Enhancing the value of radiology reports: a primer for residents.

PURPOSE: The radiology report is the primary work product of the diagnostic radiologist. Its quality is a direct reflection of his or her knowledge, experience, and confidence. Certain factors hindering one's ability to deliver a diagnostically accurate and concise report are sometimes unavoidable (e.g., study limitations and insufficient history); however, radiologists who routinely produce deficient reports not only erode their credibility and reputation amongst colleagues, they magnify their risk of litigation. METHODS: This article is directed toward radiology residents to help facilitate the adoption of effective reporting habits. RESULTS AND CONCLUSION: Up to 92% of referring physicians and 95% of radiologists agree that learning to report should be an "obligatory and well-structured" component of radiology residency education as discussed by Bosmans JM, Weyler JJ, De Schepper AM, and Parizel PM. Unfortunately, this remains the exception rather than the rule. This article is written with the following objectives: (1) to identify strategies that improve the value of radiology reporting, (2) to define the features of a high-quality radiology report, (3) to instill trust and respect from referring clinicians through clear, accurate, and effective communication, and (4) to understand and avoid potential medicolegal ramifications of deficient radiology reports.

Findings on Chest CT Performed in the Emergency Department in Patients Receiving Immune Checkpoint Inhibitor Therapy: Single-Institution 8-Year Experience in 136 Patients.

BACKGROUND. Patients undergoing immune checkpoint inhibitor (ICI) therapy may present to the emergency department (ED) with a wide range of immune-related adverse events. OBJECTIVE. The purpose of our study was to evaluate chest CT findings in patients receiving ICI therapy presenting to the ED and to explore these findings' associations with clinical parameters. METHODS. This retrospective study included 136 patients (75 men, 61 women; mean age, 65 ± 12 [SD] years) receiving ICI therapy who underwent chest CT at 163 ED visits between 2011 and 2018. Two radiologists independently reviewed chest CT examinations for various findings and resolved discrepancies by consensus. Clinical parameters, including survival at last available follow-up, were recorded. Chest CT findings were summarized, and interreader agreement was evaluated using kappa coefficients. Associations between CT findings and clinical parameters were explored using Fisher exact, chi-square, Wilcoxon, and Kruskal-Wallis tests. RESULTS. A total of 62.5% of patients had primary lung cancer; 52.9% received nivolumab monotherapy, and 30.1% received pembrolizumab monotherapy. A total of 55.8% of ED visits occurred within 60 days after ICI initiation. The most common CT findings were worsening lung tumor burden (60.1%), new consolidation unrelated to tumor (30.1%), new or worsening pleural effusion (23.9%), and ICI-associated pneumonitis (12.9%). The most common CT pneumonitis pattern was radiation recall pneumonitis (6/21, 28.6%). A total of 78.5% of ED visits with chest CT resulted in hospitalization; 66.9% of patients subsequently died. Survival was worse for patients with, versus without, worsening tumor (72.2% vs 49.1% of patients deceased vs alive at follow-up, p = .006) and for patients with, versus without, pleural effusion (39.2% vs 17.5% of patients deceased vs alive at follow-up, p = .04). Kappa values for interreader agreement of evaluated chest CT findings ranged from 0.66 (worsening tumor burden) to 1.00 (numerous findings). CONCLUSION. Most ED chest CT examinations in patients receiving ICI therapy exhibited worsening lung tumor burden, which was associated with worse survival. New consolidation and ICI-associated pneumonitis (most commonly radiation recall pneumonitis) were also commonly detected in the ED setting. CLINICAL IMPACT. Understanding pathologies detected on chest CT in patients undergoing ICI therapy who present to the ED may guide radiologists in interpreting such imaging.

E-cigarette use related lung disease, review of clinical and imaging findings in 3 cases.

Electronic-cigarette use (vaping), has gained popularity among the young adult population, causing an alarming rise in electronic-cigarette, or vaping, product use-associated lung injury (EVALI). The specific chemical agent(s) responsible for lung injuries remains to be further investigated, but tetrahydrocannabinol, the active ingredient in marijuana, and vitamin E acetate are involved in most cases. A variety of pulmonary diseases causing different imaging findings have been described with EVALI. The clinical and imaging findings of three cases recently seen in our emergency department are reviewed.

A case of liver abscesses and porto-enteric fistula caused by an ingested toothpick: A review of the distinctive clinical and imaging features.

Though foreign body (FB) ingestions are a relatively common occurrence in the bustling emergency department, particularly among children, the vast majority of FBs either pass uneventfully or can be retrieved endoscopically. Only a small percentage of patients will experience complications such as bowel obstruction, ischemia, or perforation that may progress to abscess, septic thrombophlebitis, peritonitis, or shock. Depending on their composition, small FBs can be very difficult to detect on computed tomography (CT). However, a delay in definitive treatment resulting from the failure to clinically or radiologically recognize that a FB may be responsible for the acute presentation can lead to substantial morbidity and mortality. We present a case of unresolving hepatic abscess and recurrent sepsis caused by a toothpick-induced porto-enteric fistula in which the FB was not initially identified, thereby leading to multiple treatment failures and readmissions. This is followed by a literature review with comprehensive discussion of the distinctive clinical and imaging features of migrated FB-induced liver abscesses.

Avulsion fractures of the knee: a review of the pathophysiology, radiographic, and cross-sectional imaging features.

Knee trauma is a common presenting symptom in the emergency setting. Avulsive knee injuries are important to diagnose timely and accurately to avoid unnecessary patient morbidity. Many of these avulsive knee injuries have characteristic appearances on imaging. This article presents a comprehensive review of some of the most common types with real cases used for imaging correlation.

Sonographic imaging of hand and wrist injuries: applications in the ER setting.

Acute osseous and soft tissue injuries to the hand and wrist are a common cause for ER visitation. Though diagnostic assessment has historically remained the province of conventional radiography, CT and MRI, sonography is gaining increasing acceptance and utilization. Offering multiple inherent advantages as an imaging modality, ultrasonic assessment has proven its utility in the evaluation of ligamentous and tendinous carpal and digital injuries as well as infection and inflammation. In this review, we will initially discuss sonographic technique and relevant normal anatomical features. Illustrative examples of soft tissue and osseous injuries of the hand and wrist as well as complicated infections most likely to be encountered in the emergency setting will then be presented together with a discussion of their relevant clinical considerations and management.

SAPHO Syndrome Masquerading as Metastatic Breast Cancer.

SAPHO syndrome is a rare clinical entity composed of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO). We describe a case of SAPHO syndrome masquerading as metastatic breast cancer in a patient with localized breast cancer who presented with cord compression. There was no pathologic evidence of metastatic cancer; however, a bone scan indicated osseous involvement. After multidisciplinary review of images and with additional findings of pustulosis and acne, a clinical diagnosis of SAPHO was made.

Sonographic evaluation of peripheral nerve pathology in the emergency setting.

High-resolution sonography has a growing role in both the diagnosis and management of traumatic and atraumatic peripheral nerve pathology. Sonography not only affords a cost-effective and time-efficient approach to interrogating long segments of peripheral nerves but also possesses unique advantages in terms of its dynamic, real-time nature with few clinical contraindications and limitations. In this review, we will initially discuss imaging techniques and characteristics of normal neural sonohistology, then address specific features and pitfalls pertaining to the spectrum of post-traumatic peripheral nerve injury. Additionally, we will highlight the more common sonographic applications in the clinical work-up of patients presenting with symptoms of dynamic neural impingement and entrapment. Finally, illustrative and clinical features of the more frequently encountered peripheral neural neoplastic pathologies will be addressed.

The advantages of tomosynthesis for evaluating bisphosphonate-related atypical femur fractures compared to radiography.

OBJECTIVE: To investigate the advantages of using tomosynthesis (TS) compared to radiographs in the detection, characterization, and follow-up of bisphosphonate-related atypical femur fractures (BP-AFF). SUBJECTS AND METHODS: Eight patients were identified retrospectively who underwent TS for radiographic findings suspicious for BP-AFF. Two radiologists independently interpreted 15 radiographs and 16 TS examinations, indicating the presence or absence of the following: (1) cortical "beaking" on radiographs, (2) radiolucent fracture line on radiographs, and (3) fracture lucency on TS corresponding to the site of radiographic abnormality. Radiation dose data were calculated for radiographs and TS using Monte Carlo analysis. RESULTS: There was agreement on 100 % of radiographs regarding the presence or absence of a cortical beak. Regarding the presence or absence of a fracture lucency, there was agreement on 100 % of TS examinations (Kappa = 1.0) and 73 % of radiographs (Kappa = 0.40 ± 0.24). For the 46 % of radiographs in which one or both radiologists did not visualize a fracture line, there was 100 % agreement for the presence of a fracture line on the corresponding TS. The interobserver agreement for fracture line detection was significantly higher for TS than for radiographs (p = 0.012). The effective radiation dose using TS was approximately 96 % lower compared to radiography. CONCLUSION: TS outperformed radiographs in the detection and characterization of BP-AFF. TS may also have advantages over radiography for BP-AFF follow-up through its unique ability to visualize fracture healing with lower effective radiation doses to the patient.