Initial Imaging Procedure Research Articles

Sonographic evaluation of congenital cystic neck masses with histopathological correlation

Background: Accurate diagnosis is important for planning of management of the congenital cystic neck mass. Clinical history, physical examination and appropriate knowledge of embryology and anatomy of the cervical region frequently allow the differential diagnosis to be narrowed and ultrasound especially high frequency ultrasound help to further confirmation. USG has been used as the initial imaging procedure in the evaluation of them. Ultrasound not only confirms the cystic nature of the lesion but also evaluates exact location, size, extent, relation to the surrounding structures and internal characteristic of mass.
 Objectives: To establish the usefulness of ultrasound in the evaluation of congenital cystic neck masses.
 Methods: From January 2014 to March 2018 a total 50 patients with clinically suspected congenital cystic mass in the neck region were selected who under want operative treatment and histopathological examination. A through history taking and physical examination were done then patient were scanned with gray scale ultrasound and colour Doppler in necessary case. Histopathological report collected from the patient and compare with USG diagnosis.
 Results: In USG 37 patient diagnosed as congenital lesions and 13 patient diagnosed as non-congenital lesion. Among the congenital lesions thyroglossal duct cyst-19, branchial cleft cyst-12, cystic hygroma-4, hemangioma-1 and epidermoid cyst-1. In histopathology 32 patient diagnosed as congenital lesion and 18 diagnosed as non-congenital lesion. Among the congenital lesions thyroglossal duct cyst-18, branchial cleft cyst-8, cystic hygroma-4, hemangioma-1 and epidermoid cyst-1. Among the 19 USG diagnosed thyroglossal duct cyst 17 is confirmed by histopathology and 2 is differ. Among the 12 USG diagnosed branchial cleft cyst 7 is confirmed by histopathology and 5 is differ. Over all sensitivity of USG-93.7% and specificity-64% and accuracy-74%.
 Conclusion: USG is a useful modality for the diagnosis of congenital cystic mass in the cervical region.
 Bangladesh J Otorhinolaryngol; April 2018; 24(1): 68-78

Health economic assessment of Gd-EOB-DTPA MRI versus ECCM-MRI and multi-detector CT for diagnosis of hepatocellular carcinoma in China

Limited data exists in China on the comparative cost of gadolinium ethoxybenzyl diethylenetriamine magnetic resonance imaging (Gd-EOB-DTPA-MRI) with other imaging techniques. This study compared the total cost of Gd-EOB-DTPA-MRI with multidetector computed tomography (MDCT) and extracellular contrast media–enhanced MRI (ECCM-MRI) as initial imaging procedures in patients with suspected hepatocellular carcinoma (HCC). We developed a decision-tree model on the basis of the Chinese clinical guidelines for HCC, which was validated by clinical experts from China. The model compared the diagnostic accuracy and costs of alternative initial imaging procedures. Compared with MDCT and ECCM-MRI, Gd-EOB-DTPA-MRI imaging was associated with higher rates of diagnostic accuracy, i.e. higher proportions of true positives (TP) and true negatives (TN) with lower false positives (FP). Total diagnosis and treatment cost per patient after the initial Gd-EOB-DTPA-MRI evaluation was similar to MDCT (¥30,360 vs. ¥30,803) and lower than that reported with ECCM-MRI (¥30,360 vs. ¥31,465). Lower treatment cost after initial Gd-EOB-DTPA-MRI was driven by reduced utilization of confirmatory diagnostic procedures and unnecessary treatments. The findings reported that Gd-EOB-DTPA-MRI offered higher diagnostic accuracy compared with MDCT and ECCM-MRI at a comparable cost, which indicates Gd-EOB-DTPA-MRI could be the preferred initial imaging procedure for the diagnosis of HCC in China.

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association.

### Background The use of synthetic material for reconstructive vascular surgery was first reported during the early 1950s. Infection involving vascular graft prostheses is an infrequent but devastating complication of reconstructive vascular graft surgery and is associated with a high morbidity and, in some situations, mortality. Improvements in surgical techniques and graft design, including the use of native venous or arterial tissue, have reduced the frequency of infection and severity of complications from vascular graft infection (VGI). However, these advances have also led to more frequent vascular graft procedures occurring in a patient population with multiple underlying comorbidities that would have previously disqualified them as candidates for vascular reconstructive surgery. Underlying comorbidities, such as diabetes mellitus or immune compromise, increase the risk of infection and serious infection-related complications. The major complications of VGI include sepsis, amputation, disruption of infected anastomotic suture line with rupture or pseudoaneurysm formation, embolization of infected thrombi, reinfection of reconstructed vascular grafts, enteric fistulae to the small or large bowel, bacteremic spread of infection to other sites, and death. VGIs can be categorized broadly into those that occur in an extracavitary location, primarily in the groin or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. ### Frequency The frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin.1–9 For intracavitary grafts, the infection rate is ≈1% to 5%.1–6 Graft infection is most common after emergency procedures and after reoperation.1–4,10 Aortic graft erosion or fistulous communication into the duodenum or other areas of the bowel reportedly occurs in 1% to 2% of patients after aortic reconstruction.11, …

Health economic evaluation of Gd-EOB-DTPA MRI vs ECCM-MRI and multi-detector computed tomography in patients with suspected hepatocellular carcinoma in Thailand and South Korea

Objective: The effectiveness of treatment decisions and economic outcomes of using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA-MRI) were compared with extracellular contrast media-enhanced MRI (ECCM-MRI) and multi-detector computed tomography (MDCT) as initial procedures in patients with suspected hepatocellular carcinoma (HCC) in South Korea and Thailand. Methods: A decision-tree model simulated the clinical pathway for patients with suspected HCC from the first imaging procedure to a confirmed treatment decision. Input data (probabilities and resource consumptions) were estimated and validated by clinical experts. Costs for diagnostic alternatives and related treatment options were derived from published sources, taking into account both payer’s and hospital’s perspectives. Results: All experts from Korea and Thailand agreed that Gd-EOB-DTPA-MRI yields the highest diagnostic certainty and minimizes the need for additional confirmatory diagnostic procedures in HCC. In Korea, from the payer’s perspective, total cost was USD $3087/patient to reach a confirmed treatment decision using Gd-EOB-DTPA-MRI (vs $3205/patient for MDCT and $3403/patient for ECCM-MRI). From the hospital’s perspective, Gd-EOB-DTPA-MRI incurred the lowest cost ($2289/patient vs $2320/patient and $2528/patient, respectively). In Thailand, Gd-EOB-DTPA-MRI was the least costly alternative for the payer ($702/patient vs $931/patient for MDCT and $873/patient for ECCM-MRI). From the hospital’s perspective, costs were $1106/patient, $1178/patient, and $1087/patient for Gd-EOB-DTPA-MRI, MDCT, and ECCM-MRI, respectively. Conclusions: Gd-EOB-DTPA-MRI as an initial imaging procedure in patients with suspected HCC provides better diagnostic certainty and relevant statutory health insurance cost savings in Thailand and Korea, compared with ECCM-MRI and MDCT.

Cost evaluation of gadoxetic acid-enhanced magnetic resonance imaging in the diagnosis of colorectal-cancer metastasis in the liver: Results from the VALUE Trial.

ObjectivesTo assess the costs of diagnostic workup and surgery of three strategies for patients with colorectal cancer liver-metastases (CRCLM): gadoxetic-acid-enhanced MRI (Gd-EOB-DTPA-MRI), MRI with extracellular contrast-media (ECCM-MRI) or contrast-enhanced MDCT (CE-MDCT).MethodsThe within-trial cost evaluation was modelled as a decision-tree to calculate the cost of diagnosis and surgery. The model used clinical outcomes and resource utilization data from a prospective randomized multicentre study. Analyses were performed for the 354-patient safety population from eight participating countries.ResultsThe diagnostic workup cost using Gd-EOB-DTPA-MRI upfront resulted in savings compared to ECCM-MRI in all countries except Thailand (difference <2 %). Compared to CE-MDCT, initial imaging with Gd-EOB-DTPA-MRI was less costly in all countries except Korea and Spain (differences 4 and 8 %, respectively). Significantly more patients in the Gd-EOB-DTPA-MRI group were eligible for surgery (39.3 % (48/122) vs. 31.0 % (36/116) and 26.7 % (31/116) for ECCM-MRI and CE-MDCT, respectively), allowing more patients to undergo potentially curative surgery, but resulting in higher treatment costs for the strategy starting with Gd-EOB-DTPA-MRI.ConclusionsThe benefits of Gd-EOB-DTPA-MRI due to less additional imaging and similar diagnostic workup costs in the three groups suggest that Gd-EOB-DTPA-MRI should be the preferred initial imaging procedure to evaluate hepatic resectability in patients with CRCLM.Key Points• Diagnostic imaging cost to evaluate resectability was similar among the groups • Cost for imaging was rather small compared to the cost of surgery • Significantly more patients in the Gd-EOB-DTPA-MRI arm were eligible for surgery • Gd-EOB-DTPA-MRI is recommended for evaluating hepatic resectability in patients with CRCLM Electronic supplementary materialThe online version of this article (doi:10.1007/s00330-016-4271-0) contains supplementary material, which is available to authorized users.

Use of Health Information Exchange and Repeat Imaging Costs

PurposeThe aim of this study was to quantify the association between health information exchange (HIE) use and cost savings attributable to repeat imaging. MethodsImaging procedures associated with HIE were compared with concurrent controls on the basis of propensity score matching over the period from 2009 to 2010 in a longitudinal cohort study. The study sample (n = 12,620) included patients ages 18 years and older enrolled in the two largest commercial health plans in a 13-county region of western New York State served by the Rochester Regional Health Information Organization. The primary outcome was a continuous measure of costs associated with repeat imaging. The determinant of interest, HIE use, was defined as system access after the initial imaging procedure and before repeat imaging. ResultsHIE use was associated with an overall estimated annual savings of $32,460 in avoided repeat imaging, or $2.57 per patient. Basic imaging (radiography, ultrasound, and mammography) accounted for 85% of the estimated avoided cases of repeat imaging. Advanced imaging (CT and MRI) accounted for 13% of avoided procedures but constituted half of the estimated savings (50%). ConclusionsHIE systems may reduce costs associated with repeat imaging. Although inexpensive imaging procedures constituted the largest proportion of avoided repeat imaging in our study, most of the estimated cost savings were due to small reductions in repeated advanced imaging procedures. HIE systems will need to be leveraged in ways that facilitate greater reductions in advanced imaging to achieve appreciable cost savings.

Atypical Femoral Fractures: Pearls and Pitfalls

Recently much attention has been given to the possible relationship between the use of bisphosphonates and some low-energy femoral fractures. These fractures were named “atypical fractures” to distinguish them from “typical fractures” that occur in the neck and trochanteric region of low energy trauma in the elderly and in the femoral shaft. Atypical fractures are stress fractures that occur in the femur (subtrochanteric or diaphyseal region) and are closely related to chronic use of bisphosphonates. Although the pathogenesis of atypical fracture of the femur remains unclear, several pathological mechanisms have been proposed. It is believed that prolonged use of bisphosphonates decrease osteoclast activity by reducing bone’s ability to remodel and leading to an accumulation of micro damage with reduced bone strength. There is a prodrome period of pain before the fracture is complete. The patients using bisphosphonates should be advised about the appearance of symptoms that might indicate a possible atypical femoral fracture. The emergence of pain in the groin or thigh should be investigated. Conventional radiography is usually the initial imaging procedure, followed by magnetic resonance imaging (MRI), computed tomography (CT) or bone scan. Symptomatic patients with an incomplete fracture can be treated conservatively or can have a prophylactic fixation indicated. For patients with atypical fractures or a stress reaction, the bisphosphonates must be stopped and adequate supplementation of calcium and vitamin D should be started. Alternatively, the use of parathyroid hormone (PTH) or others bone anabolic agents can be used in some cases.

Randomized multicentre trial of gadoxetic acid-enhanced MRIversusconventional MRI or CT in the staging of colorectal cancer liver metastases

BackgroundThis multicentre international randomized trial compared the impact of gadoxetic acid-enhanced magnetic resonance imaging (MRI), MRI with extracellular contrast medium (ECCM-MRI) and contrast-enhanced computed tomography (CE-CT) as a first-line imaging method in patients with suspected colorectal cancer liver metastases (CRCLM).MethodsBetween October 2008 and September 2010, patients with suspected CRCLM were randomized to one of the three imaging modalities. The primary endpoint was the proportion of patients for whom further imaging after initial imaging was required for a confident diagnosis. Secondary variables included confidence in the therapeutic decision, intraoperative deviations from the initial imaging-based surgical plan as a result of additional operative findings, and diagnostic efficacy of the imaging modalities versus intraoperative and pathological extent of the disease.ResultsA total of 360 patients were enrolled. Efficacy was analysed in 342 patients (118, 112 and 112 with gadoxetic acid-enhanced MRI, ECCM-MRI and CE-CT respectively as the initial imaging procedure). Further imaging was required in 0 of 118, 19 (17·0 per cent) of 112 and 44 (39·3 per cent) of 112 patients respectively (P < 0·001). Diagnostic confidence was high or very high in 98·3 per cent of patients for gadoxetic acid-enhanced MRI, 85·7 per cent for ECCM-MRI and 65·2 per cent for CE-CT. Surgical plans were changed during surgery in 28, 32 and 47 per cent of patients in the respective groups.ConclusionThe diagnostic performance of gadoxetic acid-enhanced MRI was better than that of CE-CT and ECCM-MRI as the initial imaging modality. No further imaging was needed in the gadoxetic acid-enhanced MRI group and comparison of diagnostic efficacy parameters demonstrated the diagnostic superiority of gadoxetic acid-enhanced MRI. Registration number: NCT00764621(http://clinicaltrials.gov); EudraCT number: 2008-000583-16 (https://eudract.ema.europa.eu/).

Diagnostics of septic arthritis in the sternoclavicular region: 10 consecutive patients and literature review

Septic arthritis in the sternoclavicular (SC) region is rare and may be difficult to diagnose clinically and radiologically. It mainly affects immunocompromised persons, and can clinically be misinterpreted as tumor and rheumatic disorders. Lacking radiological reference standard, a multimodality approach may contribute to a prolonged diagnostic process. To describe the diagnostics of septic arthritis in the SC region. Between 2001 and 2011 10 patients with Staphylococcus infection in the SC region were investigated in our institution. Clinical, biochemical, radiological, and microbiological findings were studied retrospectively; all CT and MR examinations were re-evaluated. Initial radiography in nine patients and ultrasonography in six patients were inconclusive resulting in supplementary MRI and/or CT. Five patients examined by MRI were immediately diagnosed with septic arthritis whereas CT in five patients led to the diagnosis in only one. Three were subsequently diagnosed by MRI, but delayed more than 2.5 weeks, and one was diagnosed by surgery. The median time to diagnosis was 1.5 weeks. The delay caused by imaging was 0 days to 11.5 weeks (median 0 days). By re-evaluation overlooked complications included mediastinitis in seven patients (three diffuse, four localized), and abscesses and pleuritis each in four patients. Awareness of infection in the SC region is important to avoid diagnostic delay. MRI is proposed as the initial imaging procedure.

ULTRASONOGRAPHY IN OBSTRUCTIVE JAUNDICE

Objective: To evaluate the validity of ultrasonography in patients who have obstructive jaundice. Design: Descriptive study.Place and duration of study: The study was carried out from September 2006 to May 2008 in department of Radiology Combined MilitaryHospital Quetta. Patients and Methods: A total of 30 patients; 14 male and 16 female underwent operation for obstructive jaundice. All of themhad preoperative ultrasonography. The site and nature of biliary obstruction were noted and the accuracy was determined with per-operativefindings / histological diagnosis as gold standard. Results: The cause of obstructive jaundice identified by ultrasonography with reasonablesensitivity of 90% and specificity of 90% for choledocholithiasis and sensitivity of 55.5% and specificity of 95.2% for pancreatic head tumours.Conclusions: Ultrasonography should be the first and best initial imaging procedure in patients who have obstructive jaundice and showsreasonable sensitivity and specificity to identify causes of obstruction in obstructive jaundice.

Intraperitoneal Spilled Gallstones Presenting as Fever of Unknown Origin After Laparoscopic Cholecystectomy

An otherwise healthy 63-year-old man who had undergone emergency laparoscopic cholecystectomy for acute calculous cholecystitis 6 weeks earlier developed daily fever for more than 3 weeks, malaise, weight loss, and elevated erythrocyte sedimentation rate. Initial imaging procedures (abdominal ultrasound and chest radiograph) were normal. The diagnosis of fever of unknown origin was established, and a whole-body FDG PET/CT scan was performed. PET/CT showed inflammatory changes corresponding to spilled intraperitoneal gallstones. We have described the PET/CT findings of spilled intraperitoneal gallstones, a relatively common complication of laparoscopic cholecystectomy.

Management of Postmenopausal Virilization

Mild clinical signs of hyperandrogenism such as hirsutism may appear during the menopausal transition as part of the normal aging process, but the development of frank virilization suggests a specific source of androgen excess, including androgen-secreting tumors. A 68-yr-old postmenopausal woman was referred because of a history of progressive development of hirsutism and frontal balding for the previous 8 yr, together with moderate hyperandrogenemia. Initial imaging procedures depicted a 2-cm solid nodule in the right adrenal gland and normal appearance of both ovaries. To confirm the source of androgen excess, we conducted simultaneous selective venous sampling of adrenals and ovaries. Sampling was consistent with an ovarian source. After bilateral laparoscopic salpingo-oophorectomy, the patient was diagnosed with bilateral ovarian hyperthecosis. Three weeks after surgery, her androgen levels had decreased to the normal female range. Diagnosis of hyperandrogenism in postmenopausal women is challenging. Postmenopausal virilization may be associated with adrenal or ovarian androgen-secreting tumors or with benign conditions. A detailed clinical history is critical to differentiate the progressive development of virilization that characterizes benign causes from the rapid progression that characterizes malignant tumors. Imaging techniques do not always reveal the cause of hyperandrogenism and may even be misleading. Although technically difficult, combined adrenal and ovarian venous sampling may be required to confirm the source of androgen excess before the best surgical approach is determined.

Dynamic Anal Endosonography and MRI Defecography in Diagnosis of Pelvic Floor Disorders: Comparison With Conventional Defecography

Pelvic floor disorders are frequent, especially in women. Surgeons need more information on the accuracy of available diagnostic techniques to make therapeutic decisions. This study aimed to compare the accuracy of dynamic anorectal endosonography and dynamic MRI defecography with conventional defecography as the criterion standard in the diagnosis of pelvic floor disorders. We used a prospective crossover design in which patients underwent each procedure in random order within the same month. Investigations were conducted at a regional referral center in Marseille, France. Women with dyschezia who were undergoing diagnostic evaluation were eligible. Dynamic anorectal endosonography, dynamic MRI, and conventional defecography were performed in all patients by 3 blinded operators. The accuracy of dynamic anorectal endosonography and dynamic MRI in the diagnosis of pelvic floor disorders was assessed by calculating sensitivity, specificity, positive and negative predictive values, correlation coefficients, concordance rates, and the Cohen κ statistic, with conventional defecography used as the criterion standard. The study comprised 56 women with a mean age of 50.7 (SD, 12.5) years. No significant differences were observed between dynamic anorectal endosonography and dynamic MRI in the number of patients with rectocele (P = .49), perineal descent (P = .11 when dynamic anorectal endosonography measured descent of the puborectalis muscle; P = .27 for bladder descent), or enterocele (P = .78); no differences were found between these techniques in sensitivity, specificity, or positive and negative predictive values. Diagnostic concordance with conventional defecography as the standard did not differ significantly between dynamic MRI and dynamic anorectal endosonography: Concordance rates for dynamic anorectal endosonography were 75% for rectocele, 64% for perineal descent, and 91% for enterocele (no rectal intussusception was found with dynamic anorectal endosonography); concordance rates for dynamic MRI were 82% for rectocele, 57% for perineal descent, 93% for enterocele, and 55% for rectal intussusception. Significantly more internal anal sphincter defects were found with dynamic anorectal endosonography than with dynamic MRI defecography: 21 patients (37.5%) vs 12 patients (21.4%); P = .02. Patient tolerance was significantly better for dynamic anorectal endosonography than for dynamic MRI (P = .002) or conventional defecography (P = .005). Most patients said they would choose dynamic anorectal endosonography (72.1%) rather than dynamic MRI (25.6%) or conventional defecography (2.3%) if follow-up were necessary (P < .001). Dynamic anorectal endosonography and dynamic MRI defecography show equivalent diagnostic performance in assessing pelvic floor disorders. However, because of its better tolerance and availability, dynamic anorectal endosonography may be preferable as the initial imaging procedure after clinical examination in the evaluation of pelvic floor disorders.

A six-year study of diagnostic lower extremity imaging practice patterns and outcomes in the Veterans Affairs health care system

The use of diagnostic imaging in the United States continues to increase, while investigations of the clinical implications following testing are lacking. The objectives of the present study are to describe the practice patterns and clinical outcomes that follow lower extremity diagnostic imaging. This is a retrospective cohort study with six years of data (1999 to 2004). The sources of data for the present study were Veterans Affairs Hospital administrative and clinical databases. The study population included 19,209 American veterans who had either contrast-enhanced magnetic resonance angiography (MRA) or digital subtraction angiography (DSA) for the assessment of peripheral artery occlusive disease. Descriptive statistics of the characteristics were provided, as well as adjusted ORs for having interventions or complications following an imaging procedure. The number of patients initially imaged with a contrast-enhanced MRA increased from 1999 to 2004, while those imaged with DSA decreased. The overall imaging rate remained relatively constant. In the multivariate model adjusted for the risk of complications within 30 days of the initial imaging procedure, the risk of complications following DSA increased 2.29-fold (95% CI 1.60 to 3.30). More patients had an intervention following DSA (DSA 41% versus MRA 23%, P<0.0001) but were also twice as likely to have an intervention with an amputation (adjusted OR 2.36, 95% CI 1.79 to 3.12). The present study illustrates the need for prospective evaluation of diagnostic imaging to determine how best to employ screening strategies that will optimize diagnostic imaging and treatment in patients diagnosed with peripheral artery occlusive disease.

Primary Renal Candidiasis

Primary renal candidiasis is rare but increasing in incidence. The purpose of this series is to provide imaging and clinical findings for diagnosing candidiasis and to discuss imaging in the management of this disease. Ten sonographic, 8 retrograde pyelographic, 2 intravenous pyelographic, 2 antegrade pyelographic, and 2 computed tomographic examinations of 5 patients (4 adult male patients and 1 16-year-old female patient) were reviewed. The clinical presentation was variable. Sonography showed renal pelvic wall thickening (n = 5), echogenic debris (n = 4), and fungus balls (n = 2). Papillary necrosis (n = 4), filling defects due to debris (n = 3), and fungus balls (n = 2) were seen on retrograde pyelography. Untreated candidiasis may progress to fungus ball or abscess formation. Sonography is commonly used as the initial imaging procedure. Retrograde and antegrade pyelography are used for biopsy, diagnosis, and treatment. Awareness of this condition and knowledgeable imaging evaluation can help detect and define the site, infection severity, and subsequent therapy.

NECROLYTIC MIGRATORY ERYTHAEMA AND GLUCAGONOMA SYNDROME

A 52-year old woman presented with vomiting, vague abdominal pain, progressive weight loss (85 kg to 76 kg) over the past 6 months and recurrent skin eruptions on her face, perineum and the extremities (fi gure A,B,C) which were diagnosed and treated as eczema. First evaluation revealed elevated fasting glucose level (139 mg/dl normal value 60-105) and oesophagogastroduodenoscopy showed refl ux oesophagitis grade A. CT scan and MRI of the abdomen showed a nodular hypervascular mass of 6,5 cm in the tail of the pancreas with lymph node involvement and multiple liver metastases (fi gure D). Other laboratory testing revealed markedly elevated glucagon (2970 pg/ml, normal value < 250), chromogranin A (517 μg/l, normal value 40-70). Diagnosis of a glucagonoma syndrome with necrolytic migratory erythema (NME) was made. Octreotide LAR, 20 mg once monthly was started. She underwent resection of the pancreatic tail and splenectomy. Three months later she underwent two sessions of transarterial doxorubicin based chemoembolisation of the liver, with stabilisation of her disease. She is still in follow-up with three monthly evaluations. Glucagonoma syndrome is a rare malignant disorder of the pancreas tumour, which comprises hyperglucagonaemia, diabetes mellitus, anaemia, weight loss, fatigue and NME. The incidence is 1 in 20 million per year. Dermatologic changes in NME may be misdiagnosed as they can suggest other dermatoses. The pathogenesis of NME remains controversial. Improvement in NME is often seen after surgery, somatostatin analogues and after supplementation. Spiral CT is the initial imaging procedure of choice. The optimal treatment for glucagonoma is dependent on the stage of the tumour and

Facilitated "fast track" referral reduces time from abnormal screening mammogram to diagnosis.

The Screening Mammography Program of British Columbia (SMPBC) implemented voluntary, facilitated referral to diagnostic imaging ("Fast Track") after testing 5 interventions to reduce time from an abnormal screening mammogram to diagnosis. The purpose of this study was to compare time intervals for patients evaluated through the Fast Track process with patients who were not. Data were extracted from the SMPBC database for women with abnormal screens conducted from January 1, 2003 to June 30, 2005 (N = 40,292). After exclusions, 39,607 screens were analyzed. Median and 90th percentile times were calculated from abnormal screen to diagnosis and for three subintervals: abnormal screen to notification, notification to first assessment, and first assessment to diagnosis. One third of abnormal screens were investigated through Fast Track imaging facilities. Overall, the median time from abnormal screen to diagnosis was 8 days faster for Fast Track compared with non-Fast Track. There was no clinically significant difference in time from abnormal screen to notification. The median time from notification to first assessment was 1.1 weeks (Fast Track) compared with 2.4 weeks (non-Fast Track), a reduction of 9 days or 54% in the interval targeted by the Fast Track strategy. The time interval distribution from first assessment to diagnosis was significantly different only for those having a core biopsy (average 3 days faster for Fast Track). Facilitated referral to diagnostic imaging reduces average time from notification of abnormal screen to first assessment by more than half. Additional strategies are needed to address diagnostic investigation beyond initial imaging procedures.

Facilitated “Fast Track” Referral Reduces Time from Abnormal Screening Mammogram to Diagnosis

The Screening Mammography Program of British Columbia (SMPBC) implemented voluntary, facilitated referral to diagnostic imaging (“Fast Track”) after testing 5 interventions to reduce time from an abnormal screening mammogram to diagnosis. The purpose of this study was to compare time intervals for patients evaluated through the Fast Track process with patients who were not. Data were extracted from the SMPBC database for women with abnormal screens conducted from January 1, 2003 to June 30, 2005 (N=40,292). After exclusions, 39,607 screens were analyzed. Median and 90th percentile times were calculated from abnormal screen to diagnosis and for three subintervals: abnormal screen to notification, notification to first assessment, and first assessment to diagnosis. One third of abnormal screens were investigated through Fast Track imaging facilities. Overall, the median time from abnormal screen to diagnosis was 8 days faster for Fast Track compared with non-Fast Track. There was no clinically significant difference in time from abnormal screen to notification. The median time from notification to first assessment was 1.1 weeks (Fast Track) compared with 2.4 weeks (non-Fast Track), a reduction of 9 days or 54% in the interval targeted by the Fast Track strategy. The time interval distribution from first assessment to diagnosis was significantly different only for those having a core biopsy (average 3 days faster for Fast Track). Facilitated referral to diagnostic imaging reduces average time from notification of abnormal screen to first assessment by more than half. Additional strategies are needed to address diagnostic investigation beyond initial imaging procedures.

Computed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism

Ventilation-perfusion (V(dot)Q(dot) lung scanning and computed tomographic pulmonary angiography (CTPA) are widely used imaging procedures for the evaluation of patients with suspected pulmonary embolism. Ventilation-perfusion scanning has been largely replaced by CTPA in many centers despite limited comparative formal evaluations and concerns about CTPA's low sensitivity (ie, chance of missing clinically important pulmonary embuli). To determine whether CTPA may be relied upon as a safe alternative to V(dot)Q(dot scanning as the initial pulmonary imaging procedure for excluding the diagnosis of pulmonary embolism in acutely symptomatic patients. Randomized, single-blinded noninferiority clinical trial performed at 4 Canadian and 1 US tertiary care centers between May 2001 and April 2005 and involving 1417 patients considered likely to have acute pulmonary embolism based on a Wells clinical model score of 4.5 or greater or a positive D-dimer assay result. Patients were randomized to undergo either V(dot)Q(dot scanning or CTPA. Patients in whom pulmonary embolism was considered excluded did not receive antithrombotic therapy and were followed up for a 3-month period. The primary outcome was the subsequent development of symptomatic pulmonary embolism or proximal deep vein thrombosis in patients in whom pulmonary embolism had initially been excluded. Seven hundred one patients were randomized to CTPA and 716 to V(dot)Q(dot scanning. Of these, 133 patients (19.2%) in the CTPA group vs 101 (14.2%) in the V(dot)Q(dot scan group were diagnosed as having pulmonary embolism in the initial evaluation period (difference, 5.0%; 95% confidence interval [CI], 1.1% to 8.9%) and were treated with anticoagulant therapy. Of those in whom pulmonary embolism was considered excluded, 2 of 561 patients (0.4%) randomized to CTPA vs 6 of 611 patients (1.0%) undergoing V(dot)Q(dot scanning developed venous thromboembolism in follow-up (difference, -0.6%; 95% CI, -1.6% to 0.3%) including one patient with fatal pulmonary embolism in the V(dot)Q(dot group. In this study, CTPA was not inferior to V(dot)Q(dot scanning in ruling out pulmonary embolism. However, significantly more patients were diagnosed with pulmonary embolism using the CTPA approach. Further research is required to determine whether all pulmonary emboli detected by CTPA should be managed with anticoagulant therapy. isrctn.org Identifier: ISRCTN65486961.

Invasive amebiasis: an update on diagnosis and management

In its invasive form, the trophozoite is responsible for clinical syndromes, ranging from classical dysentery to extraintestinal disease with emphasis on hepatic amebiasis. Abdominal pain, tenderness and diarrhea of watery stool, sometimes with blood, are the predominant symptoms of amebic colitis. Besides the microscopic identification of Entamoeba histolytica, diagnosis should be based on the detection of specific antigens in the stool or PCR associated with the occult blood in the stool. Amebic dysentery is treated with metronidazole, followed by a luminal amebicide. The trophozoite reaches the liver causing hepatic amebiasis. Right upper quadrant pain, fever and hepatomegaly are the predominant symptoms. The diagnosis is made by the finding of E. histolytica in the hepatic fluid, or in the necrotic material at the edge of the lesion in a minority of patients, and by detection of antigens or DNA. Ultrasonography is the initial imaging procedure indicated. The local perforation of hepatic lesion leads to important and serious complications.