Alexander T. Ruutiainen

Increased Error Rates in Preliminary Reports Issued by Radiology Residents Working More Than 10 Consecutive Hours Overnight

RATIONALE AND OBJECTIVES To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts. MATERIALS AND METHODS Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies. RESULTS We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22-8.98), and inpatient location (OR 1.81, 95% CI 1.02-3.20) were independent risk factors for major discrepancy. CONCLUSIONS In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.

Comparison of diagnostic accuracy of plain film radiographs between original film and smartphone capture: a pilot study.

The use of mobile devices for medical image capture has become increasingly popular given the widespread use of smartphone cameras. Prior studies have generally compared mobile phone capture images to digitized images. However, many underserved and rural areas without picture archiving and communication systems (PACS) still depend greatly on the use of film radiographs. Additionally, there is a scarcity of specialty-trained or formally licensed radiologists in many of these regions. Subsequently, there is great potential for the use of smartphone capture of plain radiograph films which would allow for increased access to economical and efficient consultation from board-certified radiologists abroad. The present study addresses the ability to diagnose a subset of radiographic findings identified on both the original film radiograph and the captured camera phone image.

Giant jejunal ulcers after Roux-en-Y gastric bypass

We describe the clinical and radiographic findings in two patients who developed giant, intractable ulcers in the jejunal Roux limb after gastric bypass surgery, most likely secondary to chronic jejunal ischemia. The diagnosis of such ulcers is important because of the need for aggressive medical or surgical treatment of these patients.

Subchondral insufficiency fracture of the knee: A recognizable associated soft tissue edema pattern and a similar distribution among men and women.

OBJECTIVE Primary: to describe the presence and pattern of soft tissue edema in subchondral insufficiency fractures of the knee (SIFK). Secondary: to investigate the gender distribution and identify factors associated with disease progression. METHODS MR images of 74 SIFKs in 74 patients were retrospectively reviewed for soft tissue edema presence and location, meniscal tears and extrusion and synovitis. The clinical records were reviewed for age, gender, and BMI. Follow up examinations were reviewed to assess for progression. Data were analyzed for gender distribution and for association between each imaging finding as a predictor of SIFK location and progression. RESULTS Soft tissue edema was present in 89% (66/74) of SIFK. It was located around the MCL in 78% (58/74), posterior to and abutting on the posterior distal femur in 68% (50/74), around to the tibia in only 18% (13/74), but when present it strongly predicted the presence of a medial tibial plateau SIFK (p=5.6×10^-12). Edema extended to the vastus medialis fascia in 51% (38/74) and vastus lateralis fascia in 24% (18/74). Gender distribution was 1:1 (males=38, females=36), most common in the 6th decade (29/74, 39%). Lesion progression showed a trend towards being more common in females (8/9, 89%) compared to males (9/16, 56%), and in patients with meniscal extrusion (≥3mm) (13/14, 93%) compared to those with no extrusion (2/7, 29%). CONCLUSION A recognizable soft tissue edema pattern is seen in SIFK and may have an important role in early diagnosis. Also, SIFK may affect equally males and females in the 6th decade and may progress more in females. Meniscal extrusion may predispose to disease progression.

Tibial component considerations in bicruciate-retaining total knee arthroplasty: A 3D MRI evaluation of proximal tibial anatomy

BACKGROUND Restoration of normal anatomy and proper ligament balance are theoretical prerequisites for reproducing physiological kinematics with bicruciate-retaining total knee arthroplasty (TKA). The purpose of this study was to use a 3D MRI technique to evaluate the topography of the proximal tibia and outline considerations in tibial component design for bicruciate-retaining TKA. METHODS We identified 100 consecutive patients (50 males and 50 females) between ages 20 and 40 years with knee MRIs without arthritis, dysplasia, ACL tears, or prior knee surgery. A novel 3D MRI protocol coordinating axial, coronal, and sagittal images was used to measure: 1) medial and lateral posterior tibial slopes; 2) medial and lateral coronal slopes; and 3) distance from the anterior tibia to the ACL footprint. RESULTS There was no overall difference in medial and lateral posterior tibial slopes (5.5° (95% CI 5.0 to 6.0°) vs. 5.4° (95% CI 4.8 to 6.0°), respectively (p=0.80)), but 41 patients had side-to-side differences greater than 3°. The medial coronal slope was greater than the lateral coronal slope (4.6° (95% CI 4.0 to 5.1°) vs. 3.3° (95% CI 2.9 to 3.7°), respectively (p<0.0001)). Females had less clearance between the anterior tibia and ACL footprint than males (10.8mm (95% CI 10.4 to 11.2mm) vs. 13.0mm (95% CI 12.5 to 13.5mm), respectively (p<0.0001)). CONCLUSIONS Due to highly variable proximal tibial topography, a monoblock bicruciate-retaining tibial baseplate may not reproduce normal anatomy in all patients. LEVEL OF EVIDENCE Level IV - Anatomic research study.

Utilization and reporting of bone densitometry: what can the musculoskeletal radiologist do to help, rather than to hurt?

Osteoporosis is a highly prevalent disease that predisposes patients to fragility fractures. These fractures carry serious risks, including increased mortality and the potential loss of functional independence. Effective treatments for osteoporosis are available, but these should be initiated before a fragility fracture actually occurs; to do so, osteoporosis must be diagnosed while it is still asymptomatic. The gold standard screening test used to detect low bone mass is dual-energy x-ray absorptiometry (DXA). Despite its clinical importance, the DXA report is sometimes neglected by radiologists-as though it were somehow less significant in diagnosis than our other modalities. If musculoskeletal radiologists are to help, rather than to hurt, we must raise the profile of this critical test with evidence-based utilization and coherent reporting: detailed recommendations for doing so are available from professional organizations such as the International Society for Clinical Densitometry and the National Osteoporosis Foundation. This brief survey will seek to remind the radiologist that a good densitometry report requires more than just copying numbers from a scanner.