Michael N. Patlas

Is Oral Contrast Necessary for Multidetector Computed Tomography Imaging of Patients With Acute Abdominal Pain

Purpose The purpose of our study was to validate the hypothesis that eliminating the use of oral contrast for multidetector computed tomography (MDCT) would not affect the detection of acute abdominal abnormalities in emergency room patients. Methods We conducted a retrospective study to assess the effect of discontinuing oral contrast use for MDCT scans of the abdomen and pelvis for patients presenting with acute abdominal pain and body mass index (BMI) >25. Patients with BMI <25 continued to receive oral contrast. The medical records were reviewed to determine the rate of repeat imaging within 7 days from the initial CT scan, as well as delayed or missed diagnoses related to the absence of oral contrast. The study was approved by the research ethics board at our institution. Results A total of 1378 patients had an MDCT examination of the abdomen and pelvis between November 1, 2012, and October 31, 2013. 375 patients met the inclusion criteria (174 males and 201 females; mean age 57 years; range 18-97 years). Seven of 375 (1.9%) patients had a repeat CT examination with oral contrast within 7 days. Of these 7 patients, none had a change in the course of their management due to the utilization of oral contrast. No delayed or missed diagnoses related to the absence of oral contrast were identified. Conclusion Omitting oral contrast for imaging patients with BMI >25 presenting with acute abdominal pain resulted in no delayed or missed diagnoses, in our retrospective study. The benefits of prompt imaging diagnosis outweigh the unlikely need for repeat imaging.

Cross-sectional imaging of nontraumatic emergencies of the spleen.

Multiple nontraumatic splenic emergencies are encountered during the imaging of patients in emergency room. Occasionally, patients are investigated for symptoms of suspected splenic pathology, such as abscess, infarct, symptomatic splenic artery aneurysm and pseudoaneurysm, splenic torsion, or rupture. More often, however, splenic emergencies, such as splenic masses and splenic vein thrombosis, are detected in patients in the emergency room during the evaluation of nonspecific abdominal pain. It is essential for radiologists to be vigilant in the identification of nontraumatic splenic emergencies and to be familiar with interventional radiology management options for these pathologies. Our aim is to highlight factors affecting lesion detection on multiple imaging modalities and to discuss the advantages of different cross-sectional modalities for the diagnosis of splenic abnormalities. Finally, we review the management options with emphasis on interventional radiology where applicable.

Are We Missing Traumatic Bowel and Mesenteric Injuries

Purpose Traumatic bowel and mesenteric injury (TBMI), although an uncommon entity, can be lethal if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the detection of TBMI in patients at our level 1 trauma centre. Methods We used our hospitals trauma registry to identify patients with a diagnosis of TBMI from January 1, 2006, to June 30, 2013. Only patients who had a 64-slice MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in the study cohort. Using the surgical findings as the gold standard, the accuracy of prospective radiology reports was analyzed. Results Of the 4781 trauma patients who presented to our institution, 44 (0.92%) had surgically proven TBMI. Twenty-two of 44 were excluded as they did not have MDCT before surgery. The study cohort consisted of 14 males and 8 females with a median age of 41.5 years and a median injury severity score of 27. In total 17 of 22 had blunt trauma and 5 of 22 had penetrating injury. A correct preoperative imaging diagnosis of TBMI was made in 14 of 22 of patients. The overall sensitivity of the radiology reports was 63.6% (95% confidence interval [CI]: 41%-82%), specificity was 79.6% (95% CI: 67%-89%), PPV was 53.9% (95% CI: 33%-73%), and the NPV was 85.5% (95% CI: 73%-94%). Accuracy was calculated at 75.3%. However, only 59% (10 of 17) of patients with blunt injury had a correct preoperative diagnosis. Review of the findings demonstrated that majority of patients with missed blunt TBMI (5 of 7) demonstrated only indirect signs of injury. Conclusion The detection of TBMI in trauma patients on 64-slice MDCT can be improved, especially in patients presenting with blunt injury. Missed cases in this population occurred because the possibility of TBMI was not considered despite the presence of indirect imaging signs. The prospective diagnosis of TBMI remains challenging despite advances in CT technology and widespread use of 64-slice MDCT.

Diaphragmatic injuries: why do we struggle to detect them?

Diaphragmatic injury is an uncommon traumatic condition. It can be easily missed due to a lack of awareness by both clinicians and radiologists. A high index of suspicion is required for the establishment of an early diagnosis and prevention of life-threatening complications. Multidetector computed tomography (MDCT) is the modality of choice for the detection of diaphragmatic injury. In this review article, we illustrate the MDCT appearance of blunt and penetrating diaphragmatic injuries and emphasize the role of the emergency radiologist in detecting these entities.

Mentorship in Radiology

Mentoring is an extremely important component of academic medicine, including radiology, yet it is not specifically emphasized in radiology training, and many academic radiology departments in the United States, Canada, and elsewhere do not have formal mentoring programs for medical students, residents, fellows, or junior faculty. The purpose of this article is to overview the current status of mentorship in radiology, to discuss the importance of mentorship at multiple levels and its potential benefits in particular, as well as how to conduct a successful mentor-mentee relationship. The literature on mentorship in radiology and in academic medicine in general is reviewed.

Cross-sectional imaging of nontraumatic peritoneal and mesenteric emergencies.

Multiple nontraumatic peritoneal and mesenteric emergencies are encountered at imaging of patients in the emergency department. Peritoneal and mesenteric emergencies are usually detected in patients in the emergency department during evaluation of nonspecific abdominal pain. A high index of suspicion is required for the establishment of early diagnosis and aversion of life-threatening complications in cases of peritoneal carcinomatosis, nontraumatic hemoperitoneum, and peritonitis. A correct diagnosis of omental infarction, mesenteric adenitis, and mesenteric panniculitis helps patients primarily by avoiding unnecessary surgery. In this review article, we illustrate the cross-sectional imaging appearance of various nontraumatic peritoneal and mesenteric emergencies by emphasizing the role of the emergency radiologist in detecting and managing these entities.

Incidentalomas on abdominal and pelvic CT in emergency radiology: literature review and current management recommendations.

The purpose of this article is to familiarize radiologists and clinicians with a subset of common and uncommon incidental findings on abdominal and pelvic computed tomography examinations, including hepatic, splenic, renal, adrenal, pancreatic, aortic/iliac arterial, gynecological, and a few other miscellaneous findings, with an emphasis on “incidentalomas” discovered in the emergency setting. In addition, we will review the complex problem of diagnosing such entities, and provide current management recommendations. Representative case examples, which we have encountered in our clinical practices, will be demonstrated.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre

Purpose Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre. Methods We used our hospitals trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed. Results Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury. Conclusions The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

Abdominal and Pelvic Trauma: Misses and Misinterpretations at Multidetector CT: Trauma/Emergency Radiology

Being mindful of potential diagnostic pitfalls in trauma imaging; having a thorough, efficient, and informed search strategy; and developing a working knowledge of commonly missed traumatic injuries can help radiologists improve the care of patients with abdominopelvic trauma.

A Window to the Real World of Radiology From the Ivory Tower of Academia: The Value of Community Rotations and “Career Training” in Radiology Residency Programs in Canada

We highlight what we believe are 2 major areas of weakness in current Canadian radiology training programs: insufficient community radiology training and limited preparation of residents for the job market. Although focusing on Canadian radiology programs, we suspect that these are also 2 areas of substantial concern for radiology training programs in the United States and other countries. We offer suggestions to address these deficiencies, particularly by using pre-existing hybrid radiology practices and by making relatively small changes to the current curricula of radiology residency programs.