Scan Requests Research Articles

A two-cycle prospective audit of temporal bone computed tomography scan requests: improving the clinical applicability of radiology reports

Radiologists require accurate clinical information to formulate reports. This is particularly relevant to computed tomography of the temporal bone, in which previous surgery can mimic disease. The information provided with temporal bone computed tomography scan requests was evaluated. The study aimed to minimise inappropriate requests and improve the clinical value of reports. A two-cycle prospective audit was undertaken using a proforma designed on the basis of national guidelines. Following the first cycle (in which the requests and reports of 100 scans were evaluated), new guidelines and training were implemented. A follow-up audit (of 50 scans) was then performed. Following intervention, the percentage of clinically relevant reports increased from 52 to 94 (p < 0.01), whilst unnecessary or inappropriate scan requests decreased from 11 to 2 per cent (p < 0.05). Optimising the clinical value of temporal bone computed tomography scan requests will have positive implications for patient care, time management and cost. The quality of the clinical information provided can have a significant impact on the clinical value of radiology reports, and can mean that unnecessary irradiation is avoided.

SPORT AND EXERCISE MEDICINE (SEM) IN PRIMARY CARE: A NOVEL DUAL ARMED APPROACH TO IMPROVING PHYSICAL ACTIVITY (PA) AND MUSCULOSKELETAL (MSK) SERVICES IN A HERTFORDSHIRE GENERAL PRACTICE

BackgroundWith the advent of SEM as a recognised medical specialty in the United Kingdom, a number of service models have become apparent.1 Despite government initiatives to increase for example PA...

Preapproval of Sinus Computed Tomography for Evaluation of Chronic Rhinosinusitis Does Not Save Healthcare Costs

Objectives: Evaluate cost effectiveness of required pre-approval for computed tomography (CT) of the sinuses for chronic rhinosinusitis (CRS) evaluation by weighing the associated cost of pre-approval against savings from rejected claims. Study design: Retrospective analysis of prospectively collected data. Setting: An academic otolaryngology practice. Methods: Over a 6-month period, all sinus CT scans ordered and requiring pre-approval by a third-party payer were tabulated. Characteristics of the pre-approval process that were recorded and analyzed included time spent by office administrative staff, need for peer-to peer review, and time spent by the ordering physician. Results: All 111 sinus CT scans ordered required pre-approval based on insurer requirements—38 performed by computer, 71 by telephone, and 2 required both–costing an average of 8.1 minutes per scan by administrative staff (range: 2.0 – 20.0 minutes). 13 pre-approvals required peer-to-peer telephone interaction by the ordering physician, using an average of 7.7 minutes (range 5 – 12 minutes). In no case was the insurance company “peer” an otolaryngologist. Moreover, no sinus CT scan pre-approval was ultimately rejected by the third party payer. Conclusions: Pre-approval for sinus CTs ordered by otolaryngologists neither saves costs for third-party payers nor leads to appropriate rejection of scan requests because sinus CT for the evaluation of CRS is well-established and the standard of care. However, pre-approval in this context comes at the expense of practice administrative and physicians’ time. Pre-approval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS is an unnecessary and costly requirement.

Preapproval of sinus computed tomography for otolaryngologic evaluation of chronic rhinosinusitis does not save health care costs

To evaluate the cost-effectiveness of preapproval requirements for computed tomography (CT) of the sinuses in the evaluation and management of chronic rhinosinusitis (CRS). Retrospective analysis of prospectively collected data. Over a 6-month period, all sinus CT scans ordered by an otolaryngology practice and requiring preapproval by a third-party payor were tabulated. Characteristics of the preapproval process that were recorded and analyzed included time spent by office administrative staff, need for peer-to-peer review, and time spent by the ordering physician. All 111 sinus CT scans ordered during the 6-month time period required preapproval based on insurer requirements-38 performed by computer, 71 by telephone, and two required both-costing an average of 8.1 minutes per scan by administrative staff (range, 2.0-20.0 minutes). Thirteen preapprovals required peer-to-peer telephone interaction by the ordering physician, utilizing an average of 7.7 minutes (range, 5-12 minutes). In no case was the insurance company peer an otolaryngologist. Ultimately, no sinus CT scan request was rejected by a third-party payor. Preapprovals for sinus CTs ordered by otolaryngologists are unlikely to save costs for third-party payors, as sinus CT for the evaluation of CRS is well established and therefore unlikely to be rejected. Preapproval in this context comes at the expense of practice administrative and physicians' time. Based on our results, preapproval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS appears to be an unnecessary and costly requirement. N/A.

Inappropriate requests for magnetic resonance scans of the shoulder

Magnetic resonance imaging (MRI) scans are a useful investigation for some shoulder pathology. They are costly however and a significant burden on radiology departments. In most cases clinical examination, plain radiography or ultrasound scan (USS) are sufficient for a diagnosis. There are no current UK guidelines regarding MRI shoulder scan requests. We reviewed 100 consecutive MRI shoulder scan requests and the associated formal reports; other investigations were also assessed. Overall, 56% of MRI scans were ordered inappropriately. Shoulder consultant's requests were more appropriate than other groups (70% vs. 38%. p = 0.04). Excluding shoulder consultants 63 % of scans were inappropriately ordered. Shoulder consultants were more likely to order a preceding X-ray (80% vs. 53% respectively, p = 0.03). Of those with a clinical diagnosis of cuff pathology only 29% had an USS. A high percentage of MRI shoulder scans are performed inappropriately. Shoulder consultants are more appropriate in their ordering than other groups. If all groups performed as well 50 % less MRI scans would need to be performed.

AB0823-HPR Developing nurse autonomy in a rheumatology nurse led clinic

BackgroundIn routine rheumatology clinics, return visits can account for 75% of a rheumatologists case load reducing the time available for new patients or patients who require urgent care (1) In...

Lymphoma: streamlining follow ups

follow up of patients with non-Hodgkin Lymphomas (NHL) is based on several factors including the intention of the treatment and the context in which it is carried out, whether in clinical trials or clinical practice. For patients out of clinical trials there seems to be no evidence for the routine use of imaging scans or laboratory tests in the follow up after completing treatment(1). The clinical history and physical examination are the most important procedures in the monitoring of patients after treatment in the clinical practice(1). Nevertheless many physicians indicate serial imaging scans or use laboratory markers to guide requests for scans. Lactate dehydrogenase (LDH) has proved to be an important prognostic marker and has been incorporatedin prognostic models of NHL at the moment of diagnosis(2,3); it is also often used in the after treatment follow up. In this issue of the Revista Brasileira de Hematologia e Hemoterapia an article entitled The utility of lactatedehydrogenase in the follow up of patients with diffuse large B-cell demonstrates a clear relationshipbetween LDH levels 1.5-fold above baseline and the relapse of diffuse large B-cell lymphoma (DLBCL)(4). Despite this finding, the authors considered it an inappropriate marker in the follow up of asymptomatic patients due to its low specificity and low positive and negative predictive values, which would lead to an unnecessary exposure to scans and to increases in cost(4). These data seem to be moving in the opposite direction of current technology, when the increasingly early and more frequent role of positron-emission tomography (PET-CT) is discussed in the management of lymphomas(5). Although this is the most appropriate method in the final assessment and for the identification of relapse due to the high negative predictive value, the risk of false positive results as well as the risks of excessive exposure to radiation makes its utilization in patient monitoring less interesting(6). When we imagine that the follow up of patients with lymphoma submitted to serial tomography scans during three to five years of their treatment results in a cumulative dose of over 50 mSv, we note that such management has put the patients at risk with the excessive radiation(7). As well as a chance of less than 2% of an early diagnosis of relapse(7). Faced with these findings, although the use of laboratory tests and scans are extremely widespread in theclinical practice of patients with asymptomatic lymphoma and normal physical examination, there is no evidence,as of yet in the literature that supports the indication of these complementary exams in the follow up of patients. Despite the low cost, LDH has not shown to be a useful exam in the follow up of patients withDLBCL in asymptomatic remission(4). Therefore, at present, only the medical history and clinical examination are indeed effective in the follow up after the treatment of patients.

Imaging Diagnosis of Benign Lesions of the External Auditory Canal

Introduction and objectivesBenign lesions of the external auditory canal (EAC) are an infrequent cause of temporal bone CT scan requests. We are not usually well-versed in the different pathologies located in the EAC, perhaps because it is “only” a conduit and the relevant anatomical structures are located in the middle and inner ear.Our objective was to improve knowledge of this structure by reviewing the different benign conditions found in this location. MethodsWe reviewed the CT studies from 2 years (January 2010 through January 2012), selecting those containing lesions in the EAC. To complement this, due to the importance of these lesions, these medical histories were then analysed considering the presentation and otoscopic examination findings. ResultsThe lesions were classified according to their diagnoses: exostosis, osteoma, cholesteatoma, keratosis obturans, haemangioma, non-neoplastic aural polyp, first branchial cyst and dermatologic disease (malignant external otitis). The presence of EAC occupation in the otological examination and chronic otorrhea as the symptom of presentation were the most relevant exploratory and clinical findings. ConclusionsBenign EAC lesions are an uncommon and seldom studied cause of temporal bone CT scan requests. Knowing the most relevant clinical and radiological findings is necessary for their proper diagnosis.

Diagnóstico por imagen de las lesiones benignas del conducto auditivo externo

Introduction and objectivesBenign lesions of the external auditory canal (EAC) are an infrequent cause of temporal bone CT scan requests. We are not usually well versed in the different pathologies located in the EAC, perhaps because it is “only” a conduit and the relevant anatomical structures are located in the middle and inner ear.Our objective was to improve knowledge of this structure by reviewing the different benign conditions found in this location. MethodsWe reviewed the CT studies from 2 years (January 2010 through January 2012), selecting those containing lesions in the EAC. To complement this, due to the importance of these lesions, these medical histories were then analysed considering the presentation and otoscopic examination findings. ResultsThe lesions were classified according to their diagnoses: exostosis, osteoma, cholesteatoma, keratosis obturans, haemangioma, non-neoplastic aural polyp, first branchial cyst and dermatologic disease (malignant external otitis). The presence of EAC occupation in the otological examination and chronic otorrhea as the symptom of presentation were the most relevant exploratory and clinical findings. ConclusionsBenign EAC lesions are an uncommon and seldom studied cause of temporal bone CT scan requests. Knowing the most relevant clinical and radiological findings is necessary for their proper diagnosis.

Vomiting—is this a good indication for CT head scans in patients with minor head injury?

The National Institute for Health and Clinical Excellence head injury guidelines advise CT imaging within 1 h if there is more than one episode of vomiting post-head injury in adults and three or more episodes in children. Since the guideline publication, studies have found that, following head injury, vomiting alone is associated with an abnormal CT head scan in 13-45% of cases. CT head scan requests referred from the emergency department between 1 May 2009 and 30 April 2010 were retrospectively reviewed. Patients with vomiting as the sole indication for an "immediate" CT head scan performed within 1 h were included in the study. Reports produced by experienced neuroradiologists were reviewed and the detection of significant head injury was noted. There were 1264 CT head scans performed during our study period. 151 (124 adults, 27 children) were indicated owing to vomiting following head injury. 5 of the 124 adult scans and 1 of the 27 paediatric scans showed an abnormal finding, giving positive predictive values (PPV) of 4% and 3.7%, respectively. None of these patients required either acute or delayed neurosurgical intervention. In our experience, vomiting alone has a PPV of 4% for significant head injury in adults. However, none of these injuries were serious enough to warrant acute or delayed intervention. Given these findings, vomiting following head injury is a reasonable indication for a CT head scan; however, as none of the patients required acute intervention, we suggest that these scans do not usually need to be performed within 1 h of request.

The role of cranial CT in the investigation of meningitis

ObjectiveTo assess the usage of cranial computed tomography (CT) in patients admitted with meningitis.DesignRetrospective study.SettingHeart of England NHS foundation trust, a teaching hospital in the West Midlands.ParticipantsTwo groups of adult patients admitted with meningitis between April 2001 and September 2004 and from September 2006 until September 2009.Main outcome measuresThe numbers of patients having cranial CT and lumbar puncture and whether any complications had arisen following lumbar puncture. The appropriateness of the CT request according to local criteria.ResultsA total of 111 patients were admitted in the initial time period and 47 patients in the second time period. In the first group, 67 patients underwent CT (61%), compared with 36 patients (80%) in the second group. There were eight abnormal scans (12%) in the initial group including three patients with radiological features of cerebral oedema. Of these patients, one underwent lumbar puncture and had no neurological sequelae. In the second group, there were five abnormal scans (14%) with one presenting a contraindication for lumbar puncture due to mild ventricular dilatation. A lumbar puncture was performed in this patient without complication. All patients with abnormal scans had clinical features to suggest raised intracranial pressure. CT scan requests were considered inappropriate in 26% of patients in the initial study period and 56% of patients in the second study period.ConclusionMore patients with meningitis are undergoing CT and the number of inappropriate requests are increasing. There are few abnormal CT scans presenting a contraindication for lumbar puncture and the majority of these patients usually have clinical signs to suggest raised intracranial pressure.

Pulmonary features of Birt-Hogg-Dubé syndrome: Cystic lesions and pulmonary histiocytoma

to describe clinical, radiologic and pathologic features of lung lesions in Birt-Hogg-Dubè syndrome (BHDS) (MIM 135150). review of 12 patients of BHDS from 3 unrelated Italian families evaluated at GB Morgagni Hospital, Forlì, from 2005 to 2010. mean age (±SD) at diagnosis was 44.6 (±16) years, 8 (66%) were male. All three index cases presented with a history of recurrent pneumothorax and/or cystic lung lesions evaluated by CT scan request by referring pulmonary physicians, none were diagnosed to have BHDS at the time of initial pulmonary evaluation. One of the three cases was a middle-aged female patient with a clinical phenotype indistinguishable from lymphangioleiomyomatosis (LAM), characterized by cystic lung lesions and kidney angiomyolipoma. In one case of BHDS presenting with recurrent pneumothorax and a solitary lung nodule, surgical lung resection revealed a pulmonary histiocytoma. In one case a novel mutation of BHD gene was detected (c.771 del, exon 7). BHDS is associated with cystic lung disease largely under-recognized by pulmonary physicians and can mimic LAM and may be associated with lung tumor, pulmonary histiocytoma. In one case we found a novel mutation in exon 7, c.771 del (ref.seq. NM_144997.5) never reported before.

An Effective Team Approach to Improve Postoperative Hip Fracture Care

To develop an initiative using standardized discharge orders to improve the posthip fracture care of patients aged 50 years or older. Prospective nonrandomized study. Hospital orthopaedic service. Patients at our institution older than age 50 years sustaining a hip fracture who were followed for at least 6 months and qualified for osteoporosis medication. The endocrinology and orthopaedic areas agreed to add calcium/vitamin D supplementation, a dual-energy x-ray absorptiometry scan request, and a consult with endocrinology to the hospital discharge orders. The proportions of patients using calcium or bisphosphonate before and after the intervention were compared using the McNemar test. The designated level of significance was 0.05. Originally, 37 of 137 patients were taking calcium/vitamin D supplements. Following this initiative, 92 of 137 were taking the supplement (P < 0.0001). Seventeen of 137 patients were taking bisphosphonate initially and 65 of 137 after the initiative (P < 0.0001). After the initiative, 100% of the discharged patients were offered calcium/vitamin D, a dual-energy x-ray absorptiometry scan, and an endocrinology appointment. All of the patients who reported for the endocrinology consult appointment were offered bisphosphonate therapy. Eighty-two patients kept the appointment for the dual-energy x-ray absorptiometry scan, and 54 saw the endocrinologist. The addition of a calcium/vitamin D supplement and an endocrinology appointment to the hospital discharge orders was an effective method of improving treatment and enhancing compliance.

Performance et vulgarisation de l’écho-Doppler par couplage sus-pubien et endovaginal dans le diagnostic précoce des grossesses extra-utérines en Côte d’Ivoire

Objective The aim of our study was to describe the epidemiological profile of ectopic pregnancies (EP) in Côte d’Ivoire and to show the utility of ultrasound Doppler in the early diagnosis of EP. Patients and method Our prospective study had been carried out for 24 months (from February 2006 to January 2008). It concerned 32 cases of ectopic pregnancy discovered at the suprapubic or endovaginal ultrasound scan with or without Doppler use. Results The frequency of ectopic pregnancies was estimated at 1.7%. Patients’ mean age was 26.2 years. The personal history was dominated by abortions (32%) and adnexal infections (20%). Most of the patients were nulliparous (52.5%). Requests for ultrasound scans were motivated for most of them by metrorrhagia. The ectopic pregnancy was diagnosed at the ruptured stage in 65.6% of the cases (21 patients) and at the nonruptured stage in 34.4 % of the cases (11 patients). In six cases of nonruptured stage, we used the Doppler. The elementary lesions found were hematosalpinx in 40.6% of the cases, embryonate ectopic gestational sac (31.3%) and nonembryonate ectopic gestational sac (18.7%). In three cases (9.4%), no elementary lesions were found. Conclusion in Côte d’Ivoire, the ectopic pregnancy concerns a very young nulliparous population with abortion and adnexal history. The use of color signal of Doppler added to the endovaginal ultrasound scan, allows establishing the diagnosis at the early stage.

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

Inappropriate use and interpretation of D-dimer testing in the emergency department: an unexpected adverse effect of meeting the “4-h target”

Introduction:D-dimer tests were inappropriately overused in our emergency department as a result of bloods being taken before clinical assessment to help meet the “4-hour target”. We introduced a multifaceted intervention...

Open access to MRI for general practitioners: 12 years' experience at one institution — a retrospective analysis

The aim of this study was to evaluate 12 years of general practitioner (GP) use of open access MRI services at a single London teaching hospital. A retrospective analysis of reports from all GP requests for MRI scans between 1994 and 2005 was performed. The date, scanned body part, and requester details from 1798 scans requested by 209 individual GPs over a continuous 12-year period were recorded. All scans were then graded into four categories based on the severity of reported findings from normal to gross abnormality. Over the study period, GP requests as a percentage of the total (MRI) department workload remained low at approximately 2.6%. Spine, knee and brain requests constituted 86% (n = 1546) of requested scans. 48% (n = 868) of scans were reported as normal or minor degenerative changes only. 26% (n = 466) of scans demonstrated serious pathology that was likely to warrant hospital consultant referral. There was a wide range of scans requested per requester, from 1 to 240 over the period, with an average of 8.5 scans per GP. In conclusion, any department wishing to set up open access to MRI services for GPs could cover the majority of requests by offering spine, knee and brain imaging. The percentage of normal report rates for GP requests is comparable with previous studies of outpatient referrals. A large variation in requesting patterns between GPs suggests the need for increased communication between GPs and imaging departments to optimise use of the service.

Diagnosis, incidence, and outcomes of suspected typhlitis in oncology patients—experience in a tertiary pediatric surgical center in the United Kingdom

Background Typhlitis is clinically defined by the triad of neutropenia, abdominal pain, and fever. Radiologic evidence of colonic inflammation supports the diagnosis. We report a single United Kingdom tertiary center experience with management and outcome of typhlitis for 5 years. Methods Hospital computerized records were screened for ultrasound or computerized tomographic scan requests for abdominal pain for all oncology inpatients (2001-2005). Retrospective case note analysis was used to collect clinical data for patients with features of typhlitis. Results The incidence of typhlitis among oncology inpatients was 6.7% (40/596) among oncology inpatients and 11.6% (40/345) among those on chemotherapy. Eighteen children had radiologically confirmed typhlitis, and 22 had clinical features alone. Most (93%) patients responded to conservative management. Eighteen children had a variable period of bowel rest, including 12 patients who were supported with total parenteral nutrition. Three patients had laparotomy that revealed extensive colonic bowel necrosis (1), perforated gastric ulcer (1), and a perforated appendix (1). A single child died of fulminant gram-negative sepsis without surgical intervention. Conclusions The diagnosis of typhlitis was based on clinical features, supported by radiologic evidence in almost half of the study group. Surgical intervention should be reserved for specific complications or where another surgical pathologic condition cannot reasonably be ruled out.

Non-trauma CT head scans in the emergency department: are we doing too much?

In the emergency department, CT scans of the head are routinely used for adult patients with no history of head injury. Even after careful physical examination where no abnormality has...

Vestibular Schwannoma Screening Guidelines: Change in our practise. An audit loop

Vestibular Schwannoma Screening Guidelines: Change in our practise. An audit loop