An Atypical Case of Meckel's Diverticulum Assessed by SPECT/CT Imaging.

ABSTRACT: A 17-year-old adolescent boy presented with multiple episodes of hematochezia. After a negative 99mTcO4 scan, upper endoscopy, colonoscopy, and CT angiography, the patient underwent a second 99mTcO4 scan with ranitidine. The anterior images demonstrated a faint, delayed focus of uptake in the midabdomen without correlate on lateral projections. SPECT/CT was performed for localization with the focus of activity seen in an anterior loop of distal small bowel adjacent to the umbilicus. The patient subsequently underwent diagnostic laparoscopy and resection of the diverticulum with postoperative resolution of the symptoms.

Patient Understanding of Abnormal Imaging Findings Under Pennsylvania Act 112: A Call to Revise Mandated Notification Message Language.

PURPOSE: The aim of this study was to evaluate the effect of Pennsylvania Act 112 notification reading level and presentation on patient understanding and anxiety. METHODS: Four notifications were developed by alternating 12th grade and 6th grade reading level Act 112 language with letters or infographics. Using Amazon Mechanical Turk, 909 US adult volunteers were randomly assigned to one notification followed by a survey. Participants who answered all 12 survey questions on understanding, anxiety, and sociodemographics were paid $0.10. Chi-square analysis and multivariate regression were used to determine the impact of notification type and sociodemographic data on understanding of communicated information and anxiety. RESULTS: Sixty percent of participants (489 of 821) correctly understood all three questions directly answered within notifications regarding Act 112 subject, next steps, and process for obtaining reports. Approximately half of respondents understood that notifications indirectly conveyed "definitely" or "possibly" abnormal test results (344 of 821 [42%] and 99 of 821 [12%], respectively). Compared with the 12th grade letter, correct understanding of all directly communicated information was lower with the 12th grade infographic after adjustment (odds ratio, 0.61; 95% confidence interval, 0.39-0.95; P = .028) and equivalent with the 6th grade infographic and letter (P = .744 and P = .316). Correct indirect understanding of abnormal test results was not associated with notification type after adjustment but was associated with higher anxiety (odds ratio, 2.86; 95% confidence interval, 0.57-1.35; P < .001). CONCLUSIONS: Layperson understanding of information directly and indirectly communicated in Pennsylvania Act 112 is suboptimal, regardless of reading level or presentation. New Act 112 language is needed to improve patient understanding, which would ideally be coproduced with Pennsylvania patients, policymakers, and other relevant stakeholders.

Early Impact of Pennsylvania Act 112 on Follow-up of Abnormal Imaging Findings.

OBJECTIVE: Pennsylvania Act 112 requires diagnostic imaging facilities to directly notify outpatients about significant imaging abnormalities that require follow-up care within 3 months. The effects of Act 112 on patient care are unclear. We sought to characterize follow-up discussions and care received by outpatients with significant imaging abnormalities as defined by Act 112. METHODS: We evaluated findings flagged for patient notification under Act 112 at our institution over a 1-month period. We analyzed findings for radiologic reporting, follow-up discussions between patients and ordering providers, and follow-up medical care provided. RESULTS: Follow-up discussions were documented for 87% of findings (n = 205 of 235) and occurred on average 6.0 days after imaging examinations were performed. Follow-up discussions directly attributable to the Act 112 letter occurred in 0.4% of findings. Follow-up care was provided for 74% of findings on average 31.3 days after imaging examinations were performed. Provider-initiated follow-up discussions occurred earlier and were associated with shorter time to follow-up care when compared with patient-initiated discussions. Direct contact of ordering provider by interpreting radiologist was a significant predictor of occurrence of follow-up discussions and length of time to follow-up care. DISCUSSION: Act 112 had a small impact at our institution on improving completed follow-up for abnormal imaging findings. Our results also imply that health systems should encourage timeliness of patient-provider discussions of abnormal imaging findings and facilitate direct radiologist communication with ordering providers. Future studies should evaluate the impact of Act 112 in different practice settings to understand its broader impact on follow-up care.

Use of Shoulder Imaging in the Outpatient Setting: A Pilot Study.

PURPOSE: Characterize the clinical utility of diagnostic shoulder imaging modalities commonly used in the outpatient workup of shoulder pain. MATERIALS/METHODS: Retrospective review of adults imaged for outpatient shoulder pain from 1/1/2013 to 9/1/2015. To be categorized as "useful", a study had to meet one of the following criteria: change the clinical diagnosis or treatment plan, provide a final diagnosis, or guide definitive treatment. A utility score was assigned to each study based on the number of utility criteria met (range 0-4). A score of 1 was considered low utility; a score of greater than or equal to 2 was considered high utility. Statistical analysis included binary logistic regression and generalized estimating equations. RESULTS: 210 subjects (65% male); mean age 47 (range 18-84), underwent 302 imaging studies (159 X-ray, 137 MRI, 2 CT, 4 ultrasound) during the study period. 92.1% of all studies met minimum criteria for utility (score >1). Most commonly, diagnostic studies obtained during the outpatient workup of shoulder pain were found to guide definitive treatment (70.5%) or provide a final diagnosis (53%). Most X-rays were categorized as no or low utility (85.5%). 97.8% of the MRI studies were categorized as useful with most being high utility (73%). Overall, MRI was the most useful modality in all clinical scenarios (P = 0.002) and more likely to be high utility (P < 0.001) compared to X-rays. None of the investigated patient or injury characteristics were significant predictors of useful imaging. CONCLUSION: Our study suggests that both radiographs and MRI are useful in the evaluation of adult unilateral shoulder pain in the outpatient setting. MRI appears to be the most useful imaging modality in terms of helping guide diagnosis and treatment selection. This serves as a potential first step towards the development of evidence based imaging algorithms that can be used and tested in future studies.

The Unique Macroscopic Appearance of Gouty Arthritis of the Knee.

Patients with significant gouty arthritis can develop disabling joint pain secondary to monosodium urate (MSU) articular deposition. We report a case of white, chalky MSU crystal deposition covering the articular surfaces of the knee as discovered by total knee arthroplasty. A 65-year-old male with a history of gout presented with bilateral knee pain. His radiographic imaging was negative for gouty tophi, and he elected to undergo left total knee arthroplasty. Intraoperatively a distinct chalky, white paste consistent with MSU deposition was observed covering the articular surfaces of the knee consistent with the diagnosis of gouty arthritis. Gout is the most common inflammatory arthritis affecting more than 3 million people in the USA. The inflammation results from the phagocytosis of monosodium urate crystals (MSU) and the release of inflammatory cytokines within the joint. Gout progresses from acute to chronic over many years and frequently causes chronic arthropathy. When significant knee pain and disability is associated with gouty arthropathy, total knee arthroplasty is certainly an option. The pathological appearance of gouty joints is characteristic. Macroscopic examination of joints affected by gout reveals a nodular, white, chalky appearance. Polarized microscopy of gout demonstrates negative birefringent needle-shaped MSU crystals. In this case report, we describe the characteristic chalky, white MSU deposit that covers the articular surfaces of a knee joint in a patient with a history of gout undergoing total knee arthroplasty. The investigators have obtained the patient's informed written consent for print and electronic publication of the case report.

Simultaneous Versus Staged Total Hip Arthroplasty A Review.

Total hip arthroplasty (THA) is considered one of the most effective treatments for hip arthritis, but the decision to perform simultaneous bilateral THA versus staged bilateral THA remains a source of controversy based primarily on the analysis of the risks and benefits of each approach. Many surgeons are reluctant to consider simultaneous total hip arthroplasty even though the procedure is associated with a shorter total hospitalization, shorter recovery and rehabilitation time, and decreased cost. However, in this review, we find that despite higher blood loss in the simultaneous group, there are no significant differences in terms of cardiopulmonary complications, thromboembolic events, stroke, surgical site infection, and rate of allogeneic transfusion between simultaneous and staged procedures. In addition, careful patient selection (ASA 1 and 2) can further minimize the risks of simultaneous bilateral total hip arthroplasty and increase the likelihood of consistent successful outcomes.