Impact of a statewide computed tomography scan educational campaign on radiation dose and repeat CT scan rates for transferred injured children.

PURPOSE: Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign's impact on injured children received radiation dose. METHODS: All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. RESULTS: Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). CONCLUSION: A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.

Injured Children Receive Twice the Radiation Dose at Nonpediatric Trauma Centers Compared With Pediatric Trauma Centers.

BACKGROUND: Use of cranial CT scans in children has been increasing, in part due to increased awareness of sports-related concussions. CT is the largest contributor to medical radiation exposure, a risk factor for cancer. Long-term cancer risks of CT scans can be two to three times higher for children than for adults because children are more radiosensitive and have a longer lifetime in which to accumulate exposure from multiple scans. STUDY AIM: To compare the radiation exposure injured children receive when imaged at nonpediatric hospitals (NPHs) versus pediatric hospitals. METHODS: Injured children younger than 18 years who received a CT scan at a referring hospital during calendar years (CYs) 2010 and 2013 were included. Patient-level factors included demographics, mode of transportation, and Injury Severity Score, and hospital-level factors included region of state, radiology services, and hospital type and size. Our primary outcome of interest was the effective radiation dose. RESULTS: Four hundred eighty-seven children were transferred to the pediatric trauma center during CYs 2010 and 2013, with a median age of 7.2 years (interquartile range 5-13). The median effective radiation dose received at NPHs was twice that received at the pediatric trauma center (3.8 versus 1.6 mSv, P < .001). Results were confirmed in independent and paired analyses, after controlling for mode of transportation, emergency department disposition, level of injury severity, and at the NPH trauma center level, hospital type, size, region, and radiology services location. CONCLUSION: NPHs have the potential to substantially reduce the medical radiation received by injured children. Pediatric CT protocols should be considered.

Does high body mass index obviate the need for oral contrast in emergency department patients?

INTRODUCTION: High body mass index (BMI) values generally correlate with a large proportion of intra-peritoneal adipose tissue. Because intra-peritoneal infectious and inflammatory conditions manifest with abnormalities of the adipose tissue adjacent to the inflamed organ, it is presumed that with a larger percentage of adipose surrounding a given organ, visualization of the inflammatory changes would be more readily apparent. Do higher BMI values sufficiently enhance the ability of a radiologist to read a computed tomography (CT) of the abdomen and pelvis, so that the need for oral contrast to be given is precluded? METHODS: FORTY SIX PATIENTS WERE INCLUDED IN THE STUDY: 27 females, and 19 males. They underwent abdominal/pelvic CTs without oral or intravenous contrast in the emergency department. Two board certified radiologists reviewed their CTs, and assessed them for radiographic evidence of intra-abdominal pathology. The patients were then placed into one of four groups based on their body mass index. Kappa analysis was performed on the CT reads for each group to determine whether there was significant inter-rater agreement regarding contrast use for the patient in question. RESULTS: There was increasingly significant agreement between radiologists, regarding contrast use, as the study subject's BMI increased. In addition, there was an advancing tendency of the radiologists to state that there was no need for oral or intravenous contrast in patients with higher BMIs, as the larger quantity of intra-peritoneal adipose allowed greater visualization and inspection of intra-abdominal organs. CONCLUSION: Based on the results of this study, it appears that there is a decreasing need for oral contrast in emergency department patients undergoing abdominal/pelvic CT, as a patient's BMI increases. Specifically, there was statistically significant agreement, between radiologists, regarding contrast use in patients who had a BMI greater than 25.

Volume progression in polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive enlargement of cyst-filled kidneys. METHODS: In a three-year study, we measured the rates of change in total kidney volume, total cyst volume, and iothalamate clearance in patients with ADPKD. Of a total of 241 patients, in 232 patients without azotemia who were 15 to 46 years old at baseline we used magnetic-resonance imaging to correlate the total kidney volume and total cyst volume with iothalamate clearance. Statistical methods included analysis of variance, Pearson correlation, and multivariate regression analysis. RESULTS: Total kidney volume and total cyst volume increased exponentially, a result consistent with an expansion process dependent on growth. The mean (+/-SD) total kidney volume was 1060+/-642 ml at baseline and increased by a mean of 204+/-246 ml (5.27+/-3.92 percent per year, P<0.001) over a three-year period among 214 patients. Total cyst volume increased by 218+/-263 ml (P<0.001) during the same period among 210 patients. The baseline total kidney volume predicted the subsequent rate of increase in volume, independently of age. A baseline total kidney volume above 1500 ml in 51 patients was associated with a declining glomerular filtration rate (by 4.33+/-8.07 ml per minute per year, P<0.001). Total kidney volume increased more in 135 patients with PKD1 mutations (by 245+/-268 ml) than in 28 patients with PKD2 mutations (by 136+/-100 ml, P=0.03). CONCLUSIONS: Kidney enlargement resulting from the expansion of cysts in patients with ADPKD is continuous and quantifiable and is associated with the decline of renal function. Higher rates of kidney enlargement are associated with a more rapid decrease in renal function.

Cystic ectasia of the rete testis: clinical and radiographic features.

PURPOSE: Cystic ectasia of the rete testis is a rare condition that may be incidentally noted on scrotal ultrasonography. This benign condition has a typical appearance of a collection of small anechoic structures in the confluence of the mediastinum testis. The main significance of this condition is that it must be differentiated from testicular neoplasm. We reviewed the experience with this condition at our institution. MATERIALS AND METHODS: A retrospective review was performed to identify all sonograms showing ectatic rete testis performed from 1998 through February 2002. A departmental database was used to identify all scrotal sonograms from this period showing ectasia of the rete testis and clinical correlation was done. These examinations were then reviewed by a single radiologist. RESULTS: We identified 13 cases in the last 4 years. Ultrasound was most commonly performed for a testicular or scrotal mass, or pain. Median patient age was 65 years. All except 1 patient had an underlying condition, including vasectomy, epididymal cyst/spermatocele or inguinal hernia repair, that could cause epididymal or efferent duct obstruction. No patient had a solid testicular mass. CONCLUSIONS: Based on clinical and sonographic criteria the diagnosis of cystic ectasia of the rete testis can be made without histological confirmation. Identifying this entity and its associated conditions avoids the need for biopsy or orchiectomy.

Follow-up functional radiographic studies are not mandatory for all patients after ureteroscopy.

OBJECTIVES: To evaluate the usefulness of follow-up radiographic studies after ureteroscopy by retrospective chart review. METHODS: We reviewed the charts of 118 patients who underwent 134 ureteroscopic procedures from January 1998 to November 1999. RESULTS: Follow-up was obtained at our institution for 87 patients. The follow-up period ranged from 3 to 34 weeks (mean 7, SE +/- 0.75). Of 10 patients who underwent ureteroscopy for diagnostic purposes, none had postoperative pain or obstruction on follow-up radiographic studies. Of 77 patients who underwent ureteroscopy for calculi, 12 (16%) had postoperative obstruction. One third of patients with residual obstruction (4 of 12) complained of persistent pain versus 6% of patients without evidence of obstruction (4 of 65) (P = 0.02). Twelve patients had residual stone fragments on their follow-up radiographic studies; 5 (42%) of these patients complained of pain versus 3 (5%) of 65 patients who were stone free after surgery (P = 0.002). The use of pain to predict either obstruction or residual fragments had a negative and positive predictive value of 83% and 75%, respectively. Preoperative obstruction and postoperative pain were combined as one indicator for the presence of residual fragments and postoperative obstruction. Patients who had preoperative obstruction and presented with postoperative pain had a 67% chance of having residual fragments and a 50% chance of residual obstruction, and 96% of patients without preoperative obstruction and no postoperative pain had no persistent obstruction or residual fragments (P = 0.001). CONCLUSIONS: For patients who present for ureteroscopy with no obstruction and report no pain at follow-up, a plain radiograph may be sufficient. For patients who present with obstruction and report pain during follow-up, functional imaging studies are recommended.