Cumulative doses analysis in young trauma patients: a single-centre experience

Carnitine palmitoyltransferase II (CPT II) deficiency responsible for refractory cardiac arrhythmias, acute multiorgan failure and early fatal outcome

BACKGROUND

Carnitine palmitoyltransferase II (CPT II) deficiency is a rare inborn error of mitochondrial fatty acid metabolism with autosomal recessive pattern of inheritance. Its phenotype is highly variable (neonatal, infantile, and adult onset) on the base of mutations of the CPT II gene. In affected subjects, long-chain acylcarnitines cannot be subdivided into carnitine and acyl-CoA, leading to their toxic accumulation in different organs. Neonatal form is the most severe, and all the reported patients died within a few days to 6 months after birth. Hereby, we report on a male late-preterm newborn who presented refractory cardiac arrhythmias and acute multiorgan (hepatic, renal, muscular) injury, leading to cerebral hemorrhage, hydrocephalus, cardiovascular failure and early (day 5 of life) to death. Subsequently, extended metabolic screening and target next generation sequencing (NGS) analysis allowed the CPT II deficiency diagnosis.

CASE PRESENTATION

The male proband was born at 36+ 4 weeks of gestation by spontaneous vaginal delivery. Parents were healthy and nonconsanguineous, although both coming from Nigeria. Family history was unremarkable. Apgar score was 9/9. At birth, anthropometric measures were as follows: weight 2850 g (47th centile, -0.07 standard deviations, SD), length 50 cm (81st centile, + 0.89 SD) and occipitofrontal circumference (OFC) 35 cm (87th centile, + 1.14 SD). On day 2 of life our newborn showed bradycardia (heart rate around 80 bpm) and hypotonia, and was then transferred to the Neonatal Intensive Care Unit (NICU). There, he subsequently manifested many episodes of ventricular tachycardia, which were treated with pharmacological (magnesium sulfate) and electrical cardioversion. Due to the critical conditions of the baby (hepatic, renal and cardiac dysfunctions) and to guarantee optimal management of the arrythmias, he was transferred to the Pediatric Cardiology Reference Center of our region (Sicily, Italy), where he died 2 days later. Thereafter, the carnitines profile evidenced by the extended metabolic screening resulted compatible with a fatty acid oxidation defect (increased levels of acylcarnitines C16 and C18, and low of C2); afterwards, the targeted next generation sequencing (NGS) analysis revealed the known c.680 C > T p. (Pro227Leu) homozygous missense mutation of the CPTII gene, for diagnosis of CPT II deficiency. Genetic investigations have been, then, extended to the baby's parents, who were identified as heterozygous carriers of the same variant. When we meet again the parents for genetic counseling, the mother was within the first trimester of her second pregnancy. Therefore, we offered to the couple and performed the prenatal target NGS analysis on chorionic villi sample, which did not detect any alterations, excluding thus the CPT II deficiency in their second child.

CONCLUSIONS

CPTII deficiency may be suspected in newborns showing cardiac arrhythmias, associated or not with hypertrophic cardiomyopathy, polycystic kidneys, brain malformations, hepatomegaly. Its diagnosis should be even more suspected and investigated in cases of increased plasmatic levels of creatine phosphokinase and acylcarnitines in addition to kidney, heart and liver dysfunctions, as occurred in the present patient. Accurate family history, extended metabolic screening, and multidisciplinary approach are necessary for diagnosis and adequate management of affected subjects. Next generation sequencing (NGS) techniques allow the identification of the CPTII gene mutation, essential to confirm the diagnosis before or after birth, as well as to calculate the recurrence risk for family members. Our report broads the knowledge of the genetic and molecular bases of such rare disease, improving its clinical characterization, and provides useful indications for the treatment of patients.

Overuse of brain CT scan for evaluating mild head trauma in adults

INTRODUCTION

CT scan is crucial in evaluating head trauma. However, its inappropriate use will cause unnecessary radiation exposure to patient and financial burden to health systems. Our aim is appraising amount of brain CT scans performed in our Emergency Department (ED) for evaluating mild head trauma which are not indicated according to four standardized guidelines as well as analyzing contributing factors.

METHODS

This was a descriptive prospective study. We included randomly selected adult patients under 75 years old with minor head trauma evaluated by brain CT scan at our ED. For all patients, we completed a checklist including demographic data, mechanism of trauma, specialty of the requesting physician, and whether the patient meets the brain CT guidelines criteria. Brain CT overuse was defined as scans performed for patients without criteria of any of the standardized guidelines.

RESULTS

We evaluated 170 patients. The mean age of patients was 38.38 ± 19.73 years old. The most common mechanism of trauma was falling (37.6%). The overall brain CT scan overuse was 15.3%. Most of the overused scans were performed in younger patients, and patient's age was inversely correlated to overuse. There was no significant difference based on the mechanism of trauma and the specialty of requesting physician.

DISCUSSION

Our study accentuates the high frequency of brain CT scan overuse, leading to unnecessary radiation exposure and financial burden on healthcare systems. We emphasize that using a guideline for requesting brain CT scan can eliminate unnecessary scans along with detecting patients with important decisive damages.

Potentially Harmful Ionizing Radiation Exposure from Diagnostic Tests and Medical Procedures in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Patients with aneurysmal subarachnoid hemorrhage (aSAH) may have significant potentially harmful ionizing radiation exposure (PHIRE) from diagnostic tests and medical procedures (DTMP) during their initial hospitalization.

METHODS

In this single-center, retrospective, observational study, we evaluated the incidence of PHIRE using all patients with radiographically proven aSAH who survived hospitalization over a 6-year period. Patient data were then used to fit a full logistic regression model, a reduced-variable logistic regression model with least absolute shrinkage and selection operator penalty, and a nonparametric tree-based model. Testing data were then used to calculate each predictive model's accuracy.

RESULTS

Of 192 patients included in this study, 69 (35.9%) met criteria for PHIRE. Patients with PHIRE were more likely to have a poor Hunt-Hess Score (40.6% vs. 12.2%, P < 0.0001), a poor modified Fischer Grading Scale score (30.4% vs. 16.3%, P = 0.03), ventriculostomy (91.3% vs. 47.2%, P < 0.0001), vasospasm (81.2% vs. 34.1%, P < 0.0001), and ventriculoperitoneal shunt (31.9% vs. 10.6%, P < 0.001). Parametric PHIRE prediction modeling with a full logistic regression model and reduced-logistic regression modeling with least absolute shrinkage and selection operator penalty demonstrated PHIRE prediction accuracy of 67% and 78% accuracy, respectively. Nonparametric tree-based PHIRE modeling demonstrated a prediction accuracy of 58%.

CONCLUSIONS

On the basis of our data, PHIRE occurs in approximately 35% of aSAH patients. The reduced-variable logistic regression model had the greatest predictive accuracy for PHIRE. Future studies should validate our findings and predictive models and, if our conclusions hold, further clarification of the risks of PHIRE and methods to reduce PHIRE should be investigated.

Image quality and radiation dose reduction in chest CT in pulmonary infection

PURPOSE

To evaluate the effect of dose reduction with iterative reconstruction (IR) on image quality of chest CT scan comparing two protocols.

MATERIALS AND METHODS

Fifty-nine patients were enrolled. The two CT protocols were applied using Iterative Reconstruction (ASIR™) 40% but different noise indexes, recording dose-length product (DLP) and volume computed tomography dose index (CTDI_vol). The subjective IQ was rated based on the distinction of anatomic details using a 4-point Likert scale based on the European Guidelines on Quality Criteria for CT. For each patient, two single CTs, at enrollment (group 1) and at follow-up after lowering the dose (group 2), were evaluated by two radiologists evaluating, for each examination, five different lung regions (central zone-CZ; peripheral zone-PZ; sub-pleural region-SPR; centrilobular region-CLR; and apical zone-AZ). An inter-observer agreement was expressed by weighted Cohen's kappa statistics (k) and intra-individual differences of subjective image analysis through visual grading characteristic (VGC) analysis.

RESULTS

An average 50.4% reduction in CTDI_vol and 51.5% reduction in DLP delivered were observed using the dose-reduced protocol. An agreement between observers evaluating group 1 CTs was perfect (100%) and moderate to good in group 2 examinations (k-Cohen ranging from 0.56 for PZ and AZ to 0.70 for SPR). In the VGC analysis, image quality ratings were significantly better for group 1 than group 2 scans for all regions (AUC_VGC ranging from 0.56 for CZ to 0.62). However, disagreement was limited to a score 4 (excellent)-to-score 3 (good) IQ transition; apart from a single case in PZ, both the observers scored the IQ at follow-up as 2 (sufficient) starting from a score 4 (excellent).

CONCLUSION

Dose reduction achieved in the follow-up CT scans, although a lower IQ still allows a good diagnostic confidence.

Medical radiological procedures: which information would be chosen for the report?

AIMS AND OBJECTIVES

The aim of this study was to properly define the information regarding patient exposure to Ionizing Radiations in the radiological report, according to the European Directive 2013/59/EURATOM (EU 2013/59 art.58(b)). For this purpose, we evaluated the results from other Member States EU 2013/59 transpositions and from Guidelines recommendation published by International Organizations involved in diagnostic radiology. A practical way for implementing art.58 is also traced.

MATERIALS AND METHODS

Dosimetric quantities, such as exposure, absorbed dose and effective dose which may be included in radiological report, were first analyzed; then, in order to define international state of art of Member States EU 2013/59 transposition, a Web research using French, English, Spanish and German key words was performed.

RESULTS

EU 2013/59 transposition for 5 Member States was reported. Especially regarding art.58, a European project reports that few European countries (11 of 28) have identified the dose metrics to be used in radiological report. Scientific organizations supporting clinical radiologists and medical physicists have published Guidelines reporting parameters useful to quantify the radiation output and to assess patient dose.

CONCLUSIONS

Our research revealed that there is not a shared interpretation of patient exposure information to be included in radiological report. Nevertheless, according to scientific community, authors believe that the exposure is the most appropriate information that could be included in radiological report. Alternatively, but with more expensiveness, a risk index based on effective dose could be used. Moreover, the systematic exposure information recorded could be useful for dose estimates of population from medical exposure.

Overdiagnosis and overimaging: an ethical issue for radiological protection

AIMS AND OBJECTIVES

This study aimed to analyse the key factors that influence the overimaging using X-ray such as self-referral, defensive medicine and duplicate imaging studies and to emphasize the ethical problem that derives from it.

MATERIALS AND METHODS

In this study, we focused on the more frequent sources of overdiagnosis such as the total-body CT, proposed in the form of screening in both public and private sector, the choice of the most sensitive test for each pathology such as pulmonary embolism, ultrasound investigations mostly of the thyroid and of the prostate and MR examinations, especially of the musculoskeletal system.

RESULTS

The direct follow of overdiagnosis and overimaging is the increase in the risk of contrast media infusion, radiant damage, and costs in the worldwide healthcare system. The theme of the costs of overdiagnosis is strongly related to inappropriate or poorly appropriate imaging examination.

CONCLUSIONS

We underline the ethical imperatives of trust and right conduct, because the major ethical problems in radiology emerge in the justification of medical exposures of patients in the practice. A close cooperation and collaboration across all the physicians responsible for patient care in requiring imaging examination is also important, balancing possible ionizing radiation disadvantages and patient benefits in terms of care.

Patient centring and scan length: how inaccurate practice impacts on radiation dose in CT colonography (CTC)

OBJECTIVE

The aim of this study was to acknowledge errors in patients positioning in CT colonography (CTC) and their effect in radiation exposure.

MATERIALS AND METHODS

CTC studies of a total of 199 patients coming from two different referral hospitals were retrospectively reviewed. Two parameters have been considered for the analysis: patient position in relation to gantry isocentre and scan length related to the area of interest. CTDI vol and DLP were extracted for each patient. In order to evaluate the estimated effective total dose and the dose to various organs, we used the CT-EXPO^® software version 2.2. This software provides estimates of effective dose and doses to the other various organs.

RESULTS

Average value of the patients' position is found to be below the isocentre for 48 ± 25 mm and 29 ± 27 mm in the prone and supine position. It was observed that the increase in CTDI and DLP values for patients in Group 1, due to the inaccurate positioning, was estimated at about 30% and 20% for prone and supine position, respectively, while in Group 2, a decrease in CTDI and DLP values was estimated at about 16% and 18% for prone and supine position, respectively, due to an average position above isocentre. A dose increase ranging from 4 up to 13% was calculated with increasing the over-scanned region below anal orifice.

CONCLUSION

Radiographers and radiologists need to be aware of dose variation and noise effects on vertical positioning and over-scanning. More accurate training need to be achieved even so when examination protocol varies from general practice.

Overuse of computed tomography for minor head injury in young patients: an analysis of promoting factors

AIM

To assess the amount of computed tomography (CT) scans for minor head injury (MHI) performed in young patients in our emergency department (ED), not indicated by National Institute for Health and Clinical Excellence (NICE) and Canadian Computed Tomography Head Rules (CCHR), and to analyze factors contributing to unnecessary examinations. Secondary objectives were to calculate the effective dose, to establish the number of positive CT and to analyze which of the risk factors are correlated with positivity at CT; finally, to calculate sensitivity and specificity of NICE and CCHR in our population.

MATERIALS AND METHODS

We retrospectively evaluated 493 CT scans of patients aged 18-45 years, collecting the following parameters from ED medical records: patient demographics, risk factors indicating the need of brain imaging, trauma mechanism, specialty and seniority of the referring physician. For each CT, the effective dose and the negativity/positivity were assessed.

RESULTS

357/493 (72%) and 347/493 (70%) examinations were not in line with the CCHR and NICE guidelines, respectively. No statistically significant difference between physician specialty (p = 0.29 for CCHR; p = 0.24 for NICE), nor between physician seniority and the amount of inappropriate examinations (p = 0.93 for CCHR, p = 0.97 for NICE) was found but CT scans requested by ED physicians were less inappropriate [p = 0.28, odds ratio (OR) 0.562, CI (95%) 0.336-0.939]. There was no statistically significant correlation between patient age and over-referral (p = 0.74 for NICE, p = 0.93 for CCHR). According to NICE, low speed motor vehicle accident (p = 0.009), motor vehicle accident with high energy impact (p < 0.01) and domestic injuries (p = 0.002) were associated with a higher rate of unwarranted CT; according to CCHR only motor vehicle accident with high energy impact showed a significant correlation with unwarranted CT scan (p < 0.001, OR 44.650, CI 33.123-1469.854). 2% of CT was positive. Multivariate analysis demonstrated that factors significantly associated with CT scan positivity included signs of suspected skull fracture (p < 0.001, OR 20.430, CI 2.727-153.052) and motor vehicle accident with high energy impact (p < 0.001, OR 220.650, CI 33.123-1469.854). In our series, CCHR showed sensitivity of 100%, specificity of 74%; NICE showed sensitivity of 100%, specificity of 72%.

CONCLUSION

We observed an important overuse of head CT scans in MHI; the main promoting factor for inappropriate was injury mechanism. 2% of head CT were positive, correlating with signs of suspected skull fracture and motor vehicle accident with high energy impact.