Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

Objective@#To investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED). @*Materials and Methods@#This retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate. @*Results@#According to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001). @*Conclusion@#QIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.

History of the National Health Insurance Cost for Radiological Examinations and Value of the Radiological Report Fee

Advancements of medical care with the use of new medical technologies have been promoting public health, but they can also place a financial burden on individuals and the country. Since the introduction of the health insurance system in 1977, the South Korean government has been attempting to control medical expenses. Radiological examinations have been a major target for cost reduction. Meanwhile, the radiological report fee has been combined with the technical fee for a long time; hence, its value has not been independently evaluated, and was also decreased proportionally with examination cost reduction. However, in the revised medical fee estimation system for MRI, the report fee has begun to be calculated separately from the technical fee, significantly contributing to the evaluation of the radiologists' work value. In conclusion, radiologists need to know and actively participate in the process of determining the insurance cost of radiological examinations and reports to get a proper value of their professionalism.

A Rare Case of Granulomatosis with Polyangiitis-Related Periaortitis at the Ascending Aorta

Acute aortic syndrome including intramural hematoma is a life-threatening disease encountered in the emergency department with high in-hospital mortality even when a timely diagnosis is made. Therefore, accurate differential diagnosis of acute aortic syndrome and its mimics is important to determine the patient's treatment plan. Until now, a few pathologic diseases mimicking aortic intramural hematoma such as periaortic lymphoma and immunoglobulin G4-elated periaoritis have been reported. Here, we report a rare case of granulomatosis with polyangiitis-related periaortitis misdiagnosed as aortic intramural hematoma presenting to the emergency department with chest pain and similar radiologic findings.

Complication Following Ultrasound-Guided High-Intensity Focused Ultrasound for the Treatment of Uterine Adenomyosis: Case Report of CT Imaging Features

High intensity focused ultrasound (HIFU) is a non-surgical and non-invasive treatment option in patients with uterine myoma and adenomyosis. As the use of HIFU increases in the clinical practice, it is important to be aware of imaging findings related to ultrasound (US)-guided HIFU ablation and its potential complications. However, there are few reports on the imaging findings regarding complications of US-guided HIFU ablation. Here, we report a case of acute complication after US-guided HIFU ablation, surgically confirmed as thermal injury with necrosis of skin, subcutaneous tissue, anterior abdominal wall muscles, peritoneum and uterus.

Added Value of Bone Suppression Image in the Detection of Subtle Lung Lesions on Chest Radiographs with Regard to Reader's Expertise

BACKGROUND: Chest radiographs (CXR) are the most commonly used imaging techniques by various clinicians and radiologists. However, detecting lung lesions on CXR depends largely on the reader's experience level, so there have been several trials to overcome this problem using post-processing of CXR. We investigated the added value of bone suppression image (BSI) in detecting various subtle lung lesions on CXR with regard to reader's expertise. METHODS: We applied a software program to generate BSI in 1,600 patients in the emergency department. Of them, 80 patients with subtle lung lesions and 80 patients with negative finding on CXR were retrospectively selected based on the subtlety scores on CXR and CT findings. Ten readers independently rated their confidence in deciding the presence or absence of a lung lesion at each of 960 lung regions on the two separated imaging sessions: CXR alone vs. CXR with BSI. RESULTS: The additional use of BSI for all readers significantly increased the mean area under the curve (AUC) in detecting subtle lung lesions (0.663 vs. 0.706; P < 0.001). The less experienced readers were, the more AUC differences increased: 0.067 (P < 0.001) for junior radiology residents; 0.064 (P < 0.001) for non-radiology clinicians; 0.044 (P < 0.001) for senior radiology residents; and 0.019 (P = 0.041) for chest radiologists. The additional use of BSI significantly increased the mean confidence regarding the presence or absence of lung lesions for 213 positive lung regions (2.083 vs. 2.357; P < 0.001) and for 747 negative regions (1.217 vs. 1.195; P = 0.008). CONCLUSION: The use of BSI increases diagnostic performance and confidence, regardless of reader's expertise, reduces the impact of reader's expertise and can be helpful for less experienced clinicians and residents in the detection of subtle lung lesions.

The Role of Whole-Body Computed Tomography in Severely Injured Patients Retrospective Single Center Cohort Study

PURPOSE: To assess the effects of whole-body computed tomography (WBCT) on severely injured trauma patients. METHODS: After the installation of a WBCT scanner, we compared 48 patients who underwent the WBCT (WBCT cohort) with 40 patients prior to the WBCT (pre-WBCT cohort). We evaluated the number of CT, radiation exposure, time interval to decision and clinical outcomes such as length of intensive care unit stay, ventilation period, and acute kidney injury rates. RESULTS: In the WBCT cohort, the number of CT scans was significantly less (3.5 times) than in the pre-WBCT cohort (5.5 times; p<0.001). The radiation exposure was significantly lower in the WBCT cohort (24.5 mSv) than in the pre-WBCT cohort (31.3 mSv; p=0.040). The amount of radio-contrast used differed between the groups, but not significantly. Although there were fewer acute kidney injuries in the WBCT cohort (27.1%) than in pre-WBCT cohort (37.5%; p=0.296), especially severe injuries (stage 3 Acute Kidney Injury [AKI] Network: 17.5% in pre-WBCT vs. 6.3% in WBCT; p=0.059), the difference did not reach statistical significance. The hospital length of stay was significantly shorter in the WBCT cohort (21.42 days) than in the pre-WBCT cohort (32.38 days, p=0.019). However, there were no significant differences in the time interval to decision, intensive care unit stay, ventilation days, and mortality. CONCLUSION: The WBCT decreased the number of CT scans and subsequent less use of radio-contrast amount. It also tended to reduce severe AKI.

Survey of Thoracic CT Protocols and Technical Parameters in Korean Hospitals: Changes before and after Establishment of Thoracic CT Guideline by Korean Society of Thoracic Radiology in 2008

We retrospectively reviewed the thoracic CT scan protocols and technical parameters obtained from hospitals in Korea, one group during May 2007 (n = 100) and the other group during January 2012 (n = 173), before and after the establishment of the thoracic CT Guideline in 2008. Each group was also divided into two subgroups according to the health care delivery level, i.e. the "A" subgroup from primary and the "B" subgroup from secondary and tertiary care hospitals. When comparing the data from 2007 and 2012, the tube current decreased from 179.1 mAs to 137.2 mAs. The scan interval decreased from 6.4 mm to 4.8 mm. Also, the insufficient scan range decreased from 19.0% to 8.7%, and the suboptimal quality scans decreased from 33.0% to 5.2%. Between groups A and B, group B had lower tube voltages, smaller scan thicknesses, and smaller scan intervals. However, group B had more phase numbers. In terms of the suboptimal quality scans, a decrease was seen in both groups. In conclusion, during the five-year time period between 2007 and 2012, a reduction in the tube current values was seen. And the overall image quality improved over the same time period. We assume that these changes are attributed to the implementation of the thoracic CT guideline in 2008.

Posterior Reversible Encephalopathy Syndrome in a Critically Ill Postoperative Patient / 대한중환자의학회지

Posterior reversible encephalopathy syndrome (PRES) is a transient condition characterized by altered mental status, seizure, headache, and visual disturbance with typical neuro-imaging findings in the bilateral parieto-occipital regions. Clinicians should be aware of this syndrome because delayed diagnosis and treatment result in irreversible neurologic deficits. We present the case of a 77-year-old male diagnosed with PRES in the setting of postoperative critical illness caused by small-bowel strangulation.

Posterior Reversible Encephalopathy Syndrome in a Critically Ill Postoperative Patient / 대한구급학회지

Posterior reversible encephalopathy syndrome (PRES) is a transient condition characterized by altered mental status, seizure, headache, and visual disturbance with typical neuro-imaging findings in the bilateral parieto-occipital regions. Clinicians should be aware of this syndrome because delayed diagnosis and treatment result in irreversible neurologic deficits. We present the case of a 77-year-old male diagnosed with PRES in the setting of postoperative critical illness caused by small-bowel strangulation.

Assessment of Perfusion Pattern and Extent of Perfusion Defect on Dual-Energy CT Angiography: Correlations between the Causes of Pulmonary Hypertension and Vascular Parameters

OBJECTIVE: To assess perfusion patterns on a dual-energy pulmonary CT angiography (DECTA) of pulmonary hypertension (PHT) with variable causes and to assess whether the extent of perfusion defect can be used in the severity assessment of PHT. MATERIALS AND METHODS: Between March 2007 and February 2011, DECTA scans of 62 consecutive patients (24 men, 38 women; mean age, 58.5 +/- 17.3 [standard deviation] years; range, 19-87 years) with PHT were retrospectively included with following inclusion criteria; 1) absence of acute pulmonary thromboembolism, 2) maximal velocity of tricuspid regurgitation jet (TR Vmax) above 3 m/s on echocardiography performed within one week of the DECTA study. Perfusion patterns of iodine map were divided into normal (NL), diffuse heterogeneously decreased (DH), multifocal geographic and multiple peripheral wedging patterns. The extent of perfusion defects (PD), the diameter of main pulmonary artery (MPA) and the ratio of ascending aorta diameter/MPA (aortopulmonary ratio, APR) were measured. Pearson correlation analysis was performed between TR Vmax on echocardiography and CT imaging parameters. RESULTS: Common perfusion patterns of primary PHT were DH (n = 15) and NL (n = 12). The perfusion patterns of secondary PHT were variable. On the correlation analysis, in primary PHT, TR Vmax significantly correlated with PD, MPA and APR (r = 0.52, r = 0.40, r = -0.50, respectively, all p < 0.05). In secondary PHT, TR Vmax significantly correlated with PD and MPA (r = 0.38, r = 0.53, respectively, all p < 0.05). CONCLUSION: Different perfusion patterns are observed on DECTA of PHT according to the causes. PD and MPA are significantly correlated with the TR Vmax.

Recurrent Bilateral Branch Retinal Artery Occlusion with Hearing Loss and Encephalopathy: The First Case Report of Susac Syndrome in Korea

We report the first case of Susac syndrome in Koreans, in a 23-yr-old female patient who presented with sudden visual loss and associated neurological symptoms. Ophthalmic examination and fluorescein angiography showed multiple areas of branch retinal artery occlusion, which tended to recur in both eyes. Magnetic resonance imaging showed dot-like, diffusion-restricted lesions in the corpus callosum and left fornix, and audiometry showed low-frequency sensory hearing loss, compatible with Susac syndrome. She received immunosuppressive therapy with oral steroid and azathioprine. Three months later all the symptoms disappeared but obstructive vasculitis have been relapsing. This patient demonstrated the entire clinical triad of Susac syndrome, which tends to occur in young females. Although this disorder has rarely been reported in Asian populations, a high index of suspicion is warranted for early diagnosis and timely treatment.

Chest CT Parameters to Predict the Major Adverse Events in Acute Submassive Pulmonary Embolism / 결핵및호흡기질환

BACKGROUND: The purpose of this study was to determine the prognostic significance of chest computed tomographic (CT) parameters in acute submassive pulmonary embolism (PE). METHODS: Between January 2006 and December 2009, 268 consecutive patients with acute submassive PE that was confirmed by chest CT with pulmonary angiography in emergency room were studied. One experienced radiologist measured CT parameters and judged the presence of right ventricular dysfunction. CT parameters were analyzed to determine their ability to predict a major adverse event (MAE). RESULTS: There were 220 patients included and 61 (27.7%) had MAE. Left ventricular and right ventricular maximum minor axis (36.4+/-8.0 vs. 41.7+/-7.4, p<0.01; 45.7+/-9.4 vs. 41.5+/-7.6, p<0.01), superior vena cava diameter (19.2+/-3.4 vs. 18.0+/-3.4, p=0.02), azygos vein diameter (10.0+/-2.2 vs. 9.2+/-2.3, p=0.02), septal displacement (19 vs. 18, p<0.01) were significantly higher in MAE group than in no MAE group. Patients with MAE had high right ventricular/left ventricular dimension ratio (RV/LV ratio) compared to patients without MAE (1.34+/-0.48 vs. 1.03+/-0.28, p<0.01). The most useful cut-off value of RV/LV ratio for MAE was 1.3 and the area under the curve was 0.71 (0.62~0.79). CONCLUSION: RV/LV ratio on chest CT was a significant predictor of submassive PE related shock, intubation, in-hospital mortality, thrombolysis, thrombectomy within 30 days.

Chest CT Parameters to Predict the Major Adverse Events in Acute Submassive Pulmonary Embolism / 결핵및호흡기질환

BACKGROUND: The purpose of this study was to determine the prognostic significance of chest computed tomographic (CT) parameters in acute submassive pulmonary embolism (PE). METHODS: Between January 2006 and December 2009, 268 consecutive patients with acute submassive PE that was confirmed by chest CT with pulmonary angiography in emergency room were studied. One experienced radiologist measured CT parameters and judged the presence of right ventricular dysfunction. CT parameters were analyzed to determine their ability to predict a major adverse event (MAE). RESULTS: There were 220 patients included and 61 (27.7%) had MAE. Left ventricular and right ventricular maximum minor axis (36.4+/-8.0 vs. 41.7+/-7.4, p<0.01; 45.7+/-9.4 vs. 41.5+/-7.6, p<0.01), superior vena cava diameter (19.2+/-3.4 vs. 18.0+/-3.4, p=0.02), azygos vein diameter (10.0+/-2.2 vs. 9.2+/-2.3, p=0.02), septal displacement (19 vs. 18, p<0.01) were significantly higher in MAE group than in no MAE group. Patients with MAE had high right ventricular/left ventricular dimension ratio (RV/LV ratio) compared to patients without MAE (1.34+/-0.48 vs. 1.03+/-0.28, p<0.01). The most useful cut-off value of RV/LV ratio for MAE was 1.3 and the area under the curve was 0.71 (0.62~0.79). CONCLUSION: RV/LV ratio on chest CT was a significant predictor of submassive PE related shock, intubation, in-hospital mortality, thrombolysis, thrombectomy within 30 days.

Initial Chest CT Findings of 2009 H1N1 Influenza Pneumonia in Helping Predict Clinical Outcomes / 결핵및호흡기질환

BACKGROUND: The aim of the present study was to evaluate whether findings on initial chest computed tomography (CT) of influenza pneumonia can help predict clinical outcome. METHODS: We reviewed all adult patients admitted to the Emergency Department (ED) with a confirmed diagnosis of novel influenza A H1N1 virus (2009 H1N1) pneumonia, who underwent chest CT upon admission between Aug 26, 2009 and Jan 31, 2010. Radiologic findings were characterized by type and pattern of opacities and zonal distribution. Clinical outcome measures were intensive care unit (ICU) admission, mechanical ventilation, and inhospital death. RESULTS: Of 59 patients diagnosed with 2009 H1N1 pneumonia, 41 (69.5%) underwent chest CT on admission into ED. Nine (22%) of these patients developed adverse clinical outcomes requiring the following treatments: 9 (22.0%) ICU admissions, 5 (12.2%) mechanical ventilation, and 3 (7.3%) inhospital deaths. Counting the number of patients with more than 4 involved lobes, the sensitivity, specificity, positive predictive value, and negative predictive value for detection of adverse clinical outcome were 67%, 84%, 55% and 80%, respectively. CONCLUSION: Extensive involvement of both lungs (over 4 lobes) is related to ICU admission, mechanical ventilation, and inhospital death. Initial chest CT may help predict an adverse clinical outcome of patients with 2009 H1N1 influenza pneumonia.

Pulmonary Complication of Novel Influenza A (H1N1) Infection: Imaging Features in Two Patients

Novel influenza A (H1N1) virus is the pathogen of recent global outbreaks of febrile respiratory infection. We herein report the imaging findings of pulmonary complication in two patients with novel influenza A (H1N1) infection. The first patient without secondary infection showed the ill-defined ground-glass opacity nodules and patch areas of ground-glass opacities. The second patient with secondary pneumococcal pneumonia showed areas of lobar consolidation in the right middle lobe and left lower lobe and ground-glass opacities.

Three-year Follow-up of Niemann-Pick Disease with Pulmonary Involvement: A Case Report

Niemann-Pick disease is a rare inherited metabolic storage disease that causes excessive intracellular storage of sphingomyelin in various organs. We present the pulmonary imaging findings with particular emphasis on the CT findings in a case of Niemann-Pick disease type B with pulmonary involvement. The chest radiograph showed fine reticulonodular opacities in both basal lung fields, and the high-resolution chest CT showed centrilobular nodular opacities and smooth thickening of the interlobar fissure and interlobular septum with a basal lung predominance. Coronal reformatted CT revealed a prominent interlobular septal thickening around the diaphragm. The follow-up high-resolution chest CT showed no significant interval changes over a 3-years period.

Postcontrast T1-weighted Brain Magnetic Resonance Imaging in Pediatric Patients: Comparison Between Postcontrast Fat-suppression Imaging and Conventional T1-weighted or Magnetization Transfer Imaging

PURPOSE: We wished to assess the merits and weaknesses of postcontrast fat-suppression (FS) brain MR imaging in children for the evaluation of various enhancing lesions as compared with postcontrast conventional T1-weighted or magnetization transfer (MT) imaging. MATERIALS AND METHODS: We reviewed the records of those patients with enhancing lesions on brain MR imaging who had undergone both FS imaging and one of the conventional T1-weighted or MT imaging as a postcontrast T1-weighted brain MR imaging. Thirty-one patients (21 male, 10 female; mean age, 8.7 years) with 38 enhancing lesions (18 intra-axial, 16 extra-axial and 4 orbital locations) were included in this study. There were 27 pairs of FS and conventional imagings, and 13 pairs of FS and MT imagings available for evaluation. Two radiologists visually assessed by consensus the lesions' conspicuity, and they also looked for the presence of flow or susceptibility artifacts in a total of 40 pairs of MR imagings. For 19 measurable lesions (14 pairs of FS and conventional T1-weighted imagings, 5 pairs of FS and MT imagings), the contrast ratios between the lesion and the normal brain ([SIlesion-SIwater]/[SInormal brain-SIwater]) were calculated and compared. RESULTS: Compared with conventional imaging, the lesion conspicuity on FS imaging was better in 10 cases (7 extra-axial lesions, 2 orbital lesions and 1 fat-containing intra-axial lesion), equal in 16 cases, and worse in one case. Compared with MT imaging, the lesion conspicuity on FS imaging was better in 3 cases (2 extra-axial lesions and 1 intra-axial lesion), equal in 8 cases, and worse in 2 cases. Image quality of FS imaging was compromised by flow or susceptibility artifacts for 7 patients. The contrast ratios for FS imaging were not significantly different from those for conventional imaging (2.2+/-0.7 vs. 2.2+/-0.6, respectively, p=0.914) and they were significantly lower than those for MT imaging (2.4+/-0.8 vs. 4.5+/-1.5, respectively, p=0.018). CONCLUSION:Postcontrast FS brain MR imaging appears to be better than the conventional T1-weighted imaging and comparable to MT imaging for the visual assessment of enhancing lesions. Especially, the FS imaging has the merit to delineate orbital and extra-axial enhancing lesions or fat-containing lesions, whereas it is disadvantageous when flow or susceptibility artifacts occur.