative than qualitative assessment may demonstrate more reliable performance characteristics.Table 1

Role of laparoscopy in patients with peritoneal metastases considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

BackgroundWe hypothesized that diagnostic laparoscopy (DL) was feasible for the evaluation of patients with peritoneal carcinomatosis (PC) undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).MethodsA retrospective review of PC patients treated from January 2010 to April 2013 was conducted. Data on tumor characteristics, treatment details and survival outcomes were extracted and analyzed.ResultsOf the 101 PC patients (mean age 52.9 ± 14.1 years), 73 diagnostic laparoscopies DL (61 concurrent with CRS + HIPEC) were performed in 70 patients whereas 31 patients underwent direct exploratory laparotomy (EL). Complete laparoscopic assessment was possible in 63 cases (86.3%), resulting in 18 exclusions (27.7%) while 10 cases were converted to open due to inadequate laparoscopic visualization. Subsequently, CRS + HIPEC was performed in 85.4% (of 55 selected for HIPEC, DL) versus 74.2% (EL, P value = 0.20). Among those excluded from HIPEC at the initial operation, delayed HIPEC after conversion chemotherapy was achieved in 6 (of 11 with extensive disease, DL). The incidence of grade 3 to 5 complications was 0% DL versus 10% EL (P value = 0.2). There were no port site recurrences at mean follow up of 9.1 ± 8 months.ConclusionsLaparoscopy is a feasible technique for selecting patients with PC for CRS + HIPEC, and can help select patients for conversion chemotherapy in the setting of high peritoneal carcinomatosis index (PCI) score.

Analysis of a grading system to assess the quality of small-bowel preparation for capsule endoscopy: in search of the Holy Grail.

Background: The diagnostic yield of capsule endoscopy is vulnerable to inadequate visualization related to residual bile or chyme remaining in the lumen despite intestinal lavage. It has been challenging to determine the optimal lavage preparation of the bowel and patient diet before capsule endoscopy, as well as the timing of the procedure, because no well-accepted, validated grading system for assessing the quality of intestinal lavage before capsule endoscopy is available. There remains no consensus on the reliability of qualitative, quantitative, or computer-derived assessments of the quality of preparation for capsule endoscopy. This study evaluates intra-observer and interobserver agreement for a previously validated scale. Materials and methods: The digital images of 34 patients who underwent capsule endoscopy were independently reviewed by two blinded physicians according to a previously validated grading scale. One of the physicians reviewed and graded the patients a second time. The quality of the bowel luminal preparation was assessed with a qualitative parameter (fluid transparency) and a more quantitative parameter (mucosal invisibility) for each of three small-intestinal segments, and an overall small-bowel score for each parameter was assigned as well. A weighted kappa coefficient was used to calculate intra-observer (observer 1A and 1B) and interobserver (observer 1A and observer 2) agreement. A kappa value of 0.60 or more suggests strong agreement, 0.40 to 0.60 moderate agreement, and less than 0.40 poor agreement. Results: The intra-observer weighted kappa index for both fluid transparency and mucosal visibility was 0.52, which is consistent with moderate agreement. The interobserver weighted kappa indices for fluid transparency and mucosal invisibility were 0.29 and 0.42, respectively, demonstrating suboptimal interobserver agreement. The individual segment interobserver kappa indices were better for mucosal visibility (0.52, 0.39, and 0.47 for small-bowel segments 1, 2, and 3, respectively) than for fluid transparency (0.18, 0.38, and 0.31). Conclusions: The proposed grading scale for assessing the quality of preparation for capsule endoscopy has inadequate interobserver and intra-observer agreement. Capsule endoscopy preparation grading scales that focus more on quantitative than on qualitative assessment may demonstrate more reliable performance characteristics. Optimizing the quality of preparation and diagnostic yield of capsule endoscopy will first require the development of a well-validated grading scale.

Bedside inferior vena cava filter placement by intravascular ultrasound in critically ill patients is safe and effective for an extended time.

Bedside inferior vena cava filter (IVCF) placement by intravascular ultrasound (IVUS) guidance has previously been shown to be a safe and effective technique, especially for critically ill patients, with initial experience of a prospectively implemented algorithm. The purpose of this study was to evaluate the effectiveness of IVUS-guided filter placement in critically ill patients with experience now extending out 5years from implementation. All patients undergoing bedside IVUS-guided IVCF placement from 2008 to 2012 were identified. Records were reviewed on the basis of IVCF reporting standards. Outcomes data including technical success, complications, and mortality were analyzed at 30 days. During the 5-year period, 398 patients underwent attempted bedside IVCF placement by IVUS. Technical feasibility was possible in 396 cases (99.5%); two bedside procedures were aborted because of inadequate IVUS visualization. Overall technical success was achieved in 393 of 396 (99.2%), with malpositioned IVCF in three cases. An optional IVCF was used in 372 (93.9%) and a permanent IVCF in 24 (6.1%). Single-puncture technique was performed in 388 (97.4%); additional dual access was required in 10 (2.6%). Periprocedural complications were rare (3.0%) and included malpositioning that required retrieval and repositioning or an additional IVCF (3), filter tilt ≥20 degrees (4), arteriovenous fistulas (2), insertion site thrombosis (2), and hematoma (1). Comparison of the first 100 procedures performed within the sample population with the last 100 procedures revealed an overall success rate of 96% in the first 100 compared with 100% in the last 100 (P= .043). There were no deaths related to pulmonary embolism or IVCF-related problems. On the basis of 5years of experience with bedside IVCF placement in critically ill patients, the IVUS-guided IVCF technique continues to be a safe and effective option in this high-risk population, with a time-dependent improvement in outcome measures.

Bowel preparation for colonoscopy with magnesium sulphate and low-volume polyethylene glycol

Patient compliance with bowel cleansing procedures represents one of the most objectionable aspects of colonoscopy. Adverse reactions to the purgative may result in failure to complete the preparation, inadequate visualization of the colon, polyp and even carcinoma miss rate and unwillingness to attend a follow-up colonoscopy. The primary objective of the study was to evaluate the effectiveness of bowel cleansing with magnesium sulphate and low-volume polyethylene glycol (PEG) with electrolytes. The second objective was to evaluate whether bowel cleansing was better in participants scheduled for morning colonoscopies or afternoon colonoscopies. Magnesium sulphate mineral water (2 l) and 2 l of low-volume PEG and electrolytes solution were used as our bowel cleansing protocol. A total of 13 914 participants, who participated in the Slovenian colorectal cancer screening programme in the period between 2009 and 2011, were included. Excellent bowel preparation was achieved in 11 484 (82.61%) participants; 1894 (13.62%) participants had good bowel preparation, 439 (3.16%) participants had fair bowel preparation and 85 (0.61%) participants had poor bowel preparation. Better results were achieved in the afternoon colonoscopies and in younger participant groups (P<0.001). No serious side effects of bowel cleansing were reported. This is the first study to use magnesium sulphate mineral water and PEG plus electrolytes for bowel cleansing. We found excellent bowel cleansing in 82.61% participants and in more participants if colonoscopy was performed in the afternoon.

What is the use of imaging before referral to an orthopaedic oncologist? A prospective, multicenter investigation.

Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests. (1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study? We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan. There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%-88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p < 0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68-4.69, p < 0.001). We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Su1755 Use of ERCP in Pediatric Patients With Acute Recurrent and Chronic Pancreatitis: a Report From the Insppire (International Study Group of Pediatric Pancreatitis: in Search for a Cure) Consortium

Su1752 Comparison of Colonoscopy Preparations in a Pediatric Population Caroline T. Meyer*, Christina a. Hickey, June Y. Hu, Charles M. Samson, Elizabeth C. Utterson Pediatric Gastroenterology, Washington University in St. Louis, Saint Louis, MO; Pediatrics, Washington University in St. Louis, Saint Louis, MO Background: Poor quality colonoscopy preparation in pediatric patients can lead to inadequate visualization of colonic mucosa resulting in missed diagnoses, increased time under anesthesia and the need for repeat procedures. There have been few studies in the literature comparing colonoscopy preparation regimens in pediatric patients. Aims: To compare the efficacy of 2 different colonoscopy preparation regimens in pediatric patients at our institution. Methods: For our institutional quality improvement project, three endoscopists scored the visualization of colonic mucosa based on the Boston Bowel Prep Score (scores 0-9) and time to completion of colonoscopy (measured in!30 minutes, 30 minutes-1 hour, and O1 hour) in patients 8 years and older throughout a six month time period. An adequate cleanout was determined by a score R 5. Patients were prescribed either a regimen of 240 ml of magnesium citrate with two 10mg bisacodyl suppositories (phase 1) or polyethylene glycol (PEG) 3350 (8-12 years old: 119 grams in 960 ml of fluid and O12 years old: 238 grams of PEG 3350 in 1.92 liters of fluid) with oral bisacodyl (8-12 years old: 10mg and O12 years old: 20mg) (phase 2). Both groups were instructed to drink clear liquids the day prior to the procedure. The patients and their families were asked if they had completed all portions of the regimen prior to colonoscopy. Appropriate statistical tests were performed using IBM SPSS. Results: Forty-four patients were scored on the magnesium citrate/bisacodyl suppository prep and fifty patients were scored on the PEG 3350/oral bisacodyl prep. Two patients (one in each group) completed!75% of the regimen. Patients ranged in age from 8-25 years old. There was no significant difference in the mean age (pZ0.29) or the male to female ratio between groups (pZ0.85). The mean bowel prep score of the PEG 3350 group was 6.4 compared to 5.14 in the magnesium citrate group; the distributions of the two groups differed significantly (p!0.001) with statistically different medians (pZ0.03). The proportion of patients in the PEG 3350 group with a bowel prep score R 5 was 76% compared to 59% in patients receiving magensium citrate (pZ0.08) The percent of patients where the colonscopy was completed in less than 30 minutes was significantly higher in the PEG 3350 group (46% vs. 24%, pZ0.03). Conclusions: In our quality improvement project, there was a significant improvement in the efficacy as measured by visualization of colonic mucosa in the PEG 3350/oral bisacodyl treated group and improvement in the percent of colonoscopies completed in less than 30 minutes compared to the magnesium citrate/bisacodyl suppository group. Future studies utilizing patient questionnaire data and larger prospective blinded trials would provide additional information on tolerance and efficacy of bowel preparatory regimens in pediatric patients.

Su1752 Comparison of Colonoscopy Preparations in a Pediatric Population

Poor quality colonoscopy preparation in pediatric patients can lead to inadequate visualization of colonic mucosa resulting in missed diagnoses, increased time under anesthesia and the need for repeat procedures. There have been few studies in the literature comparing colonoscopy preparation regimens in pediatric patients.

Improved quality of surgical field during endoscopic sinus surgery after clonidine premedication—a pilot study

Inadequate surgical field visualization due to intraoperative bleeding during endoscopic sinus surgery (ESS) can cause major complications. The aim of this prospective study was to compare the effect of preoperative administration of clonidine and melatonin on the quality of the surgical field visualization and selected aspects of presurgical premedication. Twenty-six patients undergoing ESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or melatonin as preoperative premedication. During the operation, the quality of the surgical field was assessed and graded using the scale proposed by Boezaart. The evaluations were done at 15, 30, and 60 minutes after incision. The effect of this premedication choice on the intraoperative and postoperative hemodynamic profile was examined in each group. Anxiolytic effects of both premedication agents were assessed using the visual analogue scale for anxiety (VAS-A). Propofol dose and induction time (the time for bispectral index [BIS] to reach 45), anesthesia and surgical procedures time, and recovery time (the time for BIS to reach 90) were assessed in both groups as well. The quality of the surgical field was consistently better in 2 of 3 time points in the clonidine group. Perioperative mean arterial pressure and intraoperative heart rate had a more favorable profile in patients premedicated with clonidine. There were no differences in other measured parameters between groups. Premedication with clonidine before ESS provides better quality of surgical field and more favorable hemodynamic profile as compared to melatonin.

Repeat Spine Imaging in Transferred Emergency Department Patients

Retrospective study. Assess frequency of repeat spine imaging in patients transferred with known spine injuries from outside hospital (OSH) to tertiary receiving institution (RI). Unnecessary repeat imaging after transfer has started to become a recognized problem with the obvious issues related to repeat imaging along with potential for iatrogenic injury with movement of patients with spine problems. Consecutive adult patients presenting to a single 1-level trauma center with spine injuries during a 51-month period were reviewed (n = 4500), resulting in 1427 patients transferred from OSH emergency department. All imaging and radiology reports from the OSH were reviewed, as well as studies performed at RI. A repeat was the same imaging modality used on the same spine region as OSH imaging. The overall rate of repeat spine imaging for both OSH imaging sent and not sent was 23%, and 6% if repeat spine imaging via traumagram (partial/full-body computed tomography [CT]) was excluded as a repeat. The overall rate of repeat CT was 29% (7% dedicated spine CT scans and 22% part of nondedicated spine CT scan).An observation of only those patients with OSH imaging that was sent and viewable revealed that 23% underwent repeat spine imaging with 23% undergoing repeat spine CT and 41% repeat magnetic resonance imaging.In those patients with sent and viewable OSH imaging, a lack of reconstructions prompted 14% of repeats, whereas inadequate visualization of injury site prompted 8%. In only 8% of the repeats did it change management or provide necessary surgical information. This study is the first to investigate the frequency of repeat spine imaging in transfers with known spine injuries and found a substantially high rate of repeat spine CT with minimal alteration in care. Potential solutions include only performing scans at the OSH necessary to establish a diagnosis requiring transfer and improving communication between OSH and RI physicians. 4.

Quantification of epicardial fat volume using cardiovascular magnetic resonance imaging

Background A growing body of data has demonstrated a direct relationship between epicardial fat volume(EFV) and cardiovascular diseases. In fact, EFV has been shown to be an independent predictor of coronary atherosclerosis and atrial fibrillation. Currently, there is no standard protocol for assessing EFV using cardiac magnetic resonance imaging (CMR). Quantification of peri-ventricular EFV utilizing end diastolic short-axis cine sequences has been described; however, this technique is often challenging due to inadequate visualization of the pericardium. Oftentimes, the pericardium is better visualized during the systolic phase. Thus, we sought to determine the correlation and reproducibility of conventional EFV quantification using end diastolic with end systolic short-axis slices.

Role of hysteroscopy and endometrial biopsy in women with unexplained infertility

This study was designed to evaluate the role of hysteroscopy and endometrial biopsy in women with unexplained infertility. Women with unexplained infertility were included in this prospective study, evaluated with transvaginal sonography and diagnostic hysteroscopy. Diagnostic hysteroscopy was performed between the 7th and 11th day of the cycle. The criteria for hysteroscopic findings were based on the cervical canal, uterine cavity, endometrium, visualization of the ostium tubae and lesions of the utero-tubal junction. After the hysteroscopic examination, endometrial biopsy was performed using a Pipelle endometrial suction curette. Patients were classified according to the hysteroscopy results into four groups: patients with no abnormality detected (14), patients with cervical abnormalities (six), patients with endometrial abnormalities (73) and patients with uterine abnormalities (seven). One hundred women with unexplained infertility were included. All patients underwent diagnostic hysteroscopy, except for seven patients: six patients had stenotic external or internal cervical ostium and one had inadequate visualization as the uterine cavity was filled with blood. Based on hysteroscopic findings, 31 patients were finally diagnosed with endometrial polyps; 14 endometritis; 15 endometrial hyperplasia; six submucous myomas; seven intrauterine synechiae (73 cases = endometrial abnormalities group); seven congenital uterine anomalies (uterine abnormalities group), six cervical stenosis (cervical abnormalities group) and 14 women without any uterine abnormalities (no abnormalities group). Analysis of samples obtained using the Pipelle endometrial suction curette was non-diagnostic in 16 cases; the most common endometrial pathological feature detected by this analysis was endometritis (15%). Routine hysteroscopy and endometrial biopsy should be used as a basic part of the work-up for women with unexplained infertility.

Premedication with N-acetylcysteine and simethicone improves mucosal visualization during gastroscopy

Diagnostic gastroscopy provides a unique opportunity to diagnose early oesophagogastric neoplasia; however, intraluminal mucus and bile can obscure mucosal visualization. The aim of this study was to determine whether the use of a premedication solution containing the mucolytic agent N-acetylcysteine and the surfactant simethicone improves mucosal visualization within a UK diagnostic gastroscopy service. A total of 75 consecutive patients were recruited from a single (S.J.) endoscopist's diagnostic gastroscopy list. They were randomized into three treatment groups: (a) standard control=clear fluids only for 6 h, nil by mouth for 2 h; (b) water control=standard control+100 ml sterile water (given 20 min before gastroscopy); and (c) solution=standard control+100 ml investigated solution (20 min before gastroscopy). The endoscopist was blinded to patient preparation. Inadequate mucosal visualization was defined as fluid/mucus during gastroscopy that could not be suctioned and required flushing with water. The volume of flush, the site at which it was used and the total procedure times were recorded. All three groups showed no statistical difference for age, sex ratio, procedure priority or indication. The mean volume of flush required to obtain clear mucosa was significantly less in the solution group compared with the other groups. The mean overall procedure time was also less in the solution group compared with the other groups. Premedication with N-acetylcysteine and simethicone markedly improves mucosal visibility during gastroscopy. It also reduces the time taken for the procedure. This low-cost and well-tolerated intervention may improve detection of early neoplasia.