Automating Import and Reconciliation of Outside Examinations Submitted to an Academic Radiology Department.

Although advances in electronic image sharing have made continuity of patient care easier, currently, the majority of outside studies are received on CD. At our institution, there were 9 full-time employees (FTE) at three locations using three workflows to manually upload, schedule, and process studies to PACS. As the demand to view and store outside studies has grown, so has the processing turnaround time. To reduce turnaround time and the need for human intervention, we developed an automated workflow to import outside studies from a CD to our PACS and reconcile them with an internal accession number and exam code.

Using a web-based application to enhance resident training and improve performance on-call.

RATIONALE AND OBJECTIVES: It is common practice in academic hospitals for radiology residents to provide preliminary interpretations for radiologic examinations performed in the emergency department (ED) during off-hours. In this study, we used a software program called Minerva to identify and track discrepancies between resident and faculty interpretation of ED studies. The objective was to determine if missed case conferences could reduce the number of resident discrepancies related to the types of cases reviewed. MATERIALS AND METHODS: We used Minerva to identify and grade faculty-modified resident preliminary reports as minor or major discrepancies depending on whether the discrepancy had the potential to affect patient management or outcome. Minor and major discrepancy rates were calculated for all residents to evaluate call performance, establish benchmarks, and develop interventions to reduce the number of discrepant cases. RESULTS: The total discrepancy rate for all residents (n = 22) was 2.6% with a standard deviation (SD) of 0.7%. The average major discrepancy rate for all residents was 1.1% with a SD of 0.4%. Trend analysis of missed cases was used to generate topic-specific resident missed case conferences on acromioclavicular joint separation injuries, elbow joint effusions, and osteochondral fractures, which resulted in an overall 64% decrease in the number of missed cases related to these injuries. CONCLUSIONS: The systematic evaluation of resident discrepancies using a simple software application provides a competency-based metric to assess call performance, establish benchmarks, and develop missed case conferences. This process is expected to result in further reduction in resident discrepancy rates and missed cases.

Achalasia with complete relaxation of lower esophageal sphincter: radiographic-manometric correlation.

PURPOSE: To evaluate retrospectively the presence of complete relaxation of the lower esophageal sphincter (LES) at manometry in patients with achalasia depicted on barium esophagograms. MATERIALS AND METHODS: The institutional review board approved this retrospective study and did not require informed consent. A search of radiology and manometry records identified 21 patients (12 men, nine women; mean age, 52.4 years) with achalasia depicted on barium esophagograms who had undergone manometric examinations and met the inclusion criteria. Radiologic reports and images were reviewed for presence or absence of primary peristalsis, impaired LES opening, esophageal dilatation, delayed emptying of barium, and nonperistaltic contractions. Manometry reports were reviewed for presence or absence of peristalsis or simultaneous esophageal contractions. Resting and residual LES pressures were recorded to determine whether LES relaxation was complete or incomplete. Medical records were reviewed to determine clinical presentation and follow-up (treatment and patient course), and radiographic files were reviewed to determine radiographic findings at follow-up examinations. Clinical characteristics (eg, age, dysphagia, and weight loss) were correlated with LES relaxation at manometry. Data were analyzed statistically with Fisher exact and Wilcoxon rank sum testing. RESULTS: All 21 patients with radiographic findings of achalasia had aperistalsis at manometry. Fourteen patients (67%) had incomplete LES relaxation at manometry during swallowing, and seven (33%) had complete LES relaxation. There were no significant differences between patients with complete LES relaxation and those with incomplete LES relaxation in mean age (P = .59), duration of dysphagia (P = .18), or weight loss (P > .99). Clinical follow-up findings were available for six patients with complete LES relaxation at manometry and 10 with incomplete relaxation. Symptoms resolved after treatment in all six patients with complete LES relaxation. Six (60%) of 10 patients with incomplete LES relaxation had resolution of symptoms after treatment, and four (40%) had substantial improvement. CONCLUSION: These data suggest that in patients with typical radiographic findings of achalasia, the barium study can be used to guide treatment without a need for manometry. If radiographic findings are equivocal, however, manometry may be required for a more certain diagnosis.

Intraobserver variability in the MR determination of tumor volume in squamous cell carcinoma of the pharynx.

BACKGROUND AND PURPOSE: If tumor volumes are to be used for evaluating responses to treatment and long-term outcomes of patients with primary pharyngeal carcinomas, the reproducibility of these measurements must be established. We determined the intraobserver variability of MR imaging-based volume measurements of these cancers and their regional metastases. METHODS: We used an interactive computer program (IDL) that enables the extraction of tumor volumes from 3D MR data to obtain 202 volume measurements in 17 patients with pharyngeal carcinoma (two to five time points each). The primary cancer and largest nodal mass were manually outlined on every T2-weighted image of each MR study. The same neuroradiologist reanalyzed this MR dataset 2-41 weeks later. Measurement error and percentage measurement error (intraobserver variability) were determined. Differences in intraobserver variability between primary lesions and nodes, as well as between stages of treatment were tested with a Wilcoxon rank sum test. RESULTS: The mean and median percentage measurement errors, respectively, were 13% and 12% (range, 0-53%; 95% CI: 10%, 16%) for primary tumors and 9% and 7% (range, 0-37%; 95% CI: 7%, 12%) for nodal metastases. The difference in the percentage measurement error between primary lesions and cervical nodes approached statistical significance (P =.07). Differences in the variation of volume measurements based on the stage of therapy were significant (P =.01). CONCLUSION: Our results suggest that MR imaging-based tumor volumes are reliably reproducible. Such measurements may be important in predicting patient outcome, determining appropriate therapy, and conducting patient follow-up.

Gastroesophageal reflux: comparison of barium studies with 24-h pH monitoring.

OBJECTIVE: To determine the correlation between massive gastroesophageal reflux (GER) on barium studies and pathologic acid reflux on 24-h pH monitoring. METHODS: A search of hospital records from January 1997 to January 2001 revealed 28 patients who underwent both barium studies and 24-h pH monitoring. The radiologic reports were reviewed to determine the presence and degree of GER. Patients with reflux to or above the thoracic inlet either spontaneously or with provocative maneuvers in the recumbent position were classified as having massive reflux, whereas the remaining patients with reflux below the thoracic inlet or no reflux comprised the control group. The pH monitoring reports were also reviewed to determine if pathologic acid reflux was present in the recumbent position. The findings on these studies were then compared to determine the frequency of pathologic acid reflux in the recumbent position on pH monitoring in patients with massive reflux on barium studies compared with the control group. RESULTS: Massive GER was observed on barium studies in 11 (39%) of the 28 patients and reflux below the thoracic inlet or no reflux in the remaining 17 patients (61%) who comprised the control group. All 11 patients (100%) with massive reflux on barium studies had pathologic acid reflux on pH monitoring in the recumbent position compared with six (35%) of 17 patients in the control group (P = 0.0009). The pH in the distal esophagus on pH monitoring was less than 4.0 for 13.1% of the recumbent period for patients with massive GER on barium studies compared with 6.2% of the recumbent period for the control group (P = 0.0076). CONCLUSION: Although 24-h pH monitoring remains the gold standard for the detection of GER, our experience suggests that patients with massive reflux on barium studies are so likely to have pathologic acid reflux in the recumbent position that these individuals can be further evaluated and treated for their gastroesophageal reflux disease (GERD) without need for pH monitoring.

Usefulness of high-density barium for detection of leaks after esophagogastrectomy, total gastrectomy, and total laryngectomy.

OBJECTIVE: The purpose of this study was to determine the usefulness of a high-density (250% weight/volume) barium compared with a water-soluble contrast agent for the detection of esophageal leaks in patients who had undergone esophagogastrectomy, total gastrectomy, or total laryngectomy. MATERIALS AND METHODS: A search of our radiology database from 1998 to 2001 revealed 46 eligible radiographic studies performed using a water-soluble contrast agent alone or a water-soluble contrast agent followed by barium that showed leaks in patients who had undergone esophagogastrectomy, total gastrectomy, or total laryngectomy. The images were reviewed to determine the morphology of the leaks (i.e., blind-ending tracks, sealed-off collections, or free extravasation of contrast material). Medical records were also reviewed to determine whether detection of the leaks seen on the radiographic studies affected patient management. RESULTS: Of the 46 leaks seen on radiographic studies, 23 (50%) were detected with a water-soluble contrast agent and 23 (50%) were detected only with high-density barium. Of the 23 leaks visualized with water-soluble contrast media, six (26%) were characterized by blind-ending tracks, 14 (61%) by sealed-off collections, and three (13%) by free extravasation of contrast material into the mediastinum or neck. Of the 23 leaks visualized only with high-density barium, 19 (83%) were characterized by blind-ending tracks and four (17%) by sealed-off collections. Thus, leaks detected only on images obtained with high-density barium were significantly more likely to be characterized by blind-ending tracks than those detected on images obtained with a water-soluble contrast agent (p = 0.0007). Of the 33 patients with clinical follow-up, the findings seen on these imaging studies affected management in 12 (86%) of 14 patients with leaks depicted by water-soluble contrast media and in 10 (53%) of 19 with leaks depicted only by high-density barium. CONCLUSION: Our findings support the use of high-density barium as part of the routine postoperative radiographic examination when no leaks are detected on images obtained with a water-soluble contrast agent.

Epiphrenic diverticulum: clinical and radiographic findings in 27 patients.

The purpose of our study was to reassess the clinical and radiographic findings in patients with epiphrenic diverticula. A search of our radiology files revealed 27 patients with epiphrenic diverticula within 10 cm of the gastroesophageal junction. Medical records and radiographic reports and images were reviewed to determine the clinical and radiographic findings. Twenty-three patients had a solitary epiphrenic diverticulum, three had two diverticula, and one had three diverticula. The diverticula arose from the right side of the distal esophagus in 19 patients and the left side in eight. The diverticula had a mean width of 4.4 cm and a mean height of 3.7 cm. Other findings included prolonged retention of barium in the diverticula in 19 patients, preferential filling in 11, retained debris in 5, regurgitation of barium or debris in 5, compression of the esophagus in 5, pseudodiverticula formation in 3, and ulceration in 1. We found a significant correlation between the width of the diverticulum and preferential filling with barium. Twelve patients had abnormal esophageal motility, with diffuse esophageal spasm in two. Seventeen patients had symptoms attributable to the diverticulum (dysphagia in 11 and/or reflux symptoms in 12). We also found a significant correlation between the size or preferential filling of the diverticulum and the presence of symptoms. Conversely, we found no correlation between esophageal dysmotility and the presence of symptoms. Our experience suggests that the development of symptoms in patients with epiphrenic diverticula is more likely to be related to the morphologic features of the diverticula than to underlying esophageal motility disorders.