Point-of-care renal ultrasound: Are longitudinal views of the kidney alone sufficient to rule out hydronephrosis?

Objective: Point-of-care ultrasound for the detection of hydronephrosis is frequently used by emergency physicians. The aim of this study was to assess the accuracy of longitudinal views of the kidney compared with a combination of longitudinal and transverse views of the kidney on emergency physician-performed renal point-of-care ultrasound to detect hydronephrosis. Methods: This was a retrospective case-control study of patients who received a renal point-of-care ultrasound examination performed and interpreted as hydronephrosis in the emergency department (ED). These were then matched with a cohort of kidneys from different patients without hydronephrosis. Longitudinal ultrasound views and transverse ultrasound views were reviewed for the presence of hydronephrosis by ultrasound-trained emergency physicians. The gold standard of hydronephrosis was an overall interpretation based on the complete ultrasound examination consisting of both transverse and longitudinal views by ultrasound-trained emergency physicians. Results: Renal point-of-care ultrasound exams from 140 kidneys performed in the ED were enrolled in the study. The sensitivity and specificity of longitudinal ultrasound views compared with a combination of longitudinal and transverse ultrasound views of the kidney as a gold standard were 84.3% (95% confidence interval [CI], 77.2-89.9) and 92.9% (95% CI, 87.3-96.5), the positive predictive value was 92.2% (95% CI, 86.1-96.2), and the negative predictive value was 85.5% (95% CI, 78.9-90.7). The positive and negative likelihood ratios were 11.8 (95% CI, 6.5-21.5) and 0.2 (95% CI, 0.1-0.2), respectively. Conclusions: Longitudinal views of the kidney on ultrasound showed good sensitivity and specificity to detect the presence of hydronephrosis compared with a combination of longitudinal and transverse ultrasound views of the kidney. However, a combination of longitudinal and transverse ultrasound views may still be warranted in high-risk patients or in those with inadequate visualization of the upper pole of the kidney.

Computed Tomography in Emergency Diagnosis and Management Considerations of Small Bowel Obstruction for Surgical vs. Non-surgical Approach.

BACKGROUND: Background: Small Bowel Obstruction (SBO) accounts for 15% of abdominal pain complaints referred to emergency departments and imposes significant financial burdens on the healthcare system. The most common symptom and sign of SBO is the absence of stool or flatus passsage and abdominal distension, respectively. Patients who do not demonstrate severe clinical or imaging findings are typically treated with conservative approaches. Patients with clinical signs of sepsis or physical findings of peritonitis are often instantly transferred to the operating room without supplementary imaging assessment. However, in cases where symptoms are non-specific or physical examination is challenging, such as in cases with loss of consciousness, the diagnosis can be complicated. This paper discusses the key findings identifiable on Computed Tomography (CT) which are vital for the emergent triage, proper treatment and appropriate decision making in patients with suspected SBO. METHODS: Narrative review of the literature. RESULTS: CT plays a key role in emergent triage, proper treatment and decision making and provides high sensitivity, specificity, and accuracy in the detection of early-stage obstruction and acute intestinal vascular compromise. CT can also differentiate between various etiologies of SBO entity which is considered an important criterion in the triage of patients into surgical vs. non-surgical treatment. CONCLUSION: There Key CT findings which may suggest a need for surgical treatment include mesenteric edema, lack of the small-bowel feces, bowel wall thickening, fat stranding in the mesentery, and intraperitoneal fluid which are predictive of urgent surgical exploration.

Trauma Computed Tomography in the Modern Era: Not Always Quick and Safe.

BACKGROUND: Computed tomography (CT) has emerged as the diagnostic modality of choice in trauma patients. Recent studies suggest its use in hemodynamically unstable patients is safe and potentially lifesaving; however, the incidence of adverse events (AE) during the trauma CT scanning process remains unknown. STUDY DESIGN: Over a 6-month period at a Level 1 trauma center, data on patients undergoing trauma CT (whole-body CT (WBCT) +/- additional CT studies) were prospectively collected. All patients requiring a trauma team activation (TTA) were included. Adverse events and specific time intervals were recorded from the time of TTA notification to the time of return to the resuscitation bay from the CT suite. RESULTS: Of the 94 consecutive patients included in the study, 47.9% experienced 1 or more AE. Median duration away from the resuscitation bay for all patients was 24 minutes. Patients with AE spent a significantly longer time away from the resuscitation bay and had longer scan times. Vasopressor support and ongoing transfusion requirement at the time of CT scanning were associated with AE. CONCLUSION: Adverse events of varying clinical significance occur frequently in patients undergoing emergent trauma CT. A standard trauma CT protocol could improve the efficiency and safety of the scanning process.

Predicting clinical outcomes in COVID-19 using radiomics on chest radiographs.

OBJECTIVES: For optimal utilization of healthcare resources, there is a critical need for early identification of COVID-19 patients at risk of poor prognosis as defined by the need for intensive unit care and mechanical ventilation. We tested the feasibility of chest X-ray (CXR)-based radiomics metrics to develop machine-learning algorithms for predicting patients with poor outcomes. METHODS: In this Institutional Review Board (IRB) approved, Health Insurance Portability and Accountability Act (HIPAA) compliant, retrospective study, we evaluated CXRs performed around the time of admission from 167 COVID-19 patients. Of the 167 patients, 68 (40.72%) required intensive care during their stay, 45 (26.95%) required intubation, and 25 (14.97%) died. Lung opacities were manually segmented using ITK-SNAP (open-source software). CaPTk (open-source software) was used to perform 2D radiomics analysis. RESULTS: Of all the algorithms considered, the AdaBoost classifier performed the best with AUC = 0.72 to predict the need for intubation, AUC = 0.71 to predict death, and AUC = 0.61 to predict the need for admission to the intensive care unit (ICU). AdaBoost had similar performance with ElasticNet in predicting the need for admission to ICU. Analysis of the key radiomic metrics that drive model prediction and performance showed the importance of first-order texture metrics compared to other radiomics panel metrics. Using a Venn-diagram analysis, two first-order texture metrics and one second-order texture metric that consistently played an important role in driving model performance in all three outcome predictions were identified. CONCLUSIONS: Considering the quantitative nature and reliability of radiomic metrics, they can be used prospectively as prognostic markers to individualize treatment plans for COVID-19 patients and also assist with healthcare resource management. ADVANCES IN KNOWLEDGE: We report on the performance of CXR-based imaging metrics extracted from RT-PCR positive COVID-19 patients at admission to develop machine-learning algorithms for predicting the need for ICU, the need for intubation, and mortality, respectively.

Current comments on contrast media administration in patients with renal insufficiency.

Contrast media administration has been associated with complications such as nephropathy, cardiovascular morbidity, and neurovascular events, particularly in patients with renal insufficiency. This association has been questioned in recent studies. This review was performed to summarize the most current evidence on contrast induced nephropathy (CIN), contributing factors, and considerations in patients with renal insufficiency. The risk of CIN was over-estimated by the previous studies, due to a lack of control groups or presence of non-randomized control groups, which led to a selection bias. However, the thresholds associated with an increased risk of CIN are controversial and require risk-benefit analysis on an individual basis. Regarding the administration of contrast media (CM) in the emergency setting, the majority of studies suggested that CM exposure does not meaningfully increase the risk of acute kidney injury in critically ill patients (including trauma patients). Several strategies have been suggested to reduce the risk of CIN, including volume expansion to increase renal blood flow, sodium bicarbonate or N-acetylcysteine administration, and use of low-osmolal contrast media in end-stage renal disease.

Responding to coronavirus disease 2019: LA County hospital experience.

The coronavirus disease 2019 (COVID-19) has rapidly spread across the world since first being identified in Wuhan, China, in late 2019. In order to prepare for the surge of patients and the corresponding increase in radiology exams, clear and detailed policies need to be implemented by hospitals and radiology departments. In this article, we highlight the experiences and policies at LAC+USC Medical Center, the largest single provider of healthcare in LA County. Our policies aim to reduce the risk of transmission, guide patient management and workflow, preserve and effectively allocate resources, and be responsive to changing dynamics. We hope this communication may help other institutions in dealing with this pandemic as well as future outbreaks.

Abbreviated MRI of the foot in patients with suspected osteomyelitis.

PURPOSE: To determine the diagnostic accuracy of an abbreviated magnetic resonance imaging (MRI) protocol of the foot for the diagnosis of osteomyelitis in patients with acute foot infection. METHODS: This retrospective study evaluated adult patients (age 18 and over) visiting an academic medical center from 1 January 2013 to 31 December 2015 who were imaged with MRI for suspected acute pedal osteomyelitis. Examinations were performed utilizing the departmental standard protocol. All examinations were retrospectively interpreted by five radiologists under two protocols: a reference standard protocol consisting of all non-contrast sequences obtained at initial acquisition and an abbreviated protocol consisting of only coronal T1-weighted and sagittal T2-weighted fast multiplanar inversion-recovery (FMPIR) sequences. Interpretation of the two imaging subsets was separated in time by at least 6 weeks for each reader. Each examination was assigned a score to represent one of four diagnostic categories: normal; soft tissue infection without bone changes or bone changes specific to a non-infectious etiology; nonspecific bone marrow changes; or bone changes specific for osteomyelitis. Diagnostic accuracy of both protocols was determined based on clinical diagnosis and treatment of osteomyelitis, and histopathology when available. RESULTS: One hundred and two MRI examinations met inclusion criteria; participants ranged in age from 26 to 91 years, with a mean age of 59 years. Seventy examinations were performed for male participants (69%) and 32 for female participants (31%). Thirty-five had a confirmed diagnosis of osteomyelitis, while the remainder (n = 67) did not. An average of 6 non-contrast sequences was performed during each examination. The most common protocol (53/102 examinations) was comprised of the following 6 sequences: axial T1-weighted, axial fat-saturated proton density, sagittal T1-weighted, sagittal T2-weighted FMPIR, coronal T1-weighted, and coronal fat-saturated proton density. After patient positioning, the abbreviated protocol sequences (sagittal T2-weighted FMPIR and coronal T1-weighted) were performed in an average total of 8 min. The reference standard protocol required an average of 22 min to complete 6 sequences. Averaged across all readers, the AUC for the reference standard full protocol and the abbreviated protocols were 0.843 and 0.873, respectively. The difference in AUC between protocols was not statistically significant (p = 0.1297), with the abbreviated protocol showing a non-significantly greater AUC. CONCLUSIONS: An abbreviated MRI protocol, including only coronal T1-weighted and sagittal T2-weighted FMPIR images, is non-inferior to standard MRI protocol for the diagnosis of acute pedal osteomyelitis. It should be considered as a diagnostic alternative for reducing imaging time and improving patient access to MRI.