"Concordance" Revisited: A Multispecialty Appraisal of "Concordant" Preliminary Abdominopelvic CT Reports.

PURPOSE: To determine whether resident abdominopelvic CT reports considered prospectively concordant with the final interpretation are also considered concordant by other blinded specialists and abdominal radiologists. METHODS: In this institutional review board-approved retrospective cohort study, 119 randomly selected urgent abdominopelvic CT examinations with a resident preliminary report deemed prospectively "concordant" by the signing faculty were identified. Nine blinded specialists from Emergency Medicine, Internal Medicine, and Abdominal Radiology reviewed the preliminary and final reports and scored the preliminary report with respect to urgent findings as follows: 1.) concordant; 2.) discordant with minor differences; 3.) discordant with major differences that do not alter patient management; or 4.) discordant with major differences that do alter patient management. Predicted management resulting from scores of 4 was recorded. Consensus was defined as majority agreement within a specialty. Consensus major discrepancy rates (ie, scores 3 or 4) were compared to the original major discrepancy rate of 0% (0/119) using the McNemar test. RESULTS: Consensus scores of 4 were assigned in 18% (21/119, P < .001, Emergency Medicine), 5% (6/119, P = .03, Internal Medicine), and 13% (16/119, P < .001, Abdominal Radiology) of examinations. Consensus scores of 3 or 4 were assigned in 31% (37/119, P < .001, Emergency Medicine), 14% (17/119, P < .001, Internal Medicine), and 18% (22/119, P < .001, Abdominal Radiology). Predicted management alterations included hospital status (0-4%), medical therapy (1%-4%), imaging (1%-10%), subspecialty consultation (3%-13%), nonsurgical procedure (3%), operation (1%-3%), and other (0-3%). CONCLUSIONS: The historical low major discrepancy rate for urgent findings between resident and faculty radiologists is likely underreported.

US of the Peripheral Nerves of the Upper Extremity: A Landmark Approach.

Ultrasonography (US) has become a first-line modality for the evaluation of the peripheral nerves of the upper extremity. The benefits of US over magnetic resonance (MR) imaging include higher soft-tissue resolution, cost effectiveness, portability, real-time and dynamic imaging, and the ability to scan an entire extremity quickly and efficiently. US can be performed on patients who are not eligible for MR imaging. Metallic implant artifacts are usually not problematic. US has been shown to have equal specificity and greater sensitivity than MR imaging in the evaluation of peripheral nerves. Any abnormal findings can be easily compared with the contralateral side. The published literature has shown that US has demonstrated clinical utility in patients with suspected peripheral nerve disease by guiding diagnostic and therapeutic decisions as well as by confirming electrodiagnostic findings. Common indications for upper extremity peripheral nerve US are the evaluation for injury due to penetrating trauma, entrapment by scar tissue, and tumor. US of the upper extremity is most commonly performed to evaluate carpal and cubital tunnel syndrome. It is important for the radiologist or sonographer to have a detailed knowledge of anatomy and specific anatomic landmarks for each nerve to efficiently and accurately perform an examination. The goal of this article is to introduce readers to the basics of US of the peripheral nerves of the upper extremity with a focus on the median, ulnar, and radial nerves. Common sites of disease and the location of important anatomic landmarks will be reviewed.

C-reactive protein enhances tissue factor expression by vascular smooth muscle cells: mechanisms and in vivo significance.

OBJECTIVE: We examined the impact of C-reactive protein (CRP) on vascular smooth muscle cell (VSMC) expression of tissue factor (TF) and TF pathway inhibitor (TFPI). METHODS AND RESULTS: TF mRNA, protein, and activity levels were significantly higher in VSMCs isolated from CRP-transgenic (Tg) mice than from wild-type (WT) mice. TFPI expression was significantly downregulated in CRP-Tg versus WT VSMCs. Transfection of human VSMCs with CRP expression plasmid significantly increased TF expression and decreased TFPI expression. Gene silencing of Fc gamma receptor IIIa (Fc gammaRIIIa) blocked the effect of CRP on VSMC TF expression. CRP activated p44/42, but not p38 or JNK MAP kinase (MAPK), and the effect of CRP on TF expression was blocked by pharmacological inhibitor of p44/42, but not p38 or JNK MAPK. Reactive oxygen species (ROS) scavengers blocked CRP-induced upregulation of VSMC TF expression. In vivo analyses revealed significant increases in TF expression and decreases in TFPI expression in carotid arteries of CRP-Tg mice versus WT mice. CONCLUSIONS: CRP increases TF and decreases TFPI expression by VSMCs in vitro and in vivo. Induction of TF expression by CRP is mediated by Fc gammaRIIIa, p44/42 MAPK, and ROS generation. These data offer important insights into the role of CRP in the pathogenesis of arterial thrombosis.