Radiologists are increasingly recommending follow-up of chest radiographs: a 10-year review.

PURPOSE: To assess for changes in trends of GP chest radiograph reporting over a 10-year period and to assess if there has been a change in recommendations for follow-up. METHODS: Retrospective study of an Irish tertiary referral center. The total number of GP-referred chest x-rays performed per year from 2007 to 2017 are recorded. One-hundred male/100 female GP-referred chest x-rays are chosen at random from NIMIS data for each of 2007, 2010, 2013, and 2017. Reports are analyzed with regard to abnormal findings, recommendation for follow-up, and yield of follow-up imaging. RESULTS: There were 4917 GP CXRs performed in 2007, 4856 in 2010, 5561 in 2013, and 6492 in 2017. Follow-up was recommended in 17 studies(8.5%) in 2007, 19 studies(9.5%) in 2010, 22 studies(11%) in 2013, and 27 studies(13.5%) in 2017. Indications for follow-up recommendation were largely to ensure resolution of infection (52%) or for nodule surveillance (43%). There has been a notable increase in lung nodule follow-up, with suggested follow-ups increasing from 6 in 2007, to 7 in 2010, 9 in 2013, and 14 in 2017, an increase of 58%. CONCLUSION: Along with the increase in the quantity of GP-referred chest radiographs over the past 10 years, suggestions for follow-up have increased, particularly for nodule surveillance. Reasons for this increase may include lack of availability of CT to GPs for lung cancer screening, insensitivity of plain radiographs to early cancer detection, and possible fear of litigation for missing lesions, making radiologists more cautious.

Enteritis and Severe Abdominal Pain as the First Presentation of Covid-19.

Presentation A male patient with no significant past medical history presented to emergency department with progressive in severity abdominal pain, associated with mild nausea and diarrhea. No other significant symptoms were reported. Diagnosis On investigation with CT, duodenojejunitis was diagnosed as the cause of abdominal pain. Lung basal changes were also visualized and subsequently proven to be secondary to Covid-19 infection. Treatment After few days of hospitalization and supportive treatment, the patient improved clinically and was discharged. Conclusion Covid-19 infection typically presents with respiratory symptoms associated with fever and myalgia. Anorexia, diarrhea and nausea have been reported. Severe abdominal pain is rare, particularly as the initial presenting compliant. It is important to be aware of the varied clinical presentations that may occur in Covid-19, including isolated gastrointestinal symptoms. This will allow to increase the timely detectability of infected patients and more effective contact control measures.

Incidence of Asymptomatic Chiari Malformation

Aim The aim of this study is to define the incidence of asymptomatic Chiari malformation in an Irish population. Methods MRIs performed over 24 months were analysed. Exclusion criteria include: space occupying lesion, hydrocephalus, Chiari symptoms and inadequate views. Data were analysed to give incidence of asymptomatic Chiari and to analyze the relationship between symptom and position of the cerebellar tonsils (Chi square and Fishers exact test). Results Sample Characteristics: 147 patients (Male = 65: Female = 82), age range 15 to 93 years (M age = 53.35, SD= 16.67). 2%had a Chiari malformation (n=2). There was no significant association between symptom and tonsil position (Fishers exact test, ² (8) = 9.98, p = .23.) Conclusion This study shows an asymptomatic Chiari Malformation rate of 2%. This study supports the idea that in asymptomatic patients, a tonsil herniation of up to 5 millimeters may be an incidental and inconsequent finding.

Are we Over-Imaging the Obese Patient with Suspected Pulmonary Embolus in Ireland

Aims To assess if there was a significant difference in the number of positive studies for pulmonary embolism between obese and non obese patients. Methods A retrospective analysis of all CTPAs performed in our institution over one year in patients aged 18-50 was performed. Data regarding the diagnosis of pulmonary embolism, the presence of airways disease, other significant chest findings, D dimer values and demographic data including a BMI surrogate was obtained. Results Two hundred and thirty CTPAs were performed in our institution over 12 months. Two hundred and twenty-one were included for analysis, of which 129 were male and 92 were female. Sixty-nine (31%) patients were classified as obese. Eleven (16%) of these had positive studies. One hundred and fifty-two patients were in the non obese category, of which 24 (15%) had positive studies. Conclusions We are not over imaging the obese patient, but are over imaging patients in general with suspected PE, but are exposing a significant number overall, to unnecessary radiation.

Peripherally Inserted Central Catheters (PICCs) and Potential Cost Savings and Shortened Bed Stays In an Acute Hospital Setting.

Peripheral inserted central catheters (PICCs) have increasingly become the mainstay of patients requiring prolonged treatment with antibiotics, transfusions, oncologic IV therapy and total parental nutrition. They may also be used in delivering a number of other medications to patients. In recent years, bed occupancy rates have become hugely pressurized in many hospitals and any potential solutions to free up beds is welcome. Recent introductions of doctor or nurse led intravenous (IV) outpatient based treatment teams has been having a direct effect on early discharge of patients and in some cases avoiding admission completely. The ability to deliver outpatient intravenous treatment is facilitated by the placement of PICCs allowing safe and targeted treatment of patients over a prolonged period of time. We carried out a retrospective study of 2,404 patients referred for PICCs from 2009 to 2015 in a university teaching hospital. There was an exponential increase in the number of PICCs requested from 2011 to 2015 with a 64% increase from 2012 to 2013. The clear increase in demand for PICCs in our institution is directly linked to the advent of outpatient intravenous antibiotic services. In this paper, we assess the impact that the use of PICCs combined with intravenous outpatient treatment may have on cost and hospital bed demand. We advocate that a more widespread implementation of this service throughout Ireland may result in significant cost savings as well as decreasing the number of patients on hospital trollies.

Primary Renal Carcinoid - A Case Report.

Carcinoid tumours in the abdomen are uncommon, but typically occur in the gastrointestinal tract. Primary renal carcinoid is an extremely rare tumour, poorly described in the literature. We describe an unusual case where an atypical renal mass on imaging led to a preoperative diagnosis of renal carcinoid on imaging guiding biopsy.

Prevalence and Seasonal Variation of Incidental MRI Paranasal Inflammatory Changes in an Asymptomatic Irish Population.

Inflammatory changes in the paranasal sinuses are a common incidental finding on magnetic resonance imaging (MRI) of the head and neck. This study aimed to assess the prevalence and seasonal variation of inflammatory paranasal sinus changes in an asymptomatic Irish population. Retrospective analysis was performed on 221 patients who underwent brain MRI at the time points of winter and summer. T2-weighted sequences were evaluated for paranasal sinus disease. Nearly half the patients in the study exhibited morphological paranasal sinus changes on imaging suggesting that these could be considered a normal variant. Correlation of imaging findings with clinical symptoms and signs remain crucial to the diagnosis of sinusitis.

Frequency and analysis of non-clinical errors made in radiology reports using the National Integrated Medical Imaging System voice recognition dictation software.

BACKGROUND: Voice recognition (VR) dictation of radiology reports has become the mainstay of reporting in many institutions worldwide. Despite benefit, such software is not without limitations, and transcription errors have been widely reported. AIM: Evaluate the frequency and nature of non-clinical transcription error using VR dictation software. METHODS: Retrospective audit of 378 finalised radiology reports. Errors were counted and categorised by significance, error type and sub-type. Data regarding imaging modality, report length and dictation time was collected. RESULTS: 67 (17.72 %) reports contained ≥1 errors, with 7 (1.85 %) containing 'significant' and 9 (2.38 %) containing 'very significant' errors. A total of 90 errors were identified from the 378 reports analysed, with 74 (82.22 %) classified as 'insignificant', 7 (7.78 %) as 'significant', 9 (10 %) as 'very significant'. 68 (75.56 %) errors were 'spelling and grammar', 20 (22.22 %) 'missense' and 2 (2.22 %) 'nonsense'. 'Punctuation' error was most common sub-type, accounting for 27 errors (30 %). Complex imaging modalities had higher error rates per report and sentence. Computed tomography contained 0.040 errors per sentence compared to plain film with 0.030. Longer reports had a higher error rate, with reports >25 sentences containing an average of 1.23 errors per report compared to 0-5 sentences containing 0.09. CONCLUSION: These findings highlight the limitations of VR dictation software. While most error was deemed insignificant, there were occurrences of error with potential to alter report interpretation and patient management. Longer reports and reports on more complex imaging had higher error rates and this should be taken into account by the reporting radiologist.

Examining the End-User Experience of the National Integrated Medical Imaging System (NIMIS).

The National Integrated Medical Imaging System (NIMIS) is used to store and retrieve medical imaging studies in Ireland. The purpose of this audit was to obtain feedback from its end-users in relation to key NIMIS functionality and to understand their perception of its existing interface while identifying potential improvements. The results showed that, while the majority of respondents are satisfied with NIMIS, they identified a number of areas of concern. These included difficulty in identifying the appropriate code for a study, 88 (34%); dissatisfaction with ordering and viewing scans, 82 (32%); and a need for improved communication between end-users and local Radiology departments, with 104 (40%) unsure when to contact the department and 137 (53%) dissatisfied with the feedback they received in relation to requests. Respondents indicated that addressing these issues would improve the NIMIS end-user experience while allowing it to continue to meet current and future clinical needs.

The improved accuracy of planar bone scintigraphy by adding single photon emission computed tomography (SPECT-CT) to detect skeletal metastases from prostate cancer.

BACKGROUND: Planar bone scintigraphy (PBS) is a standard radiological technique to detect skeletal metastases from prostate cancer (PC), the addition of SPECT-CT to PBS improves its diagnostic accuracy. The aim of this study was to assess the additional value of targeted SPECT-CT with PBS in detecting skeletal metastasis form prostate cancer, considering resource implications in an Irish hospital setting. METHODS: 54 PC patients with increased radiotracer uptake on PBS were retrospectively recruited from 2012 to 2013. All underwent targeted evaluation with SPECT-CT. PBS and SPECT-CT images were reviewed by two nuclear medicine radiologists and reported independently. The final diagnosis was made based on the CT finding corresponding to the area of radiotracer uptake. RESULTS: The mean age was 70.9 years (48-88 years) and median PSA at presentation was 13.9 ng/ml (4.2-215 ng/ml). 68.5 % (n = 37) men received treatment for PC while 31.5 % (n = 17) patients had not received treatment prior to PBS. 164 areas of increased radiotracer uptake were identified on PBS; 13 areas were characterised as metastatic on SPECT-CT; iliac bone (n = 3), ribs (n = 1), skull (n = 2), sacrum (n = 1), ischium (n = 1), femur (n = 3), thoracic spine (n = 1) and cervical spine (n = 1). 151 areas were characterised as benign on SPECT-CT. One area of increased radiotracer uptake in the ribs was subsequently described as indeterminate after evaluation with SPECT-CT. CONCLUSION: SPECT-CT improves the diagnostic accuracy of PBS in detecting skeletal metastasis from PC and is superior to PBS alone in differentiating benign from malignant lesions. Notwithstanding resource implications of increased cost, specialist equipment and specialist manpower hours; we recommend the use of SPECT-CT in conjunction with PBS for targeted evaluation of suspicious bony lesions in this cohort of patients.

Imaging features of poorly controlled congenital adrenal hyperplasia in adults.

Congenital adrenal hyperplasia (CAH) is a genetic autosomal recessive condition most frequently as a result of a mutation in the 21-hydroxylase enzyme gene. Patients with poorly controlled CAH can manifest characteristic imaging findings as a result of adrenocorticotrophic hormone stimulation or the effects of cortisol precursor excess on various target organs. We present a spectrum of imaging findings encountered in adult patients with poorly treated CAH, with an emphasis on radiological features and their clinical relevance.

A retrospective analysis of oesophageal thickening diagnosed as an incidental finding at Computed Tomography with endoscopic and histological correlation.

PURPOSE: A retrospective analysis of oesophageal thickening diagnosed as an incidental finding at Computed Tomography (CT) with endoscopic and histological correlation. MATERIALS AND METHODS: Retrospective review of CT studies at a University Teaching Hospital in a 3-month period was performed and those who had a correlating upper gastrointestinal endoscopy within 6 months of the CT were included in the study. The findings were correlated with results from endoscopy to histology. The CT images were reviewed by two Consultant Radiologists with a sub-speciality interest in Abdominal Imaging prior to correlation with endoscopic and histology results from the patient's medical records. RESULTS: Three hundred and sixty-one patients met the inclusion, of which 20% (n = 72) were felt to have a thickened distal oesophagus on CT. Of these, 30.6% (n = 22) had a mass or abnormal mucosal thickening on endoscopy, found to be malignant on subsequent biopsy in 50% (n = 11) and Barrett's epithelium in 50% (n = 11), a statistically significant finding compared to those who had a normal CT. CONCLUSION: Endoscopic evaluation is recommended for incidental oesophageal thickening detected at Computed Tomography to exclude underlying malignancy.

Added Value of Stroke Protocol MRI Following Negative Initial CT in the Acute Stroke Setting.

The aim of the study was to determine the added value of stroke protocol MRI following negative initial CT brain in the acute stroke setting. A retrospective study was performed over a 6 month period in a tertiary referral stroke centre. Patients were selected from the stroke and radiology databases. Inclusion criteria: clinical stroke syndrome, negative initial CT with subsequent MRI study with diffusion weighted sequences. Ninety two patients were reviewed and 73 (M:F of 39:34, mean age 62.1 ± 14.0 years) met the inclusion criteria. Twenty MRI studies (27.4%) were positive for acute/subacute ischaemia in the setting of a normal initial CT. The average time interval between initial CT and MRI brain imaging was 4.7 ± 2.6 days. Whilst CT continues to be the first line imaging investigation for acute stroke, MRI has substantial added value following negative initial CT in the diagnosis of stroke.

Inferior vena cava filter insertion and retrieval patterns in a tertiary referral centre in Ireland.

BACKGROUND: Inferior vena cava (IVC) filters are widely used in clinical practice to prevent large, clinically significant pulmonary emboli. Modern filters are designed to be retrievable within a specific time window; however, many become lost to follow-up. AIM: To examine the insertion and retrieval patterns of IVC filters in a tertiary referral teaching hospital in Ireland. METHODS: A retrospective review of all IVC filter insertions and retrievals was performed in a tertiary referral university teaching hospital which incorporates the national referral centre for pelvic and acetabular trauma, over a 22-month period. RESULTS: Fifty-seven patients underwent IVC filter insertion with 100% technical success. The most common indication was prophylaxis in patients at high risk of deep venous thrombosis or pulmonary emboli (64.9%), followed by patients with contra-indication to anticoagulation (24.6%) and breakthrough thromboembolic events despite anticoagulation (10.5%). IVC filter retrievals were attempted in 48.9% of patients with a success rate of 86.9%. The mean dwell time for retrieved IVC filters was 159.4 days. CONCLUSION: Inferior vena cava filter insertion and retrieval patterns in our centre were comparable to trends reported internationally with scope for improvement in terms of filter retrieval rates and minimising filter dwell time. Particular vigilance is required in younger patients where the indication for filter insertion was prophylactic.

Analysis of the last decade of weekend out-of-hours CT imaging: how have things changed?

CT has become an invaluable diagnostic tool. The clinical applications and technological capacity of CT has continued to increase. There is an increasing demand for radiology services including during weekend on-call hours. The objective of this study was to assess the trend in weekend CT imaging requests over a ten-year period form 2001-2010. Electronic data was retrieved from the hospital Radiology Inpatient System. In total 8530 CT scans were performed during weekend on-call hours. Over the decade weekend imaging grew from 466 to 1448 (210.7%) CT examinations. CT brain imaging accounted for 3944 of the total 8530(46%) and this was a 126% increase. A ten-fold, eight-fold and three-fold increase occurred in adult CT thorax, CT pelvis and CT abdominal imaging respectively. These results demonstrate rising demand on radiology services and need to plan for continued future growth. Radiology and emergency departments need to prepare and develop pathways to deal with this projected growth.