Selective Radiography Research Articles

Development and validation of the paediatric elbow trauma (PET) rules as a decision rule for radiography in traumatic elbow injuries: a study protocol

BackgroundTraumatic elbow injuries in children occur frequently and are among the most common traumatic injuries seen in the emergency department (ED) and in general practice. The use of a validated...

Selective Prereduction Radiography in Anterior Shoulder Dislocation: The Fresno-Quebec Rule

BackgroundShoulder dislocation is one of the most frequent dislocations encountered by emergency physicians. Typical emergency care usually includes performing both prereduction and postreduction radiography. However, selective radiography has the potential benefits of reducing emergency department (ED) time and radiation exposure. ObjectivesTo refine and combine two existing clinical decision rules for selective radiography in the ED management of anterior shoulder dislocation, thus creating the Fresno-Quebec rule (FQR). MethodsPatients presenting to the ED with an anterior shoulder dislocation were enrolled in a prospective cohort study in two university-affiliated EDs. Patients with a clinically important fracture-dislocation were compared with those with an uncomplicated dislocation. We refined our new decision rule to detect all fracture-dislocations while maximizing specificity. ResultsA total of 207 patients were included in this study, of which 24 (11.8%) had a clinically important fracture-dislocation. The refined rule consisting of three criteria had a sensitivity of 100% (95% confidence interval [CI] 87.5–100%), specificity of 50% (95% CI 42.5–57.5%), negative predictive value of 100% (95% CI 96–100%), and a negative likelihood ratio of 0.21 (95% CI 0.14–0.30). No patient with an atraumatic, recurrent dislocation had a fracture. Patients over age 35 years had an increased risk of fracture-dislocation if they sustained blunt injury or had a first episode of dislocation. Using this rule could have reduced prereduction radiographs by 44%. ConclusionThe refined Fresno-Quebec shoulder dislocation rule detected all clinically important prereduction fracture-dislocations and could have reduced prereduction films by 44%. Prospective validation is warranted.

Trauma Computed Tomography: Benefits and Hazards

To the Editor, With much interest and attention, we read the paper of Sierink et al. [1] in the April 2014 issue of the World Journal of Surgery. In that article, based on the study results—i.e., lower 30-day mortality rate among patients who underwent immediate total-body computed tomography (TBCT) compared with those evaluated with conventional imaging followed by selective CT scans—the authors defended the role of immediate TBCT in the acute trauma care setting. It seems fair to note some points. Despite its advantage, the routine use of immediate TBCT to evaluate trauma patients can expose them to unnecessary doses of radiation, consequently putting them at a probable increased risk of cancer [2]. Another major concern associated with contrast-enhanced CT is contrast-induced nephropathy, a main cause of hospital-acquired acute renal injury [3]. From the aspect of the time used to assess the patients, the authors criticized the use of X-ray imaging in trauma cases. However, it should be noted that selective use of conventional cervical, chest, or pelvic imaging instead of routine radiography for all patients can be significantly time saving [4, 5]. In this respect, a review of the literature turned up several articles regarding efforts made to develop some criteria for the use of selective radiography in trauma cases. Transferring trauma patients between the admission ward and the CT room is yet another difficulty associated with the routine use of immediate TBCT in these cases. In addition, such an approach can increase health care costs for the patients and can lead to an increase in the costs associated with the use of technical personnel and those that result from the inevitable wear and tear of the equipment. Another negative point is that long-term use of routine immediate TBCT probably affects the quality of surgeons’ skills in history taking and physical examination of trauma patients. It also may lead to findings of questionable clinical importance [4, 5]. Finally, it should be remembered that CT is not available in all regions of the world. Also, in conditions such as a disaster, the increased number of trauma patients can affect the availability of the use of CT. Therefore, the need for alternative approaches in the acute trauma care setting is still present.

A Narrowed Decision Instrument for Selective Chest Radiography in Blunt Trauma

A Narrowed Decision Instrument for Selective Chest Radiography in Blunt Trauma

Attitude of the Korean dentists towards radiation safety and selection criteria

PurposeX-ray exposure should be clinically justified and each exposure should be expected to give patients benefits. Since dental radiographic examination is one of the most frequent radiological procedures, radiation hazard becomes an important public health concern. The purpose of this study was to investigate the attitude of Korean dentists about radiation safety and use of criteria for selecting the frequency and type of radiographic examinations.Materials and MethodsThe study included 267 Korean dentists. Five questions related to radiation safety were asked of each of them. These questions were about factors associated with radiation protection of patients and operators including the use of radiographic selection criteria for intraoral radiographic procedures.ResultsThe frequency of prescription of routine radiographic examination (an example is a panoramic radiograph for screening process for occult disease) was 34.1%, while that of selective radiography was 64.0%. Dentists' discussion of radiation risk and benefit with patients was infrequent. More than half of the operators held the image receptor by themselves during intraoral radiographic examinations. Lead apron/thyroid collars for patient protection were used by fewer than 22% of dental offices. Rectangular collimation was utilized by fewer than 15% of dental offices.ConclusionThe majority of Korean dentists in the study did not practice radiation protection procedures which would be required to minimize exposure to unnecessary radiation for patients and dental professionals. Mandatory continuing professional education in radiation safety and development of Korean radiographic selection criteria is recommended.

Multi-Frame Energy-Selective Imaging System for Fast-Neutron Radiography

A new instrument for high resolution imaging of fast-neutrons is presented here. It is designed for energy selective radiography in nanosecond-pulsed broad-energy (1 - 10 MeV) neutron beams. The device presented here is based on hydrogenous scintillator screens and single- or multiple-gated intensified camera systems (ICCD). A key element is a newly developed optical amplifier which generates sufficient light for the high-speed intensified camera system, even from such faint light sources as fast plastic and liquid scintillators. Utilizing the Time-of-Flight (TOF) method, the detector incorporating the above components is capable of simultaneously taking up to 8 images, each at a different neutron energy.

Selective radiography in 100 patients with suspected shoulder dislocation

We sought to prospectively validate an algorithm for selective radiography in the Emergency Department (ED) management of patients with suspected shoulder dislocation. Physicians ordered pre- and post-reduction radiographs based on an algorithm incorporating the mechanism of injury, previous dislocations, and the physician’s clinical certainty of joint position. Follow-up consisted of telephone calls and chart review. Of 100 patients, 94 had shoulder dislocation, and 59% were recurrent. Thirty percent had both pre- and post-reduction radiographs, 45% had pre- or post-reduction only, and 25% had no shoulder films, yielding an overall 46% reduction in X-ray utilization. Mean ED times were significantly shorter for patients managed without radiographs. On telephone follow-up (76%) and chart review (100%), we found no missed fractures or persistent dislocations. Use of a clinical decision rule for selective radiography reduced the number of radiographs and time spent in the ED, while missing no fractures or dislocations.

Longitudinal Trends in the Use of Individualized Radiographic Examinations at Dental Schools in the United States and Canada

In the spring of 2002, a mail survey was conducted to determine the use of individualized radiographic examinations (selective radiography) for comprehensive care patients at all sixty-four U.S. and Canadian dental schools. Results from previous surveys were used to evaluate the long-term longitudinal trends. Among sixty-two schools (97 percent response rate), selective radiography was used by 34 percent of schools for dentulous adult patients, by 100 percent for edentulous adults, and by 28 percent for children. Having a credentialed chief of service increased the likelihood that selective radiography would be used for dentulous adults (odd ratio[OR]=2.36) and for children (OR=2.33). Selective radiography for dentulous adults increased from 2 percent of schools in 1977 to 36 percent in 1997 and leveled off thereafter. Between 1987 and 2002, selective radiography for edentulous adults was used at nearly all schools (96-100 percent) and for children at about a quarter of dental schools (22-28 percent). Among the sixty-one schools for which there are complete data since 1987, the continuous use of routine radiography was most common (39 percent of schools) for dentulous adult patients, whereas the continuous use of selective radiography was uncommon (7 percent).

Selective Radiography in Anterior Shoulder Dislocation: Prospective Validation of a Clinical Decision Rule

Selective Radiography in Anterior Shoulder Dislocation: Prospective Validation of a Clinical Decision Rule

Excellence in publishing: the Wuehrmann prize

The American Academy of Oral and Maxillofacial Radiology (AAOMR) established “The Wuehrmann Prize” for the best radiology journal article of the year in 1995. The Award is named after Dr. Arthur H. Wuehrmann, a Distinguished Life Member of the Academy. Since then, eight published articles have been selected. The purpose of the award is to recognize excellence in publishing, which happens to be the motto of our publisher, Mosby Inc. The winning papers have been: White SC, Sapp JP, Seto BG, Mankovich NJ. Absence of radiometric differentiation between periapical cysts and granulomas. OOOOE 1994;78:650-4. Callender KI, Brooks SL. Usefullness of tomography in the evaluation of patients with temporomandibular joint disorders: a retrospective study. OOOOE 1996;81(6):710-9. Brooks SL, Brand JW, Gibbs SJ, Hollander L, Lurie AG, Omnell KA, Westessen PL, White SC. Imaging of the temporomandular joint: a position paper of the American Academy of Oral and Maxillofacial Radiology. OOOOE 1997;83(5):609-18. Christgau M, Hiller KA, Schmalz G, Kolbeck C, Wenzel A. Accuracy of quantitative digital subtraction radiography for determining changes in calcium mass in mandibular bone: an in vitro study. Journal of Periodontology Research. 1998;33(3):138-49. Bohay RN, Stephens RG, Kogan SL. A study of the impact of screening or selective radiography in the treatment and postdelivery outcome in edentulous patients. OOOOE 1998;86(3):353-9. White SC, Pullinger AG. Impact of TMJ radiographs on clinician decision making. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79:375-81. Liang H, Tyndall DA, Ludlow JB, Liang LA, Nunn NE. Accuracy of mandibular cross-sectional imaging with tuned-aperture computed tomography (TACT), iteratively reconstructed TACT, and multidirectional, linear, and transverse panoramic radiography. OOOOE 2001;91(5):594-602. Rushton VE, Lorner K, Worthington HU. Routine panoramic radiography of new adult patients in general dental practice: relevance of diagnostic yield to treatment and identification of radiographic selection criteria. OOOOE 2002;93(4):488-95. The Wuehrmann Prize is given to a paper published in OOOOE between July of the previous year and June of the year the prize is to be given. Papers eligible for the prize are those that present basic/clinical/epidemiological/survey research of relevance to OMFR that adheres to the principles of the scientific method. Position papers, case reports, and review articles are not considered for the Prize. Papers are judged based upon: (a) relevance to OMFR, (b) originality of research objectives and/or ideas presented, (c) innovativeness of study design (novelness of approaches/concepts), (d) appropriateness of epidemiological/statistical methods, and (e) clearness of presentation. The Awards Committee selects a Wuehrmann Prize Subcommittee, consisting of the Journal Section Editor as chair and 4 members of the Editorial Board, with a rotating membership. The Editor identifies approximately 7-10 notable articles meeting the criteria and provides the subcommittee with a list of these candidates within 2 weeks after publication of the June issue of OOOOE. Prior to this, subcommittee members may submit to the Editor titles of papers for consideration. The number of articles selected by the Editor for submission to the subcommittee is up to the discretion of the Editor. Each subcommittee member reads the candidate papers and ranks the top 5, sending the results to the Editor within one month. The Editor tallies the votes and notifies the Executive Secretary so the appropriate plaque can be made in time for the annual meeting. If there is not a clear winner after the first ballot, the subcommittee reaches consensus via e-mail and/or telephone discussion. Scanning the titles of the Prize winners reveals an interesting diversity of topics. New applications of technology, radiographic selection criteria, dental and jaw pathology, and an AAOMR position paper are included. Recognition of excellence in publishing should be a stimulating factor in the continuous improvement of the quality of articles in the Journal, and it is hoped that this Prize will result in that goal.

Prospective evaluation of criteria for obtaining thoracolumbar radiographs in trauma patients

This study examined if use of clinical screening criteria for selective radiography of blunt trauma patients can identify all patients with thoracolumbar (TL) spine injuries. The study was a prospective cohort of patients undergoing TL spine radiographs following blunt trauma. Patients were considered at risk for TL spine injury if they had any of the following clinical criteria: 1) complaints of TL spine pain, 2) TL spine tenderness, 3) a decreased level of consciousness, 4) intoxication with ethanol or drugs, 5) a neurologic deficit, or 6) a painful distracting injury. Patients without any of these findings were considered at low risk for TL spine injury. Severity of mechanism of injury was also recorded. Data sheets were completed prior to TL radiography. Injury status was determined by the final faculty radiologist interpretation of all radiographic studies. A total of 2404 patients were enrolled. TL spine injuries were identified in 152 patients. Of these 152 patients with spine injuries, all 152 (100%, 95% confidence interval 98–100%) were considered high risk by having at least one of the high-risk criteria. These criteria have a specificity of 3.9%, a positive predictive value of 6.6%, and a negative predictive value of 100%. All of the high-risk criteria but intoxication with ethanol or drugs were important as sole predictors of TL spine injury. The use of high-risk clinical screening criteria identified virtually all blunt trauma patients with acute TL spine injuries. These criteria, however, have poor specificity and positive predictive value.

Blunt Trauma and the Role of Routine Pelvic Radiographs

We evaluated clinical factors that are predictive of pelvic X-ray findings. We sought to identify whether routine pelvic films are necessary in blunt trauma and addressed whether removal of these films would minimize cost. We performed a retrospective chart review of 111 patients without pelvic fractures and 108 with pelvic fractures seen at our Level 1 trauma center between August 1998 and September 1999. We evaluated initial hemodynamics, physical examination findings, laboratory data, and hospital charges. Patients with fractures had higher Injury Severity Scores (P < 0.001), a higher number of associated injuries (P < 0.001), and lower blood pressures (P < 0.001). The back and pelvic examinations were significantly associated with X-ray results (P < 0.001), and the potential savings with selective radiography was $168,300.00 per year. We believe that clinical factors identified in our study predict the need for pelvic X-ray. Because removal of these films would minimize cost we recommend the elimination of routine pelvic films for the awake and alert blunt trauma patient.

Frequency of arteriovenous shunts in hepatic cavernous hemangiomas in adults as seen on selective arteriography and postembolization radiography.

To study the frequency and angiographic findings of arteriovenous shunts (AVS) associated with adult cavernous hemangiomas of the liver (CHL) on hepatic artery digital subtraction angiography (DSA) and optimize the imaging technique of DSA to improve its diagnostic efficacy. We retrospectively analyzed 43 intraarterial DSA procedures performed on 30 adults with CHL. Of the 30 patients 22 were found to have an AVS. Transcatheter arterial embolization with Lipiodol (L-TAE) was performed on 21 of these and radiographs were taken immediately after embolization to observe the distribution of the injected iodized oil. The results were compared with those of the AVS found on DSA images. AVS were identified by DSA in 22 (73.3%) of 30 patients. All AVS were located in the peritumoral liver tissue and had a parallel track appearance, or early filling of small draining veins during the arterial phase of DSA. Radiographs taken immediately after L-TAE in 21 of the 22 cases with AVS showed iodized oil filling a few portal branches or draining veins as a result of incompletely occluded shunts in 11 patients. In 10 patients there was complete occlusion and no filling of any vein, or only the originating end of draining veins filled with iodized oil. No evidence of AVS was found in the other eight patients in this series, and in six of these the DSA was not considered diagnostic. The present study indicates that AVS are frequently seen in adults with CHL. DSA with high-quality images is helpful in identifying small AVS of CHL. The formation of an AVS in CHL may be closely related to the pathological changes in the peritumoral liver tissue.

Prospective evaluation of a protocol for selective thoracolumbar radiography

Prospective evaluation of a protocol for selective thoracolumbar radiography

Selective radiography with etched track detectors

A new technique of selective enhancement and evaluation of radiographic images in etched track detectors was developed. It is based on the image processing of individual image element units – etched tracks – by a track analysis system. A selective radiograph is obtained on the basis of the assessment of the size and optical properties of individual tracks. The computer-generated image, in addition to its selectivity, which enables, for instance, multi-elemental analysis from an autoradiograph, also offers a contrast enhancement for better visual observation and/or evaluation. The applicability of the technique is illustrated by selective imaging of 10B distribution in a whole body samples of a tumour-bearing mouse.

A study of the impact of screening or selective radiography on the treatment and postdelivery outcome for edentulous patients

Objective. The purpose of this study was to assess the impact of radiographic findings on complete denture treatment and on the postdelivery course of those patients who had pretreatment radiographs (the screening group) and those who did not (the selection group). Method. In total, 375 cases were randomly selected by systematic sampling. Data collected included patient demographic information and denture history, predenture fabrication radiographic findings, and postdenture delivery complaints. Results. Of the screening patients, 100% had pretreatment radiographs made; this compared with 13.5% of the selection patients. In the screening group, 68.3% of patients had one or more positive radiographic findings recorded. Of the screening patients, 8.3% received treatment before denture fabrication; this compared with 1.2% of the selection patients. Of the 375 cases, 2 screening patients had postdelivery complaints that required management other than denture adjustment. Conclusion. The results indicate that there is weak scientific support for the guideline recommending routine pretreatment radiography for new denture patients.

Clinical criteria for using radiography for children with acute knee injuries.

To evaluate clinical criteria for selective radiography for knee injuries in children. Retrospective chart review. Emergency department (ED) of a children's hospital. All patients evaluated by radiography for an isolated, acute knee injury during 12 months. Patients were excluded for injuries: >1 week; isolated to superficial lacerations/abrasions; with prior knee surgery; being reassessed. Two hundred fifty-four patients (60% male; 12.7 years median age) were included. Twelve patients (4.7%) sustained a fracture. Evaluated criteria were point tenderness, inability to bear weight in the ED, and inability to flex the knee to 90 degrees. Point tenderness was not statistically associated with fracture, P = 0.7. Inability to bear weight in the ED (37% fracture rate, P = 0.001) and inability to flex to 90 degrees (52% fracture rate, P < 0.001) were associated with the presence of fracture.[table in text] Applying a rule combining nobearwt and noflex90 would decrease the number of x-rays by 73%, with no missed fractures. Point tenderness was not a good predictor of knee fracture in children. Using the clinical criteria to select patients requiring knee radiography may greatly reduce the number of unnecessary x-rays.

An analysis of the scientific basis for the radiographic guideline for new edentulous patients

The FDA Radiology Guideline for the new edentulous patient recommends an initial survey of the arches. In the process of developing this recommendation, the expert panel reviewed the available literature and concluded that there was sufficient evidence to warrant screening radiography rather than selective radiography, which is the principle on which all the other recommendations are based. Our evaluation of the literature used by the panel for the edentulous recommendation identifies critical errors in the analysis of the data. Factors such as a vague definition of abnormality and a geographically diverse sample population might have led the expert panel to suggest a very conservative recommendation for this group of patients. The recommendation failed to consider the treatment impact of findings and was based simply on the large number of observations, regardless of their treatment or pathologic significance. However, in studies in which treatment is considered, it is clear that screening radiography for new edentulous patients does not yield sufficient clinically relevant information to support the guideline.

A survey of the radiographic practices of general dentists for edentulous patients

The objective of the study was to evaluate the radiographic practice of general dentists for edentulous patients. A questionnaire was sent to a sample of graduates from the two Ontario dental schools. The adjusted response rate for the survey was 80%. Fifty-three percent of the respondents used screening radiography for new patients. The overwhelming choice for these dentists was the panoramic film. There was a significant positive association between ownership of a panoramic unit and use of this radiograph. Dentists who do not own a panoramic unit rarely chose to refer their patients for this radiograph either routinely or selectively. When dentists, rather than the auxiliaries, made the greater proportion of the radiographs, they tended to use selective radiography. Most dentists chose selective radiography for the recall patient. Almost half the dentists did not follow the Food and Drug Administration/American Dental Association guideline of screening radiography for the new edentulous patient. Of those dentists who did follow the guideline the vast majority both owned panoramic units and chose to use a panoramic survey. Most dentists followed the guideline for selective radiography for the recall patient.

Radiographic examination of children: A survey of prescribing practices of general dentists

Objectives The purpose of this article was to assess the radiographic prescribing practices of a sample of general practitioners for the pediatric dental patient in relation to current guidelines. Study design Questionnaires were mailed to a sample of 963 dentists. The adjusted response rate was 80%. Results For the new patient under age 6, slightly more than two thirds of respondents reported the use of selective radiography. For ages 6 to 14 years, a slight majority chose a protocol of survey radiography. Of those who used a predetermined protocol, 69% chose “bite-wings only” for the child under 6 years, whereas for the child 6 to 14 years, the protocol of choice was a complete radiographic survey, predominantly the panoramic/bite-wing. For recall patients in both age groups, less than 1% of dentists used survey radiography. Conclusions From our results, we conduded that the majority of dentists followed the guideline for children under 6 years. However, for children in the transitional dentition years, our respondents choices were divided between selective or survey radiography. The ambiguity in the wording or interpretation of the guideline for this age group may have contributed to this result.