Ronald L. Eisenberg

Compliance with Fleischner Society Guidelines for Management of Small Lung Nodules: A Survey of 834 Radiologists

PURPOSE To determine the familiarity of radiologists with the Fleischner Society guidelines for management of small lung nodules and to assess whether their decisions for nodule management are consistent with these recommendations. MATERIALS AND METHODS Institutional review board exemption was granted for this electronic survey, which was sent to a sample of 7000 radiologists randomly selected from the Radiological Society of North America (RSNA) directory. Three clinical scenarios for nodule management were presented. Information about policies and guidelines for nodule management, awareness of published guidelines, and respondent demographics was obtained. Associations between these parameters and management recommendations were assessed by using a chi(2) test. Respondents were also asked about tube current settings for routine chest computed tomographic examinations and those performed solely for nodule follow-up. RESULTS Of 834 respondents (response rate, 11.9%), 649 (77.8%) were aware of the Fleischner Society guidelines and 490 (58.8%) worked in practices that employed them or similar guidelines. Management selections were consistent with the Fleischner guidelines in 34.7%-60.8% of responses for the three scenarios. A significantly higher rate of concordance was associated with awareness of the Fleischner guidelines, presence of written policies based on them, a teaching practice setting, practice in a group with at least one member having chest radiology fellowship training, and fewer than 5 years of experience practicing radiology (P < .05 for all associations). The spectrum of tube current settings used was similar between the subgroups of respondents who were aware and those who were unaware of the Fleischner guidelines. CONCLUSION Among survey respondents, there was high awareness and adoption of the Fleischner guidelines, but radiologists showed varying degrees of conformance with these recommendations. Future efforts are necessary to bridge the gap between awareness and implementation of these evidence-based guidelines.

Cystic Lesions of the Liver

Simple cyst Benign developmental hepatic cyst von Meyenburg complex Caroli disease Adult polycystic liver disease Complex cyst Neoplasm Biliary cystadenoma or cystadenocarcinoma Cystic metastases Hepatocellular carcinoma Cavernous hemangioma Embryonal sarcoma Inflammatory or infectious Abscess Pyogenic Amebic Echinococcal cyst Postraumatic and miscellaneous Pseudocyst Hematoma Biloma Infected or hemorrhagic cysts Cystic liver lesions, or fluid-containing lesions of the liver, are commonly encountered findings on radiologic examinations that may represent a broad spectrum of entities ranging from benign developmental cysts to malignant neoplasms (Table 1). The wide range of pathologic processes that may result in cystic liver lesions can present a difficult diagnostic conundrum. The radiologist must carefully assess such imaging features as location, size, and unifocal or multifocal nature of the cyst or cysts as well as evaluate cyst complexity and associated findings. In addition, because radiologic features of various cystic liver lesions overlap, it is necessary to integrate imaging with clinical and laboratory findings to allow more definitive diagnosis. An important first step in narrowing the differential diagnosis is to determine the presence or absence of complex features in cystic liver lesions. To this end, fluid-containing liver lesions can be grouped broadly into simple or complex cysts. Vachha et al. Cystic Lesions of the Liver

Normal cerebral arteriography in patients with spontaneous subarachnoid hemorrhage.

Previous studies have reported that 18 to 27 percent of patients with spontaneous subarachnoid hemorrhage have normal cerebral arteriograms. Our series of 220 patients from three hospitals demonstrated normal arteriograms in only 16 (7 percent). Recent improvements in neuroradiologic techniques, such as femoral catheterization, magnification angiography, oblique and basal projections, and subtraction most probably contribute to the improved yield. Nonvisualization of a cerebral aneurysm probably represents the most common explanation for a normal cerebral arteriogram.

Quality Improvement in Radiology: Basic Principles and Tools Required to Achieve Success

All imaging departments are expected to establish and maintain effective quality, safety, and performance improvement programs. Essential components of such programs include adherence to the basic principles of quality management and appropriate utilization of quality tools. The initial step is the gathering of relevant information, followed by the collection and analysis of quality and performance data; analysis and ranking of causes that likely contributed to a process failure, error, or adverse event; and prioritization and local implementation of solutions, with careful monitoring of newly implemented processes and wider dissemination of the tools when a process proves to be successful. Quality improvement requires a careful, dedicated, and continuously planned effort by a number of skilled and committed team members, with the goal being to do the right thing in a timely fashion in every case. This process can be sustained by offering rewards and celebrating successes, with all lessons learned disseminated throughout the department or organization.

Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain.

In an effort to develop referral criteria for the ordering of abdominal radiographs for patients presenting with abdominal symptoms, we prospectively studied the relation between clinical data and radiographic abnormalities. Of 1780 examinations, 179 (10.0%) showed some radiographic abnormality. If abdominal radiographs would have been limited to those patients who had moderate or severe abdominal tenderness, or to patients with a high clinical suspicion of bowel obstruction, renal or ureteral calculi, trauma, ischemia, or gallbladder disease, regardless of the degree of tenderness, 956 (53.7%) examinations would not have been done. All radiographic abnormalities reflecting a serious pathologic process would have been identified. Only 33 (3.5%) abnormalities of limited significance, almost all localized or generalized ileus, would have been undetected. The adoption of these referral criteria would result in minimal loss of clinically useful information, large financial savings, and a reduction in radiation exposure.

Evaluation of Plain Abdominal Radiographs in the Diagnosis of Abdominal Pain

In an effort to develop referral criteria for the ordering of abdominal radiographs for patients presenting with abdominal symptoms, we prospectively studied the relation between clinical data and radiographic abnormalities. Of 1780 examinations, 179 (10.0%) showed some radiographic abnormality. If abdominal radiographs would have been limited to those patients who had moderate or severe abdominal tenderness, or to patients with a high clinical suspicion of bowel obstruction, renal or ureteral calculi, trauma, ischemia, or gallbladder disease, regardless of the degree of tenderness, 956 (53.7%) examinations would not have been done. All radiographic abnormalities reflecting a serious pathologic process would have been identified. Only 33 (3.5) abnormalities of limited significance, almost all localized or generalized ileus, would have been undetected. The adoption of these referral criteria would result in minimal loss of clinicall useful information, large financial savings, and a reduction in radiation exposure.

Neurologic complications of angiography in patients with critical stenosis of the carotid artery.

We retrospectively studied 85 patients with angiographically demonstrable critical carotid stenosis. None suffered either immediate or delayed complications after angiography. In patients with critical stenosis of the carotid artery, the benefits of cerebral angiography clearly outweigh the small potential risk when the procedure is performed with meticulous attention to technical detail.

Managing an Acute Adverse Event in a Radiology Department

Many local and national regulatory organizations require that all serious adverse events be promptly investigated, managed, and reported, with the first goal being to institute actions to prevent or minimize the occurrence of similar events. However, the tools and processes necessary for effective incident review and management have been developed largely by industrial organizations, and radiologists may not be familiar with such processes. Data analysis requires a root cause analysis to identify all possible active and latent contributors to the event, as well as the use of algorithms to determine the degree of responsibility when human error is implicated. Acceptable corrective actions that are reasonable, achievable, and measurable should be instituted. These changes should be monitored according to defined timelines by a designated person. In some cases, additional training or even remediation may be required. Subsequently, the focus should be on actively managing and improving error detection and reporting systems, as well as on seeking strategies for minimizing the occurrence of preventable errors.

Low Yield of Chest Radiography in a Large Tuberculosis Screening Program

PURPOSE To assess the frequency and spectrum of abnormalities on routine screening chest radiographs in the pre-employment evaluation of health care workers with positive tuberculin skin test (TST) results. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant retrospective study and waived the need for written informed patient consent. Chest radiographic reports of all 2586 asymptomatic individuals with positive TST results who underwent pre-employment evaluation between January 1, 2003, and December 31, 2007, were evaluated to determine the frequency of detection of evidence of active tuberculosis (TB) or latent TB infection (LTBI) and the spectrum of imaging findings. All chest radiographs interpreted as positive were reviewed by an experienced board-certified radiologist. If there was a discrepancy between the two readings, a second experienced radiologist served as an independent and final arbiter. Any follow-up chest radiographs or computed tomographic images that had been acquired by employee health services or by the employees private physician as a result of a suspected abnormality detected at initial screening were also evaluated. RESULTS Of the 159 (6.1%) chest radiographic examinations that yielded abnormal results, there were no findings that were consistent with active TB. There were 92 cases of calcified granulomas, calcified lymph nodes, or both; 25 cases of apical pleural thickening; 16 cases of fibrous scarring; and 31 cases of noncalcified nodules. All cases of fibrous scarring involved an area smaller than 2 cm(2). All noncalcified nodules were 4 mm in diameter or smaller, with the exception of one primary lung malignancy and one necrotizing granuloma (negative for acid-fast bacilli) that grew Mycobacterium kansasii on culture. CONCLUSION Universal chest radiography in a large pre-employment TB screening program was of low yield in the detection of active TB or increased LTBI reactivation risk, and it provided no assistance in deciding which individuals to prioritize for LTBI treatment.

Spinal Epidural Hematoma after Lumbar Puncture in Liver Disease

Excerpt Spinal epidural hematoma after lumbar puncture has been reported in patients receiving anticoagulant therapy. We describe a lumbar puncture-induced spinal epidural hematoma in a patient who...