Jamlik-Omari Johnson

Ventriculoperitoneal Shunt Malfunction: Cumulative Effect of Cost, Radiation, and Turnaround Time on the Patient and the Health Care System

OBJECTIVE The purpose of this study was to reiterate the predominance of CT in evaluating ventriculoperitoneal shunt malfunction in terms of cost-effectiveness, reduction of radiation exposure, and turnaround time as the measurement parameters. MATERIALS AND METHODS This retrospective study included patients 18 years and older with a history of ventriculoperitoneal shunt insertion who presented to the emergency department with symptoms of shunt malfunction and underwent shunt series radiography and head CT within 12 hours. Shunt revision occurring contemporaneously with imaging was defined as revision within 48 hours of the original imaging report. The effective radiation dose was calculated by multiplying dose-length product from the scanner with the standard conversion coefficient k (k = 0.0021 mSv/mGy × cm). The turnaround time for patients who underwent both head CT and shunt series radiography was calculated from time of the first study to the time of completion of the last study. RESULTS There were 16 shunt revisions in 239 patients. The sensitivity of CT was 87.5%; specificity, 91.4%; positive predictive value, 42.4%; and negative predictive value, 99%. The sensitivity of shunt series radiography was 18.7%; specificity, 90.9%; positive predictive value, 13%; and negative predictive value, 93.9%. There were 223 observations of CT radiation dose per patient (mean, 1.87 ± 0.45). There also were 223 observations of shunt radiography radiation dose per patient (mean, 1.57 ± 0.60). The median turnaround time among patients undergoing CT and shunt radiography was 109 ± 84 minutes. CONCLUSION Shunt series radiography is a low-yield diagnostic imaging modality for identifying shunt malfunction and prolongs turnaround time, increases medical cost, and exposes patients to unnecessary radiation.

Intra-abdominal solid organ injuries: an enhanced management algorithm.

The organ injury scale grading system proposed by the American Association for the Surgery of Trauma provides guidelines for operative versus nonoperative management in solid organ injuries; however, major shortcomings of the American Association for the Surgery of Trauma injury scale may become apparent with low-grade injuries, in which conservative management may fail. Nonoperative management of common intra-abdominal solid organ injuries relies increasingly on computed tomographic findings and other clinical factors, including patient age, presence of concurrent injuries, and serial clinical assessments. Familiarity with characteristic imaging features is essential for the prompt diagnosis and appropriate treatment of blunt abdominal trauma. In this pictorial essay, the spectrum of the American Association for the Surgery of Trauma organ injury scale grading system is illustrated, and a multidisciplinary management algorithm for common intra-abdominal solid organ injuries is proposed.

Incidental Findings on Bedside Ultrasonography: Detection Rate and Accuracy of Resident-Performed Examinations in the Acute Setting

Background Bedside ultrasonography has become a valuable tool in the emergent care setting for triage and rapid evaluation of patients who are acutely ill. Given the cross-sectional nature of ultrasound technology, incidental findings are frequently encountered during imaging. These can impact clinical management and can pose a diagnostic dilemma for emergency medicine (EM) physicians and EM residents. Purpose Our retrospective study was designed to evaluate the prevalence and detection rate of incidental findings on bedside ultrasound examinations performed by EM residents. We also sought to identify types of incidental findings encountered and the diagnostic accuracy of those findings. Materials and Methods Board-certified radiologists retrospectively reviewed bedside ultrasonography examinations performed and interpreted by EM residents at a large urban academic hospital. Our sample included patients who presented with traumatic and nontraumatic symptoms in the acute setting. Findings were defined as incidental only if they were previously unknown and not related to a patients presenting symptoms. The results were corroborated with electronic medical records and additional pertinent imaging when available. Results Of 196 examinations analysed, EM residents identified incidental findings on 26% of the studies, which mostly involved the renal and biliary system. Radiologist review detected incidental findings in 20.9% but was more accurate when supplemental imaging was available. EM residents detected incidental findings at rates similar to that published previously and had moderate interobserver agreement with radiologist review. Worrisome and indeterminate findings were confirmed by additional work-up and further imaging. Conclusion Incidental findings are frequently encountered on bedside ultrasonography and have the potential to alter clinical management. Expertise in detection and knowledge of the presence and spectrum of these incidental findings is essential for appropriate triage, patient management, and follow-up.

Inefficient Resource Use for Patients Who Receive Both a Chest Radiograph and Chest CT in a Single Emergency Department Visit

PURPOSE The goal of this study was to examine emergency department (ED) ordering practices in patients receiving both chest radiography (CXR) and chest CT (CCT). METHODS Consecutive ED patients receiving both CXR and CCT in a single ED visit from January 2009 to December 2013 were included. For each examination, the time of order entry, time of study completion, and time of final interpretation were recorded and analyzed. RESULTS A total of 3,627 patients met the inclusion criteria. In 3,437 (94.8%) patients, the CXR was ordered first; in 43 (1.2%), the CCT was ordered first; and in 91 (2.5%), the CCT and CXR were ordered simultaneously. In 50.3% (1,826 of 3,627) of all cases, imaging in the second modality (whether CCT or CXR) was ordered before final report availability of the first exam. In 9.8% (n = 354 of 3,627) of all cases, imaging in the second modality (whether CCT or CXR) was ordered before image availability from the first examination. CONCLUSIONS These results suggest inefficient resource usage, for which targeted technology solutions may be helpful.

Small-bowel obstruction associated with Crohn’s enterolith

One of the lesser known clinical manifestations of Crohn’s disease is the formation of small-bowel enteroliths. These concretions precipitate in the setting of small-bowel stasis within the alimentary tract and are associated with a variety of disease states causing strictures or diverticula. In the acute setting, patients typically present with signs of intestinal obstruction due to stone impaction. The case we report involves a 67-year-old female with long-standing Crohn’s disease who presented with a 6-day history of worsening abdominal pain. Plain abdominal radiographs demonstrated dilated bowel loops consistent with intestinal obstruction. Computed tomography revealed a 2.5-cm calcified density at the transition point in the distal ileum, and two additional stones were present in the proximal ileum. At surgery, multiple ileal strictures were found, and ileocolic resection with primary anastomoses was performed. The accurate diagnosis of enterolithiasis in the setting of Crohn’s disease has significant clinical implications for management and is a harbinger of underlying bowel stenosis.

Small bowel diverticulitis: an imaging review of an uncommon entity

In this review, we discuss the clinical and radiologic findings of small bowel diverticulosis, which is infrequently encountered during practice and far less common than colonic diverticulosis. Small bowel diverticulosis can present with a range of emergent symptomatic complications including diverticulitis, perforation, or hemorrhage. Here, we focus on the clinical features, pathogenesis, radiologic findings, and treatment of small bowel diverticulitis. Although not routinely considered in the differential diagnosis of an acute abdomen, prospective radiologic diagnosis of small bowel diverticulitis is important and can lead to conservative treatment thus preventing unnecessary exploratory laparotomy.

Lipofibromatous Hamartoma of the Median Nerve: A Case Report

Lipofibromatous hamartoma is a rare and slow growing benign fibro-fatty tumor. It is characterized by the proliferation of mature adipocytes within the epineurium and the perineurium of the peripheral nerves. In the upper extremity, it most commonly affects the median nerve. Median nerve involvement commonly leads to pain, numbness, paresthesia and carpal tunnel syndrome. This article presents a case of lipofibromatous hamartoma in an 8-year-old child followed by a discussion of the epidemiology, diagnosis, imaging details and treatment options for this condition.

Association of lumbar fractures, abdominal aortic calcification, and osteopenia☆

PURPOSE The purpose was to assess if abdominal aortic calcification (AAC) and low bone mineral density (BMD) are associated with fractures on lumbar spine radiographs in trauma patients. METHODS Retrospectively, 303 consecutive lumbar radiographs were independently reviewed by two radiologists for AAC, low BMD, and traumatic findings. RESULTS Thirty-one percent of patients had low BMD, 34% had AAC, and 24% had both. Eleven percent of radiographs showed traumatic findings. Seventy-six percent of positive cases had low BMD (P<.001), and 64% had AAC (P<.001). CONCLUSION A higher index of suspicion for fractures is warranted when AAC and low BMD are present.

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients With Blunt Chest and Abdominal Trauma

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

Information Systems in Emergency Department Diagnostic Imaging

Information systems that support diagnostic imaging in emergency settings have the potential to improve efficiency, quality, and patient safety while moderating costs. The imaging value chain includes forming a diagnostic inquiry, performing a diagnostic procedure, establishing a diagnostic result, and completing communication and follow-up tasks. This cycle serves as a useful framework to assess existing information systems and emerging technologies.