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In-utero post-mortem MRI, opportunistic imaging with diagnostic yield. Prenat Diagn 2024. [PMID: 38686965 DOI: 10.1002/pd.6582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024]
Abstract
Key pointsWhat's already known about this topic?
The role of post‐mortem extra‐uterine MRI as part of a minimally invasive autopsy has been established.
Antenatal in‐utero MRI during life has shown similar diagnostic accuracy to post‐mortem extra‐uterine MRI
Post mortem in utero MRI prior to delivery has not yet been documented or fully evaluated.
What does this study add?
We illustrate the feasibility and potential diagnostic value of post‐mortem intrauterine MRI
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Current and future funding streams for paediatric postmortem imaging: European Society of Paediatric Radiology survey results. Pediatr Radiol 2023; 53:273-281. [PMID: 36097227 PMCID: PMC9468234 DOI: 10.1007/s00247-022-05485-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/11/2022] [Accepted: 08/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perinatal and childhood postmortem imaging has been accepted as a noninvasive alternative or adjunct to autopsy. However, the variation in funding models from institution to institution is a major factor prohibiting uniform provision of this service. OBJECTIVE To describe current funding models employed in European and non-European institutions offering paediatric postmortem imaging services and to discuss the perceived barriers to future postmortem imaging service provision. MATERIALS AND METHODS A web-based 16-question survey was distributed to members of the European Society of Paediatric Radiology (ESPR) and ESPR postmortem imaging task force over a 6-month period (March-August 2021). Survey questions related to the radiologic and autopsy services being offered and how each was funded within the respondent's institute. RESULTS Eighteen individual responses were received (13/18, 72.2% from Europe). Only one-third of the institutions (6/18, 33.3%) have fully funded postmortem imaging services, with the remainder receiving partial (6/18, 33.3%) or no funding (5/18, 27.8%). Funding (full or partial) was more commonly available for forensic work (13/18, 72%), particularly where this was nationally provided. Where funding was not provided, the imaging and reporting costs were absorbed by the institute. CONCLUSION Increased access is required for the expansion of postmortem imaging into routine clinical use. This can only be achieved with formal funding on a national level, potentially through health care commissioning and acknowledgement by health care policy makers and pathology services of the value the service provides following the death of a fetus or child. Funding should include the costs involved in training, equipment, reporting and image acquisition.
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Prenatal MR Imaging Phenotype of Fetuses with Tuberous Sclerosis: An Institutional Case Series and Literature Review. AJNR Am J Neuroradiol 2022; 43:633-638. [PMID: 35332020 PMCID: PMC8993194 DOI: 10.3174/ajnr.a7455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/10/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Most patients with tuberous sclerosis complex (TSC) do not receive prenatal diagnosis. Our aim was to describe MR imaging findings to determine the following: 1. Whether normal fetal MR imaging is more common in fetuses imaged at ≤24 weeks' gestation compared with >24 weeks 2. The frequency of cardiac rhabdomyoma 3. The range of MR imaging phenotypes in fetal tuberous sclerosis complex. MATERIALS AND METHODS Our institutional fetal MR imaging data base was searched between January 1, 2011 and June 30, 2021, for cases of TSC confirmed either by genetic testing, postnatal imaging, postmortem examination, or composite prenatal imaging findings and family history. A MEDLINE search was performed on June 8, 2021. RESULTS Forty-seven published cases and 4 of our own cases were identified. Normal findings on fetal MR imaging were seen at a lower gestational age (mean, 24.7 [SD, 4.5 ] weeks) than abnormal findings on MR imaging (mean, 30.0 [SD, 5.3] weeks) (P = .008). Nine of 42 patients with abnormal MR imaging findings were ≤24 weeks' gestation. Subependymal nodules were present in 26/45 cases (57.8%), and cortical/subcortical lesions, in 17/46 (37.0%). A foramen of Monro nodule was present in 15 cases; in 2/7 cases in which this was unilateral, it was the only abnormal cerebral finding. Cardiac rhabdomyoma was absent in 3/48 cases at the time of fetal MR imaging but was discovered later. Megalencephaly or hemimegalencephaly was observed in 3 cases. CONCLUSIONS Fetuses with abnormal cranial MR imaging findings were older than those with negative findings. Fetal hemimegalencephaly and megalencephaly should prompt fetal echocardiography. Cardiac rhabdomyoma was not always present at the time of fetal MR imaging.
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Quality improvement 101 in medical imaging: Why, what, how. J Med Imaging Radiat Oncol 2022; 66:175-184. [PMID: 35243778 DOI: 10.1111/1754-9485.13387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 01/26/2022] [Indexed: 11/30/2022]
Abstract
Quality is consistently doing something well; in healthcare, this centres on providing consistently safe, effective and appropriate, timely and accessible, efficient and equitable care. The ability to identify and rectify failures in the delivery of quality care and to continuously improve the quality of the care we provide is a fundamental requirement of healthcare professionals in the 21st century. There is both a scientific and an empirical basis to quality improvement methodology. The project management techniques that underpin these can be taught, and learned, but rarely are, in postgraduate medical curricula. This overview of how to do a quality improvement project will provide medical imaging professionals with a systematic approach to understanding a problem and its causes, assembling the team to fix it, planning interventions, measuring outcomes and sustaining change. Good project management brings order to what can feel like chaos; time, money and relationships may be saved. Like experiments in the kitchen, not every quality improvement project can or does work; however, there is a recipe, and following it is a good start.
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Quality use of artificial intelligence in medical imaging: What do radiologists need to know? J Med Imaging Radiat Oncol 2022; 66:225-232. [PMID: 35243782 DOI: 10.1111/1754-9485.13379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
The application of artificial intelligence, and in particular machine learning, to the practice of radiology, is already impacting the quality of imaging care. It will increasingly do so in the future. Radiologists need to be aware of factors that govern the quality of these tools at the development, regulatory and clinical implementation stages in order to make judicious decisions about their use in daily practice.
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The Fetus with Ganglionic Eminence Abnormality: Head Size and Extracranial Sonographic Findings Predict Genetic Diagnoses and Postnatal Outcomes. AJNR Am J Neuroradiol 2021; 42:1528-1534. [PMID: 33958329 DOI: 10.3174/ajnr.a7131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/17/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Ganglionic eminence abnormalities on fetal MR imaging are associated with cerebral malformations. Their presumed genetic basis and associated postnatal outcomes remain largely unknown. We aimed to elucidate these through a multicenter study. MATERIALS AND METHODS Between January 2010 and June 2020, seven hospitals in 2 countries performing fetal MR imaging examinations identified fetal MR imaging studies demonstrating ganglionic eminence enlargement, cavitation, or both. Cases with no genetic diagnosis, no whole exome sequencing, or no outcome of a liveborn child were excluded. Head size was classified as large (fronto-occipital diameter > 95th centile), small (fronto-occipital diameter <5th centile), or normal. RESULTS Twenty-two fetuses with ganglionic eminence abnormalities were identified. Of 8 with large heads, 2 were diagnosed with MTOR mutations; 1 with PIK3CA mutation-producing megalencephaly, polymicrogyria, polydactyly, hydrocephalus (MPPH) syndrome; 3 with TSC mutations; 1 with megalencephaly capillary malformation syndrome; and 1 with hemimegalencephaly. Cardiac rhabdomyoma was present prenatally in all cases of TSC; mutation postaxial polydactyly accompanied megalencephaly capillary malformation and MPPH. Of 12 fetuses with small heads, 7 had TUBA1A mutations, 1 had a TUBB3 mutation, 2 had cobblestone lissencephaly postnatally with no genetic diagnosis, 1 had a PDHA1 mutation, and 1 had a fetal akinesia dyskinesia sequence with no pathogenic mutation on trio whole exome sequencing. One of the fetuses with a normal head size had an OPHN1 mutation with postnatal febrile seizures, and the other had peri-Sylvian polymicrogyria, seizures, and severe developmental delay but no explanatory mutation on whole exome sequencing. CONCLUSIONS Fetal head size and extracranial prenatal sonographic findings can refine the phenotype and facilitate genetic diagnosis when ganglionic eminence abnormality is diagnosed with MR imaging.
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Current state of perinatal postmortem magnetic resonance imaging: European Society of Paediatric Radiology questionnaire-based survey and recommendations. Pediatr Radiol 2021; 51:792-799. [PMID: 33367939 PMCID: PMC8055569 DOI: 10.1007/s00247-020-04905-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/02/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postmortem magnetic resonance imaging (MRI) in perinatal and childhood deaths is increasingly used as a noninvasive adjunct or alternative to autopsy. Imaging protocols vary between centres and consensus guidelines do not exist. OBJECTIVE Our aim was to develop practical, standardised recommendations for perinatal postmortem MRI. MATERIALS AND METHODS Recommendations were based on the results of two surveys regarding local postmortem MRI practices sent electronically to all 14 members of the European Society of Paediatric Radiology (ESPR) Postmortem Imaging Task Force and 17 members of the International Society of Forensic Radiology and Imaging Task Force (25 different centres). RESULTS Overall, 11/14 (78.6%) respondents from different institutions perform postmortem MRI. All of these centres perform postmortem MRI for perinatal and neonatal deaths, but only 6/11 (54.5%) perform imaging in older children. CONCLUSION We propose a clinical standard for postmortem MRI sequences plus optional sequences for neuroimaging and cardiac anatomy depending on available scanning time and referral indications.
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Imaging triage of acute stroke patients for endovascular clot retrieval: Effect of increased therapeutic window on the utilization of CT perfusion. J Med Imaging Radiat Oncol 2020; 65:152-159. [PMID: 33615685 DOI: 10.1111/1754-9485.13122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/11/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recent randomized trials showing improved outcomes for later-presenting acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO) treated with endovascular clot retrieval (ECR) may result in substantial increases in CTP utilization. This 3-hospital, single-institution cohort study aimed to compare 2017 and 2018 patient cohorts for the following: CTP use in AIS. Prevalence of LVO in all patients having CTP. Number and clinical characteristics of patients triaged to ECR. Number of patients receiving CTP relative to similar-acuity total ED presentations. METHODS Inclusion criteria: Consecutive adult emergency (ED) patients receiving CTP for suspected AIS. Study period 1:1 January-30 June 2017; Period 2:1 January-30 June 2018. DATA COLLECTION age, gender, triage category, NIHSS (National Institute of Health Stroke Score), symptoms/signs, time elapsed since last seen well (TESLSW) to triage, disposition (home/other). RESULTS A 38.7 % increase in CTP (512 in 2017, 710 in 2018) occurred with 39/512 (7.6%) and 72/710 (10.1%) having intended ECR. CTPs per intended ECR declined from 13.1 to 9.9. 36/512 (7.0%) and 58/710 (8.2%) patients had ECR (61.1% increase) and 22/36 (61.1%) and 25/58 (43.1%) of these were discharged home in 2017 and 2018, respectively, an increase of 3/22(14%). CONCLUSION Despite a 38.7% increase in CTP utilization, we experienced a reduction in the number of CTPs performed/patient triaged to ECR. This did not reflect higher LVO prevalence among later presenters but may reflect changed selection criteria for CTP and/or decision making about suitability for ECR.
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Erratum: The Value of Quantitative Musculoskeletal Imaging. Semin Musculoskelet Radiol 2020; 24:e1. [PMID: 33086390 DOI: 10.1055/s-0040-1719097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
AbstractMusculoskeletal imaging is mainly based on the subjective and qualitative analysis of imaging examinations. However, integration of quantitative assessment of imaging data could increase the value of imaging in both research and clinical practice. Some imaging modalities, such as perfusion magnetic resonance imaging (MRI), diffusion MRI, or T2 mapping, are intrinsically quantitative. But conventional morphological imaging can also be analyzed through the quantification of various parameters. The quantitative data retrieved from imaging examinations can serve as biomarkers and be used to support diagnosis, determine patient prognosis, or monitor therapy.We focus on the value, or clinical utility, of quantitative imaging in the musculoskeletal field. There is currently a trend to move from volume- to value-based payments. This review contains definitions and examines the role that quantitative imaging may play in the implementation of value-based health care. The influence of artificial intelligence on the value of quantitative musculoskeletal imaging is also discussed.
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Semistructured interviews regarding patients' perceptions of Choosing Wisely and shared decision-making: an Australian study. BMJ Open 2019; 9:e031831. [PMID: 31467057 PMCID: PMC6720255 DOI: 10.1136/bmjopen-2019-031831] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES This study aimed to examine how patients perceive shared decision-making regarding CT scan referral and use of the five Choosing Wisely questions with their general practitioner (GP). DESIGN This is a qualitative exploratory study using semistructured interviews. SETTING This study was conducted in a large metropolitan public healthcare organisation in urban Australia. PARTICIPANTS Following purposive sampling, 20 patients and 2 carers participated. Patient participants aged 18 years or older were eligible if they were attending the healthcare organisation for a CT scan and referred by their GP. Carers/family were eligible to participate when they were in the role of an unpaid carer and were aged 18 years or older. Participants were required to speak English sufficiently to provide informed consent. Participants with cognitive impairment were excluded. FINDINGS Eighteen interviews were conducted with the patient only. Two interviews were conducted with the patient and the patient's carer. Fourteen participants were female. Five themes resulted from the thematic analysis: (1) needing to know, (2) questioning doctors is not necessary, (3) discussing scans is not required, (4) uncertainty about questioning and (5) valuing the Choosing Wisely questions. Participants reported that they presented to their GP with a health problem that they needed to understand and address. Participants accepted their GPs decision to prescribe a CT scan to identify the nature of their problem. They reported ambivalence about engaging in shared decision-making with their doctor, although many participants reported valuing the Choosing Wisely questions. CONCLUSIONS Shared decision-making is an important principle underpinning Choosing Wisely. Practice implementation requires understanding patients' motivations to engage in shared decision-making with a focus on attitudes, beliefs, knowledge and emotions. Systems-level support and education for healthcare practitioners in effective communication is important. However, this needs to emphasise communication with patients who have varying degrees of motivation to engage in shared decision-making and Choosing Wisely.
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Diagnostic assessment of foetal brain malformations with intra-uterine MRI versus perinatal post-mortem MRI. Neuroradiology 2019; 61:921-934. [PMID: 31076826 PMCID: PMC6620257 DOI: 10.1007/s00234-019-02218-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/16/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate differences in diagnostic yield of intra-uterine foetal (iuMR) and post-mortem MRI (PMMR) for complex brain malformations, using autopsy as the reference standard. METHODS In this retrospective, multicentre study spanning 2 years, we reviewed 13 terminated singleton pregnancies with a prenatal ultrasound finding of complex foetal cerebral abnormalities, referred for both iuMR and PMMR. The iuMR and PMMR studies of the brain were reported independently by two groups of radiologists, blinded to each other's reports. Descriptive statistics were used to compare differences in intracranial abnormalities with autopsy (and genetic testing, where present) as reference standard. RESULTS The median gestational age at termination was 24.6 weeks (IQR 22-29) with median time between delivery and PMMR of 133 h (IQR 101-165). There was full concordance between iuMR and PMMR findings and autopsy in 2/13 (15.3%) cases. Partial concordance between both imaging modalities was present in 6/13 (46.2%) and total discordance in the remainder (5/13, 38.5%). When compared to autopsy, PMMR missed important key findings specifically for neuronal migration and cerebellar anomalies, whereas iuMR appeared to overcall CSF space abnormalities which were less crucial to reaching the final overall diagnosis. CONCLUSIONS iuMR should be performed to improve foetal phenotyping where there is a prenatal ultrasound for complex foetal brain abnormalities. Reliance on PMMR alone is likely to result in misdiagnosis in a majority of cases.
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Protect-me: a parallel-group, triple blinded, placebo-controlled randomised clinical trial protocol assessing antenatal maternal melatonin supplementation for fetal neuroprotection in early-onset fetal growth restriction. BMJ Open 2019; 9:e028243. [PMID: 31230020 PMCID: PMC6596968 DOI: 10.1136/bmjopen-2018-028243] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Fetal growth restriction (FGR) is a serious pregnancy complication, associated with increased rates of perinatal death and morbidity among survivors. Most commonly FGR results from placental insufficiency, where the placenta fails to deliver the oxygen and nutrients required for normal fetal growth. This leads to fetal oxidative stress, resulting in organ damage through lipid peroxidation. The early developing brain is particularly susceptible, such that FGR is associated with poorer neurodevelopment, witnessed as cognitive and behavioural dysfunction, and cerebral palsy. Promisingly, melatonin, a lipid soluble antioxidant is neuroprotective in animal models of FGR. We present a protocol outlining a randomised, placebo-controlled trial to explore whether antenatal maternal melatonin supplementation in pregnancies with severe, early-onset FGR can improve neurodevelopment among survivors at 2 years of age. METHODS AND ANALYSES We will recruit 336 women with a singleton pregnancy complicated by FGR between 23+0 and 31+6 weeks gestation. Participants will be randomised, stratified by gestational age, to either 30 mg melatonin per day or a visually identical placebo, continued until birth. Measures of maternal and fetal health will be collected until birth. Timing of birth will be determined by the treating clinical team in discussion with the woman. Neonatal and infant neurodevelopmental assessments will be undertaken, consisting of brain MRI at term corrected age, general movements assessment at term and 3 months' corrected age, and Bayley Scales of Infant & Toddler Development-III and Infant Toddler Social Emotional Assessment at 2.5 years corrected age. Analyses will be on intention to treat. The primary outcome is a difference of 5 points in the cognitive domain of the Bayley-III. Secondary outcomes address maternal and fetal safety. ETHICS AND DISSEMINATION This trial has Monash Health Human Research and Ethics committee approval (17-0000-583A). Findings will be disseminated through peer-reviewed publications, conference presentations and to participants. TRIAL REGISTRATION NUMBER ACTRN12617001515381; Pre-results.
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Interobserver agreement and diagnostic performance of individual MRI criteria for diagnosis of placental adhesion disorders. Clin Radiol 2018; 73:908.e1-908.e9. [PMID: 30041952 DOI: 10.1016/j.crad.2018.05.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/16/2018] [Indexed: 11/28/2022]
Abstract
AIM To assess the diagnostic accuracy of several criteria for the diagnosis of placental adhesion disorder (PAD) on magnetic resonance imaging (MRI) and to assess interobserver agreement and reader accuracy based on years of interpretive experience. MATERIALS AND METHODS Blinded evaluation of the placental MRI studies of 28 randomly selected women, 18 with PADs and 10 without PADs, was undertaken by three radiologists with 10, 5, and 2 years' experience in placental MRI interpretation. The presence of placenta praevia, dark intraplacental bands, heterogeneity, uterine bulging, "shaggy dog" appearance of the uterine serosa, subjective impression of extraplacental invasion, and dark intraplacental bands on diffusion-weighted imaging were assessed. Placental histology was reviewed blinded to the original reports and to MRI interpretation and this, along with clinical information at the time of delivery, formed the reference standard. RESULTS Dark intraplacental bands on T2-weighted imaging were the most sensitive and specific as well as the most agreed upon (kappa=0.7) criterion for PAD for the three readers. Assessment of uterine bulging (kappa=0.42) and placental heterogeneity (kappa=0.48) did not improve diagnostic accuracy. DWI improved sensitivity but decreased specificity for the least experienced reader and did not change sensitivity or specificity for the more experienced readers. CONCLUSION Assessment of the placenta for dark bands is the most sensitive, specific, and reproducible criterion for diagnosis of PADs using MRI.
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Comparison of safety and efficacy of image-guided enema reduction techniques for paediatric intussusception: A review of the literature. J Med Imaging Radiat Oncol 2017; 61:711-717. [DOI: 10.1111/1754-9485.12601] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/07/2017] [Indexed: 11/26/2022]
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What's in a name? Everything. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:803-804. [PMID: 27933704 DOI: 10.1002/uog.17312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/05/2016] [Indexed: 06/06/2023]
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Audit of demand for after-hours CT scanning services in RANZCR-accredited training departments. J Med Imaging Radiat Oncol 2015; 60:35-41; quiz 41-6. [PMID: 26549057 DOI: 10.1111/1754-9485.12409] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 09/24/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aims of this study were to measure: (i) the growth in after-hours emergency department--referred CT (ED-CT) performed in accredited training departments between 2011 and 2013; (ii) the growth in ED CT relative to growth in ED presentations at the same hospitals; and (iii) trainee workload resulting from after-hours ED CT. METHODS Ethics approval was obtained for all participating sites. Accredited training facilities in Australia and New Zealand with three or more trainees and serving one or more EDs were invited to participate (N = 32). Four nights were surveyed between August and December 2013. For data collection, the number of ED patients having one or more CT scans; ED CT scan total images; non-contrast head CTs; and ED patients (total and categories 1 and 2) attending the ED in the preceding 24 h and first half of calendar year were collected for 2013 and corresponding days in 2012 and 2011. Trainee staffing levels were measured. RESULTS Eleven of 32 sites provided data for all four nights and 14 of 32 for one or more nights. A 15.7% increase in number of ED CTs between 1700 and 2200 h and 16.8% increase between 2201 and 0730 h occurred in the 2 years between 2011 and 2013 compared with a 6.9% increase in overall ED and 26% increase in categories 1 and 2 presentations over the same period. The number of CT images, however, increased 23%. CONCLUSION Growth in demand by EDs for after-hours CT services has implications for service provision and trainee workloads in Royal Australian and New Zealand College of Radiologists-accredited training departments.
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Impact of Interactive e-Learning Modules on Appropriateness of Imaging Referrals: A Multicenter, Randomized, Crossover Study. J Am Coll Radiol 2015; 12:1207-14. [PMID: 26421852 DOI: 10.1016/j.jacr.2015.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/12/2015] [Accepted: 06/16/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Health care expenditure on diagnostic imaging investigations is increasing, and many tests are ordered inappropriately. Validated clinical decision rules (CDRs) for certain conditions are available to aid in assessing the need for imaging. However, awareness and utilization of CDRs are lacking. This study compared the efficacy and perceived impact of interactive e-learning modules versus static versions of CDRs, for learning about appropriate imaging referrals. METHODS A multicenter, randomized, crossover trial was performed; participants were volunteer medical students and recent graduates. In week 1, group 1 received an e-learning module on appropriate imaging referrals for pulmonary embolism; group 2 received PDF versions of relevant CDRs, and an online quiz with feedback. In week 2, the groups crossed over, focusing on imaging referrals for cervical spine trauma in adults. Online assessments were administered to both groups at the end of each week, and participants completed an online questionnaire at the end of the trial. RESULTS Group 1 (e-learning module) performed significantly better on the pulmonary embolism knowledge assessment. After the crossover, participants in group 2 (e-learning module) were significantly more likely to improve their scores in the assessment of cervical spine trauma knowledge. Both groups gave positive evaluations of the e-learning modules. CONCLUSIONS Interactive e-learning was significantly more effective for learning in this cohort, compared with static CDRs. We believe that the authentic clinical scenarios, feedback, and integration provided by the e-learning modules contributed to their impact. This study has implications for implementation of e-learning tools to facilitate appropriate referrals for imaging investigations in clinical practice.
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Paediatric CT dose: a multicentre audit of subspecialty practice in Australia and New Zealand. Eur Radiol 2015; 25:3109-22. [PMID: 26037714 DOI: 10.1007/s00330-015-3727-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 03/17/2015] [Accepted: 03/20/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate paediatric CT dosimetry in Australia and New Zealand and calculate size-specific dose estimates (SSDEs) for chest and abdominal examinations. METHODS Eight hospitals provided data from 12 CT systems for 1462 CTs in children aged 0-15. Imaging data were recorded for eight examinations: head (trauma, shunt), temporal bone, paranasal sinuses, chest (mass) and chest HRCT (high-resolution CT), and abdomen/pelvis (mass/inflammation). Dose data for cranial examinations were categorised by age and SSDEs by lateral dimension. Diagnostic reference ranges (DRRs) were defined by the 25th and 75th percentiles. Centralised image quality assessment was not undertaken. RESULTS DRRs for 201 abdominopelvic SSDEs were: 2.8-4.7, 3.6-11.5, 8.5-15.0, 7.6-15, and 10.6-16.2 for the <15 cm, 15-19 cm, 20-24 cm, 25-29 cm and >30 cm groups, respectively. For 147 chest examinations using these body width categories, SSDE DRRs were 2.0-4.4, 3.3-7.9, 4.0-9.4, 4.5-12, and 6.5-12. Kilovoltage peak (kVp), but not AEC or IR, was associated with SSDE (parameter estimate [standard error]: 0.12 (0.03); p < 0.0001). CONCLUSIONS Australian and New Zealand paediatric CT DRRs and abdominal SSDEs are comparable to international data. SSDEs for chest examinations are proposed. Dose variations could be reduced by adjusting kVp. KEY POINTS • SSDEs can be calculated for all patients, CT systems, and practices • Kilovoltage peak (kVp) has the greatest association with dose in similar-sized patients • Paediatric DRRs for CT are now available for use internationally.
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Isolated iliac vein thrombosis in pregnancy. Intern Med J 2015; 45:460-1. [PMID: 25827515 DOI: 10.1111/imj.12718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/11/2015] [Indexed: 11/30/2022]
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Isolated ventriculomegaly on prenatal ultrasound: what does fetal MRI add? J Med Imaging Radiat Oncol 2015; 59:154-62. [PMID: 25728263 DOI: 10.1111/1754-9485.12287] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/19/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Cerebral ventriculomegaly is one of the most commonly detected fetal anomalies at the midtrimester ultrasound. Current evidence suggests that magnetic resonance imaging (MRI) is indicated when the isolated ventriculomegaly (IVM) on ultrasound is severe (>15 mm), but there is less agreement when IVM is mild or moderate (10-15 mm). The current study aimed to determine the frequency and nature of additional findings on MRI in IVM and their relationship to the severity of VM and gestational age. METHODS Data were gathered prospectively from all pregnant women with ultrasound-diagnosed IVM referred for MRI between November 2006 and February 2013. Cases with IVM and no other suspected cranial abnormality on a tertiary ultrasound performed at our institution, at or after 20 weeks gestation, were included. RESULTS Of the 59 fetuses with unilateral or bilateral IVM, additional findings were seen on MRI in 10 cases (17%) and half of these findings were identified in fetuses with mild IVM. Five of 40 (12.5%) fetuses with mild IVM had additional findings and 3/5 (60%) were potentially clinically significant. No additional abnormalities were identified in fetuses less than or equal to 24 weeks gestation with mild or moderate IVM. There was no statistically significant relationship between gestational age and additional findings on MRI in mild IVM. Callosal and septum pellucidum lesions, periventricular abnormalities and malformations of cortical development accounted for all of the significant additional findings. CONCLUSION This study helps to inform referral of pregnant women with a fetus who has IVM for prenatal MRI.
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Early MRI in term infants with perinatal hypoxic-ischaemic brain injury: interobserver agreement and MRI predictors of outcome at 2 years. Clin Radiol 2013; 69:72-81. [PMID: 24210250 DOI: 10.1016/j.crad.2013.09.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/22/2013] [Indexed: 11/29/2022]
Abstract
AIM To compare diffusion-weighted imaging (DWI) and non-DWI magnetic resonance imaging (MRI), proton MR spectroscopy (1H-MRS), and clinical biomarkers for prediction of 2 year developmental outcome in term infants with perinatal hypoxic-ischaemic encephalopathy (HIE). MATERIALS AND METHODS Nineteen infants ≥36 weeks gestation with HIE were recruited and MRI performed day 3-7 (mean = 5). MRI was scored independently by three radiologists using a standardized scoring system. Lactate-to-N-acetylaspartate ratio (Lac:NAA) in the lentiform nucleus was calculated. Developmental assessment was performed at 2 years using the Bayley Scales of Infant and Toddler Development (BSID-III). Interobserver agreement about abnormality in 10 brain regions was measured. Univariate analysis was performed to determine variables associated with adverse outcome (i.e., death or Bayley score for any domain <70). RESULTS Good interobserver agreement (kappa = 0.61-0.69) on scores for DWI was obtained for the cortex, putamen, and brainstem, but not for any region on non-DWI. A significant association was found between outcome and Lac:NAA (p < 0.003) and DWI scores for lentiform nucleus, thalamus, cortex, posterior limb of the internal capsule (PLIC), and paracentral white matter (p = 0.001-0.013), but for non-DWI score only in the vermis or brainstem. A combination of Lac:NAA ≥0.25 or DWI/apparent diffusion coefficient (ADC) signal abnormality in the PLIC had 100% specificity and sensitivity for poor outcome. CONCLUSION Interobserver agreement for non-DWI performed during the first week is poor. Agreement by three radiologists about the presence of abnormal signal within the PLIC on ADC/DWI images or elevation of Lac:NAA above 0.25 improved sensitivity without reducing the prognostic specificity of MRS in the 19 patients, but this requires validation in a larger group of infants with HIE who have been treated with hypothermia.
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What do radiologists do all day? Quantifying workload and planning production in a medical imaging department. J Med Imaging Radiat Oncol 2013; 57:527-8. [PMID: 24119264 DOI: 10.1111/1754-9485.12127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 09/16/2013] [Indexed: 11/30/2022]
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Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346:f2360. [PMID: 23694687 PMCID: PMC3660619 DOI: 10.1136/bmj.f2360] [Citation(s) in RCA: 1287] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the cancer risk in children and adolescents following exposure to low dose ionising radiation from diagnostic computed tomography (CT) scans. DESIGN Population based, cohort, data linkage study in Australia. COHORT MEMBERS: 10.9 million people identified from Australian Medicare records, aged 0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December 2005; all exposures to CT scans funded by Medicare during 1985-2005 were identified for this cohort. Cancers diagnosed in cohort members up to 31 December 2007 were obtained through linkage to national cancer records. MAIN OUTCOME Cancer incidence rates in individuals exposed to a CT scan more than one year before any cancer diagnosis, compared with cancer incidence rates in unexposed individuals. RESULTS 60,674 cancers were recorded, including 3150 in 680,211 people exposed to a CT scan at least one year before any cancer diagnosis. The mean duration of follow-up after exposure was 9.5 years. Overall cancer incidence was 24% greater for exposed than for unexposed people, after accounting for age, sex, and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval 1.20 to 1.29); P<0.001). We saw a dose-response relation, and the IRR increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was greater after exposure at younger ages (P<0.001 for trend). At 1-4, 5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to 1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34), respectively. The IRR increased significantly for many types of solid cancer (digestive organs, melanoma, soft tissue, female genital, urinary tract, brain, and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There was an excess of 608 cancers in people exposed to CT scans (147 brain, 356 other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The absolute excess incidence rate for all cancers combined was 9.38 per 100,000 person years at risk, as of 31 December 2007. The average effective radiation dose per scan was estimated as 4.5 mSv. CONCLUSIONS The increased incidence of cancer after CT scan exposure in this cohort was mostly due to irradiation. Because the cancer excess was still continuing at the end of follow-up, the eventual lifetime risk from CT scans cannot yet be determined. Radiation doses from contemporary CT scans are likely to be lower than those in 1985-2005, but some increase in cancer risk is still likely from current scans. Future CT scans should be limited to situations where there is a definite clinical indication, with every scan optimised to provide a diagnostic CT image at the lowest possible radiation dose.
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Evidence-based guideline for the written radiology report: methods, recommendations and implementation challenges. J Med Imaging Radiat Oncol 2012; 57:1-7. [PMID: 23374546 DOI: 10.1111/1754-9485.12014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 08/28/2012] [Indexed: 11/26/2022]
Abstract
The written radiology report is the dominant method by which radiologists communicate the results of diagnostic and interventional imaging procedures. It has an important impact on decisions about further investigation and management. Its form and content can be influential in reducing harm to patients and mitigating risk for practitioners but varies markedly with little standardisation in practice. Until now, the Royal Australian and New Zealand College of Radiologists has not had a guideline for the written report. International guidelines on this subject are not evidence based and lack description of development methods. The current guideline seeks to improve the quality of the written report by providing evidence-based recommendations for good practice. The following attributes of the report are addressed by recommendations: Content Clinical information available to the radiologist at the time the report was created Technical details of the procedure Examination quality and limitations Findings (both normal and abnormal) Comparison with previous studies Pathophysiological diagnosis Differential diagnoses Clinical correlation and/or answer to the clinical question Recommendations, particularly for further imaging and other investigations Conclusion/opinion/impression Format Length Format Language Confidence and certainty Clarity Readability Accuracy Communication of discrepancies between an original verbal or written report and the final report Proofreading/editing of own and trainee reports.
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Alarm about computed tomography scans is unjustified. Med J Aust 2011; 194:150-1. [DOI: 10.5694/j.1326-5377.2011.tb04204.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 10/12/2010] [Indexed: 11/17/2022]
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Multidetector CT dose: clinical practice improvement strategies from a successful optimization program. J Am Coll Radiol 2011; 7:614-24. [PMID: 20678731 DOI: 10.1016/j.jacr.2010.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 03/17/2010] [Indexed: 10/24/2022]
Abstract
PURPOSE The aims of this study were to collect data relating to radiation dose delivered by multidetector CT scanning at 10 hospitals and private practices in Queensland, Australia, and to test methods for dose optimization training, including audit feedback and didactic, face-to-face, small-group teaching of optimization techniques. METHODS Ten hospital-based public and private sector radiology practices, with one CT scanner per site, volunteered for the project. Data were collected for a variety of common adult and pediatric CT scanning protocols, including tube current-time product, pitch, collimation, tube voltage, the use of dose modulation, and scan length. A one-day feedback and optimization training workshop was conducted for participating practices and was attended by the radiologist and medical imaging technologist responsible for the project at each site. Data were deidentified for the workshop presentation. During the feedback workshop, a detailed analysis and discussion of factors contributing to dose for higher dosing practices for each protocol occurred. The postoptimization training data collection phase allowed changes to median and spread of doses to be measured. RESULTS During the baseline survey period, data for 1,208 scans were collected, and data from 1,153 scans were collected for the postoptimization dose survey for the 4 adult protocols (noncontrast brain CT, CT pulmonary angiography , CT lumbar spine, and CT urography). A mean decrease in effective dose was achieved with all scan protocols. Average reductions of 46% for brain CT, 28% for CT pulmonary angiography, 29% for CT lumbar spine, and 24% CT urography were calculated. It proved impossible to collect valid pediatric data from most sites, because of the small numbers of children presenting for multidetector CT, and phantom data were acquired during the preoptimization and postoptimization phase. Substantial phantom dose reductions were demonstrated at all sites. CONCLUSION Audit feedback and small-group teaching about optimization enabled clinically meaningful dose reduction for a variety of common adult scans. However, access to medical radiation physicists, assistance with time-consuming data collection, and technical support from a medical imaging technologist were costly and critical to the success of the program.
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Systematic Review of Current Guidelines, and Their Evidence Base, on Risk of Lactic Acidosis after Administration of Contrast Medium for Patients Receiving Metformin. Radiology 2010; 254:261-9. [DOI: 10.1148/radiol.09090690] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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National health reform needs strategic investment in health services research. Med J Aust 2008; 188:735-6. [DOI: 10.5694/j.1326-5377.2008.tb01868.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Accepted: 02/26/2008] [Indexed: 11/17/2022]
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Towards the appropriate use of diagnostic imaging. Med J Aust 2007; 187:473; author reply 474. [DOI: 10.5694/j.1326-5377.2007.tb01364.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 08/21/2007] [Indexed: 11/17/2022]
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Can an evidence-based guideline reduce unnecessary imaging of road trauma patients with cervical spine injury in the emergency department? ACTA ACUST UNITED AC 2007; 50:563-9. [PMID: 17107528 DOI: 10.1111/j.1440-1673.2006.01655.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to determine if an unvalidated imaging guideline can reduce the use of imaging in patients with cervical spine trauma. A non-randomized clinical trial using historical controls was conducted in the emergency department from October 2001 to September 2002. Following an education programme, which introduced the imaging guideline to clinicians, the use of guideline and imaging were measured. The guideline was also converted to decision-support software for use in the emergency department. Three hundred and fifty-three patients satisfied inclusion criteria during the study period and these were compared with 403 historical control subjects. No significant difference was found between the two groups for age, sex or fracture prevalence. A significant increase was observed during the study period in the proportion of patients who were managed without the use of any cervical spine imaging (21.25 vs 31.2%; P=0.03; 95% confidence interval, 3-13). There were no delayed diagnoses of cervical spine injury among those not imaged. It is feasible to disseminate and implement an evidence-based imaging guideline for patients with cervical spine trauma. The use of a computerized decision-support system can facilitate this and is associated with a safe reduction in the proportion of patients imaged.
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Economic evaluation of a clinical protocol for diagnosing emergency patients with suspected pulmonary embolism. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2006; 4:12. [PMID: 16803623 PMCID: PMC1550258 DOI: 10.1186/1478-7547-4-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Accepted: 06/27/2006] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The objective of this paper is to estimate the amount of cost-savings to the Australian health care system from implementing an evidence-based clinical protocol for diagnosing emergency patients with suspected pulmonary embolism (PE) at the Emergency department of a Victorian public hospital with 50,000 presentations in 2001-2002. METHODS A cost-minimisation study used the data collected in a controlled clinical trial of a clinical protocol for diagnosing patients with suspected PE. The number and type of diagnostic tests in a historic cohort of 185 randomly selected patients, who presented to the emergency department with suspected PE during an eight month period prior to the clinical trial (January 2002-August 2002) were compared with the number and type of diagnostic tests in 745 patients, who presented to the emergency department with suspected PE from November 2002 to August 2003. Current Medicare fees per test were used as unit costs to calculate the mean aggregated cost of diagnostic investigation per patient in both study groups. A t-test was used to estimate the statistical significance of the difference in the cost of resources used for diagnosing PE in the control and in the intervention group. RESULTS The trial demonstrated that diagnosing PE using an evidence-based clinical protocol was as effective as the existing clinical practice. The clinical protocol offers the advantage of reducing the use of diagnostic imaging, resulting in an average cost savings of at least $59.30 per patient. CONCLUSION Extrapolating the observed cost-savings of $59.30 per patient to the whole of Australia could potentially result in annual savings between $3.1 million to $3.7 million.
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Prenatal magnetic resonance imaging in Gomez-Lopez-Hernandez syndrome and review of the literature. Am J Med Genet A 2006; 138:369-73. [PMID: 16158443 DOI: 10.1002/ajmg.a.30967] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gomez-Lopez-Hernandez syndrome, or cerebello-trigeminal-dermal dysplasia (OMIM#601853), is a rare syndrome comprising cerebellar abnormalities, parieto-occipital alopecia, trigeminal nerve anesthesia, intellectual impairment, craniosynostosis, short stature, and craniofacial anomalies. It has been reported in ten patients, five of whom are Brazilian. Rhombencephalosynapsis is a rare sporadic cerebellar anomaly comprising fusion of the cerebellar hemispheres with agenesis of the cerebellar vermis. Rhombencephalosynapsis is a constant feature of Gomez-Lopez-Hernandez syndrome. We present the clinical and imaging findings of a Caucasian male infant with Gomez-Lopez-Hernandez syndrome. Rhombencephalosynapsis was diagnosed with fetal magnetic resonance imaging (MRI) after an abnormally shaped small cerebellum was detected by antenatal ultrasound (US). Gomez-Lopez-Hernandez syndrome was diagnosed at age 6 weeks when parietal alopecia was noted. Prenatal imaging studies of Gomez-Lopez-Hernandez syndrome have not been published before. When rhombencephalosynapsis is diagnosed prenatally, the clinical features of Gomez-Lopez-Hernandez syndrome should be sought at postnatal review. Gomez-Lopez-Hernandez syndrome and isolated rhombencephalosynapsis may have a common etiology.
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Reducing the use of diagnostic imaging in patients with suspected pulmonary embolism: Validation of a risk assessment strategy. Emerg Med Australas 2005; 17:16-23. [PMID: 15675900 DOI: 10.1111/j.1742-6723.2005.00675.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aims of this study were to measure the: (i) effects of implementation of a new risk assessment strategy for patients with suspected pulmonary embolism (PE) on the use of imaging and D-dimer assay; (ii) negative predictive value for PE of a combination of low risk and negative D-dimer assay; and (iii) compliance of ED clinicians with the strategy. METHODS A non-randomized clinical trial was conducted in the ED of a 720-bed teaching hospital between November 2002 and August 2003. Study subjects with suspected PE were compared with 191 randomly selected historical controls. The risk assessment strategy of Kline et al. was disseminated and implemented. RESULTS The negative predictive value for PE was 99% (95% confidence interval [CI] = 97-100%) in 114 patients with low risk and negative D-dimer. There was a 21% absolute reduction in the rate of imaging following the implementation of the risk assessment strategy (56% vs 77%, P < 0.001). CONCLUSION Low risk combined with a negative D-dimer result may allow exclusion of PE without imaging.
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Development of an evidence-based guideline for imaging in cervical spine trauma. AUSTRALASIAN RADIOLOGY 2003; 47:240-6. [PMID: 12890242 DOI: 10.1046/j.1440-1673.2003.01170.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cervical spine trauma is a common reason for presentation to an emergency department. However, less than 5% of patients who have suffered possible neck injury actually have an injury requiring medical treatment. Nevertheless, the consequences, both for the patient and the doctor, of a missed injury are well recognized by emergency department medical staff. This results in the vast majority of these patients receiving some form of diagnostic imaging. We describe the development of an evidence-based imaging guideline for use in the patient who has suffered cervical spine trauma. The guideline aims to help clinicians determine, at the bedside, when it is appropriate to use imaging and which imaging modality should be used first. Correct utilization of the guideline should lead to a reduction in the number of imaging tests required to reach a diagnosis without adverse patient outcomes.
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Abstract
PURPOSE To determine whether breast cancers missed at screening mammography have distinguishing characteristics from those of detected cancers. MATERIALS AND METHODS The mammograms of 146 women with mammographically identifiable breast cancer were viewed independently by two radiologists who were blinded as to whether the cancer had been missed or detected (group 1 lesions, missed cancers; group 2 lesions, detected cancers) at screening. The mammographic lesions were characterized as to location, size, density, type, and visibility on two views. RESULTS A significant difference between missed and detected cancers was found for diameter (P = .03), number of views (P < .0017), and density (P = .0007). Stepwise multivariable logistic regression showed that density (P = .01) and the number of views (P = .03) but not diameter (P = .27) were independently significant in distinguishing the groups. No statistically significant difference was found between the two groups for lesion type (P = .32 for reader 1 and P = .27 for reader 2) or location (P = .86 for reader 1 and P > .96 for reader 2). CONCLUSION Missed cancers were statistically significantly lower in density and more often seen on only one of two views than detected cancers.
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Abstract
PURPOSE Our goal was to determine the accuracy of MRI in the diagnosis of infraspinatus tendon injury and more specifically to determine if the antero-posterior extent of a rotator cuff tear is predictive of infraspinatus tearing. METHOD The MR images of 41 shoulders with surgically proven supraspinatus tears at surgery were retrospectively reviewed. The following were assessed for each of the 41 studies: the number of oblique coronal images on which a tendon defect could be seen, the angle subtended by the tear on axial images (the rotator cuff "axial angle"), and the extent of signal abnormality on sagittal images. RESULTS The rotator cuff axial angle was 75.6 degrees in patients with infraspinatus tendon tears (ITTs) versus 40 degrees in those without ITTs, and this difference was significant (p < 0.001, t = 3.06). The mean number of oblique coronal images (obtained with a 4 mm slice and 1 mm gap) showing signal abnormality was 5.4 in the ITT group versus 2.9 in those without ITTs, and this difference was also significant (p < 0.001, t = 4.45). The mean sagittal extent of the tendon abnormality was 24.6 mm in the ITT group and 11.6 mm in those without ITTs, but the difference was not significant (p > 0.05, t = 1.1364). CONCLUSION The axial angle and the number of oblique coronal images in which signal abnormality was present were significantly related to a higher incidence of infraspinatus tears.
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Patterns of contrast enhancement in the pediatric spine at MR imaging with single- and triple-dose gadolinium. Radiology 1996; 198:273-8. [PMID: 8539393 DOI: 10.1148/radiology.198.1.8539393] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To assess patterns of nerve root and spinal cord contrast enhancement in the pediatric spine at magnetic resonance (MR) imaging with single- and triple-dose gadolinium. MATERIALS AND METHODS In three control patients with no suspected pathologic spinal condition and 19 patients with a suspected condition, spinal cords were evaluated prospectively for potential spread of tumor to cerebrospinal fluid ("drop metastases") (n = 18) or Guillain-Barré syndrome (n = 1). After enhancement with 0.1 mmol/kg gadolinium, patients without definite drop metastases (n = 8) received a booster of 0.2 mmol/kg gadolinium 30-40 minutes later; clinical follow-up was obtained 12 1/2 to 19 months later. RESULTS Drop metastases appeared as nodular areas of enhancement in 11 patients. Vascular enhancement related to the spinal cord surface and emerging nerve roots was observed in images obtained in all control patients, as well as in patients with negative findings at lumbar puncture and at clinical or MR imaging follow-up examination (n = 6). Vascular and nerve root enhancement increased with triple-dose gadolinium and was greater in patients after radiation therapy (n = 17) than in control patients (n = 3). CONCLUSION Use of triple-dose gadolinium did not result in detection of additional cases of drop metastases.
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Abstract
OBJECTIVE To determine sensitivity and specificity of colour-assisted compression ultrasound (CUS) in the diagnosis of deep venous thrombosis (DVT) isolated to the calf veins. DESIGN Prospective comparison of CUS with contrast venography in patients undergoing both procedures, with blinded evaluation of results. SETTING Alfred Hospital, Melbourne (an urban tertiary referral hospital), between November 1990 and May 1992. SUBJECTS Patients presenting for contrast venography with signs or symptoms of lower limb DVT. OUTCOME MEASURES Presence of DVT; technical adequacy of examination. RESULTS 92 of 402 patients (104 limbs) were examined. DVT was detected by venography in 43 limbs and was isolated to the calf veins in 19. It was diagnosed by CUS for eight of these 19. Calf CUS was technically inadequate in 26 limbs. Sensitivity and specificity of CUS for isolated calf DVT were 67% (95% confidence interval [CI], 40%-94%) and 93% (95% CI, 83%-100%), respectively, when the CUS was adequate. The low sensitivity of CUS was related to small size of the thrombi, inadequate studies because of previous DVT or very swollen limbs and technical errors. CONCLUSION CUS is accurate for detecting larger isolated calf DVT when the calf study is adequate. Including the calf veins as well as the femoropopliteal veins in the initial CUS examination for symptomatic suspected lower limb DVT may reduce the need for follow-up CUS.
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Conspicuity of tumors of the head and neck on fat-suppressed MR images: T2-weighted fast-spin-echo versus contrast-enhanced T1-weighted conventional spin-echo sequences. AJR Am J Roentgenol 1995; 164:1213-21. [PMID: 7717234 DOI: 10.2214/ajr.164.5.7717234] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the conspicuity of tumors of the head and neck on MR images acquired with T2-weighted fat-suppressed fast-spin-echo and contrast-enhanced T1-weighted fat-suppressed conventional spin-echo sequences. MATERIALS AND METHODS The MR images of 29 patients with 36 pathologically proved tumors of the head and neck were retrospectively analyzed. The conspicuity of these tumors was assessed on the T2-weighted sequence (4700/108 [TR/TE]) and on the contrast-enhanced T1-weighted sequence (500/16) with a 1.5-T system. Qualitative tumor-to-background contrast was graded separately against background muscle, fat, and mucosa (0 = not visualized, 1 = poorly visualized, 2 = fairly well visualized, 3 = well visualized), and the best overall sequence was noted for each tumor. Quantitative tumor-to-background ratios were measured for 10 of the tumors by using the same background markers. RESULTS The mean overall qualitative tumor-to-background contrast grades for the T2-weighted sequence were tumor/muscle = 2.84, tumor/fat = 2.20, and tumor/mucosa = 1.23, and for the contrast-enhanced T1-weighted sequence, they were tumor/muscle = 2.02, tumor/fat = 1.58, and tumor/mucosa = 0.73. Overall, 86% of the tumors were better or equally well visualized on the T2-weighted images. The mean overall quantitative tumor-to-background ratios for the T2-weighted sequence were tumor/muscle = 7.93, tumor/fat = 3.34, and tumor/mucosa = 0.68, and for the contrast-enhanced T1-weighted sequence, they were tumor/muscle = 2.43, tumor/fat = 2.28, and tumor/mucosa = 0.85. CONCLUSION The T2-weighted fat-suppressed fast-spin-echo sequence offers better contrast between tumors and adjacent muscle, fat, and mucosa than does the contrast-enhanced T1-weighted fat-suppressed spin-echo sequence and thus improves overall tumor conspicuity. In addition, the T2-weighted sequence does not require IV contrast material and can be performed more rapidly than can the contrast-enhanced T1-weighted sequence. The contrast-enhanced T1-weighted sequence may offer complementary information on the precise characterization of complex tumors and on the potential determination of tumor extent.
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Comparison of ultrasound and blood pool scintigraphy in the diagnosis of lower limb deep venous thrombosis. Clin Radiol 1994; 49:382-90. [PMID: 8045061 DOI: 10.1016/s0009-9260(05)81822-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We report a prospective, blinded comparison of compression ultrasound (US) and Tc-99m erythrocyte-labelled venous blood pool scintigraphy (BPS) in patients presenting with symptoms of deep venous thrombosis (DVT). Contrast venography (CV) was used as the gold standard. Ninety-eight lower limbs of 76 patients were examined. DVT was present at CV in 38 of 98 limbs and was isolated to the calf veins in eight. Sensitivity and specificity of ultrasound for femoropopliteal thrombus were 81.5% and 96% and of venous blood pool scintigraphy were 55% and 96%. For deep venous thrombosis in the whole limb sensitivity and specificity of ultrasound were 74% and 90% and of venous blood pool scintigraphy were 61% and 88%. In the calf sensitivity and specificity of US were 61% and 94% and of venous blood pool scintigraphy were 61% and 89%. Excluding equivocal venous blood pool scintigraphy results, the predictive values of a positive and negative venous blood pool scintigraphy study for the whole limb were 84% and 86%. The predictive values of a positive and negative ultrasound where the examination was adequate were 82% and 86%. US is a more sensitive alternative to CV than BPS for femoropopliteal DVT. When neither US nor CV can be performed, BPS remains a useful initial test for DVT, provided it is unequivocally positive or negative.
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Perimesencephalic subarachnoid haemorrhage: negative angiography and favourable prognosis. AUSTRALASIAN RADIOLOGY 1993; 37:156-60. [PMID: 8512504 DOI: 10.1111/j.1440-1673.1993.tb00040.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The computed tomography (CT) scans of 110 consecutive patients who presented, over a 4.5-year period, following spontaneous subarachnoid haemorrhage (SAH), were reviewed. All 110 patients also had one or more 4-vessel digital subtraction cerebral angiograms. The CT scans were reviewed in each case without knowledge of the angiographic result. In nine patients (8%), SAH was confined to the perimesencephalic area, interpeduncular cistern and/or prepontine region at CT. All nine patients had at least two, and some as many as four, negative cerebral angiograms. Eighteen of the 110 patients (16%) ultimately had negative angiography. Hence, the patients with isolated perimesencephalic haemorrhage (PMH) accounted for 50% of the negative angiograms. There was a significant association between isolated PMH and negative angiography (chi 2 = 50.1, P < 0.005). The specificity of PMH for negative angiography was 100% (95% confidence interval (CI) = 97-100%) and the sensitivity of PMH for a negative study was 50% (95% CI = 16-84%). Six of the 110 patients had basilar artery aneurysms demonstrated angiographically as the cause of their SAH but none of these six had isolated PMH at CT. All patients with isolated PMH were alive and well at follow up and none had suffered repeat SAH or vasospasm-related ischaemic cerebral injury. Perimesencephalic haemorrhage should be distinguished from SAH in general, because of the good prognosis associated with it and the doubtful need for repeat cerebral angiography after an initial negative study.
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Pulmonary arteriovenous malformations: pathology, clinical features and treatment with balloon and coil occlusion. AUSTRALASIAN RADIOLOGY 1992; 36:222-9. [PMID: 1445105 DOI: 10.1111/j.1440-1673.1992.tb03156.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This paper discusses the cases of 5 patients who have had therapeutic occlusion of their pulmonary arteriovenous malformations (PAVM) performed radiologically at Alfred Hospital in the past 4 years. The salient pathological, clinical and radiological features of PAVM are also presented.
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Abstract
Intraventricular neurocytoma (IN), a recently recognized, benign cerebral tumor of young adults, can be confused with oligodendroglioma and other neoplasms. The authors compared the radiologic features of six pathologically confirmed cases of IN with those of 26 previously reported cases. The presenting symptoms were headache (62%), raised intracranial pressure (41%), and seizures (12%). Radiologically, the tumor frequently demonstrated a characteristic attachment to the septum pellicidum and confinement to the lateral and third ventricles. Calcification, which is common in IN and an important diagnostic feature, was seen to best advantage on computed tomographic (CT) scans. The results indicate that IN can be suggested radiologically on the basis of its CT appearance and should be included in the pathologic differential diagnosis of intraventricular tumors.
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