Overuse Of CT Research Articles

A multicenter retrospective cohort study on incidence and diagnostics in emergency department patients with acute vestibular syndrome.

Acute vestibular syndrome (AVS) is a common symptom presented by emergency department (ED) patients. Differentiating peripheral from central etiology poses a challenge and clinical practice lacks a uniform diagnostic approach. This study aims to provide insight on incidence and diagnostics in ED patients presenting with AVS in the Netherlands. A multicenter retrospective cohort study on ED patients presenting with AVS in two hospitals during 3 years. Primary endpoints are incidence, diagnostics and diagnosis at ED versus follow-up. A secondary endpoint includes therapy. 500 AVS cases were included. The annual incidence was 0.1%. 85 ED patients (17.0%) were diagnosed with stroke, 285 (57.0%) with non-stroke and 130 (26.0%) with an unsure etiology. At follow-up, diagnosis was corrected in 145 patients (29.0%), with stroke missed in 29 (5.8%). A triad of clinical tests (HINTS) was reported in 106 (21.2%) patients, a CT in 342 (68.2%) and a MRI in 153 (30.6%). Antiplatelet therapy was prescribed in 135 cases. In 69% of these, initial diagnosis was corrected to non-stroke. For 8 patients who received thrombolysis, initial diagnosis was corrected in 3. Of those patients where stroke was initially not identified, 23 (79%) received suboptimal treatment in lieu of antiplatelet therapy. The annual incidence of AVS in Dutch ED patients is 0.1%. ED diagnosis is often uncertain, with one-third of diagnoses corrected. This study substantiates clinical practice lacks a uniform diagnostic pathway with an overuse of CT and underuse of HINTS. Further research on optimal diagnostic approach is warranted to improve treatment of AVS.

A Center-Wide Study of D-Dimer Testing for Pulmonary Embolism in the ED Setting

Abstract Pulmonary embolism (PE) is a life-threatening condition associated with a very high mortality. While its diagnosis remains challenging, the use of diagnostic tests has increased tremendously. There are many different guidelines used to work up suspected PE. The Wells and/or Geneva scores are used to estimate the pretest probability (PTP) of PE before any complementary testing is done. While a CT pulmonary angiography (CTPA) should not be performed in individuals with a low/intermediate PTP and a negative D-dimer (DD), some data suggest that up to 55% of patients with low PTP undergo a CTPA, even though they might not have had a DD or had a negative DD. As such, in this study, we wanted to evaluate the use of DD in our emergency department (ED). A pilot study was conducted using an interactive software developed in-house for the evaluation of health care quality, efficiency, and effectiveness. The EMR database (EPIC) we use consists of laboratory, clinical, pathological, and radiological reports, allowing us to use different search criteria and to outline cutoff values for continuous and categorical variables while permitting us to define a timeframe for the different observations. We looked at all ED visits in the period from 2014 to 2018 in which CTPAs were done for suspected PE. A total of 8,873 ED visits from 2014 to 2018 had a CTPA done for suspected PE. Of these, 6,117 cases had no DD done and 1,812 had a DD done along with CTPA. The high percent of visits with imaging done without a DD (69%) is justified if these are all cases with a high PTP (DD not indicated). If this assumption was true, then we expected a high percent of positive confirmation of PE by imaging. However, only 11% of these cases showed positive findings of PE. This rate is similar to published studies in many US hospitals that demonstrate overuse of CT owing to a lack of using the PTP-based approach. On the other hand, a vast majority of cases in our study with normal DD (<0.5 μg/L) had negative CT results (98%). Interestingly, all four cases that had positive PE findings by CT despite a negative DD (2%) were women (three below the age of 62 with chronic and/or subsegmental PE and one 47-year-old with a DD = 0.49 μg/L). This finding calls for consideration of age and possibly gender-based DD reference ranges. Lastly, while CTPA is considered the gold standard for PE diagnosis, it has limitations: cost, increased length of stay, unnecessary exposure of radiation, contrast, and unnecessary treatment of subsegmental PE. Therefore, an approach using PTP and using DD appropriately is warranted in order to prevent patients from being exposed to unnecessary risks and also to reduce costs.

Overuse of CT and MRI in paediatric emergency departments.

The aim of this review is to survey CT and MRI overuse in the paediatric emergency department (ED) population. CT is one of the most important modalities employed in the ED. Not surprisingly, its high accuracy, rapid acquisition and availability have resulted in overuse. An obvious limitation of CT is ionizing radiation; in addition there are economic implications to overuse. Studies from the last two decades have shown increase in paediatric ED CT utilization in the first decade, reaching a plateau forming around 2008, followed by a decrease in the last decade. This decrease occurred in conjunction with campaigns raising awareness to the risks of radiation exposure. Although a trend of decrease in overuse have been observed, great variability has been shown across different facilities, as well as among physicians, with more pronounced overuse in non-teaching and non-children dedicated EDs. The leading types of paediatric ED CTs are head and abdominal scans. Decision rules, such as PECARN for head injury and the Alvarado score for abdominal pain, as well as using alternative imaging modalities, have been shown to reduce CT overuse in these two categories. MRI has the obvious benefit of avoiding radiation exposure, but the disadvantages of higher costs, less availability and less tolerability in younger children. Although anecdotally paediatric ED MRI usage has increased in recent years, only scarce reports have been published. In our opinion, there is need to conduct up-to-date studies covering paediatric CT and MRI overuse trends, usage variability and adherence to clinical protocols.

Selecting children for head CT following head injury

ObjectiveIndicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield.DesignCross-sectional study.SettingHospital inpatient...

MP11-01 VALUE OF ULTRASOUND IN THE DIAGNOSIS OF URETERIC STONE – A SINGLE INSTITUTION STUDY

You have accessJournal of UrologyImaging/Radiology: Uroradiology II1 Apr 2015MP11-01 VALUE OF ULTRASOUND IN THE DIAGNOSIS OF URETERIC STONE – A SINGLE INSTITUTION STUDY Arun Panackal and Santhosh Kumar Arun PanackalArun Panackal More articles by this author and Santhosh KumarSanthosh Kumar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.382AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES CT scan is generally accepted as the imaging modality of choice to evaluate patients with ureteric colic. Recently, there is growing awareness and concerns about the overuse of CT in evaluation of patient with ureteric colic, particularly the radiation exposure, overuse and costs. Instead of the recent advancement in Ultrasound technology, most of the radiologists have difficulty in localizing the ureteric stones. Many recent studies have reported and encouraged the use of twinkling sign to improve the accuracy of ultrasound to detect ureteral stones. In this retrospective study, we evaluated the accuracy of Ultrasound (gray-scale and Color Doppler), in diagnosis of ureteral calculi. METHODS We conducted this retrospective study by reviewing the medical records of patients diagnosed with acute ureteric colic in the emergency room and in the urology outpatient from January 2009 to December 2013.900pt were diagnosed with ureteric stone and all of them underwent ultrasound as the primary imaging modality. Sensitivity, specificity, positive and negative predictive value in determining the size, position of the stone in the ureter by Ultrasound has been documented. RESULTS Out of 900 patients, there were 800 males (90 %) and 100 females (10%). Age range was 13–65 years. Our study found that color Doppler ultrasound with twinkling sign, diagnosis was made with confidence in 835 cases (92.7%). 65patients whom failed the ultrasound, the stones were confirmed by helical CT, failure to detect the stone was mainly due to poor visualization (due to bowel gases and obesity) and smaller size of stone. Right side stones were seen in 338 (37.6%) patients while left side stones were seen in 562 (62.4%). Stones were detected bilaterally in 4 cases (0.4%). The range of stones size was 3–1.5mm There were 190 (21.1%), 77 (8.5%) and 633 (70.5%) upper, middle and lower ureteral stones. CONCLUSIONS There is no doubt that Spiral CT is superior in the demonstrating of ureteral calculi. The present study emphasized that utilization of color Doppler ultrasound with twinkling in trained hands can provide an excellent alternative modality with high sensitivity and specificity in diagnosis of acute ureteric colic and with confidence can be used as first imaging modality, hence we could avoid high cost, higher radiation dose and high workload. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e118-e119 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arun Panackal More articles by this author Santhosh Kumar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Diagnosing and Staging of Cystic Echinococcosis: How Do CT and MRI Perform in Comparison to Ultrasound?

BackgroundImaging plays the key role in diagnosing and staging of CE. The description of CE-specific imaging features and the WHO CE cyst classification is based on ultrasound. The reproducibility of the ultrasound-defined features of CE cysts is variable in MR- and CT-imaging. This is of particular importance for cysts that are not accessible by US and because of the increasing availability and overuse of CT and MR imaging.Methodology/Principal FindingsRetrospective analysis of patients with abdominal CE cysts of an interdisciplinary CE clinic who had CT and/or MRI scans performed additionally to US imaging. All images were read and interpreted by the same senior radiologist experienced in the diagnosis of CE. US, CT and MR images were staged according to the WHO classification criteria. The agreement beyond chance was quantified by kappa coefficients (κ). 107 patients with 187 CE cysts met the inclusion criteria. All cysts were assessed by US, 138 by CT, and 125 by MRI. The level of agreement beyond chance of the individual CE stages 1–4 was clearly lower for CT, with κ ranging from 0.62 to 0.72, compared to MRI with values of κ between 0.83 and 1.0. For CE5 cysts CT (κ = 0.95) performed better than MRI (κ = 0.65).ConclusionsUltrasound remains the corner stone of diagnosis, staging and follow up of CE cysts. MRI reproduces the ultrasound-defined features of CE better than CT. If US cannot be performed due to cyst location or patient-specific reasons MRI with heavily T2-weighted series is preferable to CT.

Overuse of CT in Patients with Complicated Gallstone Disease

When compared with ultrasound, CT scans are more expensive, have substantial radiation exposure and lower sensitivity, specificity, positive, and negative predictive values for patients with gallstone disease. We reviewed data on patients emergently admitted with complicated gallstone disease between January 2005 and May 2010. Use of CT and ultrasound imaging on admission was described. Multivariate logistic regression was used to evaluate factors predicting receipt of CT. Five hundred and sixty-two consecutive patients presented emergently with complicated gallstone disease. Mean age was 45 years. Seventy-two percent of patients were female, 46% were white, and 41% were Hispanic. Seventy-two percent of patients had an ultrasound during the initial evaluation and 41% had a CT. Both studies were performed in 25% of patients (n = 141), 16% (n = 93) had CT only, and 47% (n = 259) had ultrasound only. CT was performed first in 67% of those who underwent both studies. Evening imaging (7 PM-7 AM, odds ratio [OR] = 4.44; 95% CI, 2.88-6.85), increased age (OR = 1.14 per 5-year increase; 95% CI, 1.07-1.21), leukocytosis (OR = 1.67; 95% CI, 1.10-2.53), and hyperamylasemia (OR = 2.02; 95% CI, 1.16-3.51) predicted use of CT. Our study demonstrates the overuse of CT in evaluation of complicated gallstone disease. Evening imaging was the biggest predictor of CT use, suggesting that CT is performed not to clarify the diagnosis, but rather a surrogate for the indicated study. Surgeons and emergency physicians should be trained to perform right upper quadrant ultrasound to avoid unnecessary studies in the appropriate clinical setting.

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith-repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders. This was a cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993-2005) was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD-9], 386.11) or APV (ICD-9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure. A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV). Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.

Reply: Scintigraphy or Multidetector CT Angiography for Suspected Pulmonary Embolism?

REPLY: I am most appreciative of Dr. Bury's kind comments about my views on the use of ventilation–perfusion scintigraphy versus multidetector CT angiography for the study of pulmonary embolic disease. It appears as if we are in accord on most issues; most importantly, the overuse of CT

48: Overuse of CT in ED Patients with Presenting Complaint of Headache

48: Overuse of CT in ED Patients with Presenting Complaint of Headache