Hematocrit and lactate trends help predict outcomes in trauma independent of CT and other clinical parameters.

Background: Hematocrit and lactate have an established role in trauma as indicators of bleeding and cell death, respectively. The wide availability of CT imaging and clinical data poses the question of how these can be used in combination to predict outcomes. Purpose: To assess the utility of hematocrit or lactate trends in predicting intensive care unit (ICU) admission and hospital length of stay (LOS) in patients with torso trauma combined with clinical parameters and injury findings on CT. Materials and Methods: This was a single-center retrospective study of adults with torso trauma in one year. Trends were defined as a unit change per hour. CT findings and clinical parameters were explanatory variables. Outcomes were ICU admission and hospital LOS. Multivariate logistic and negative binomial regression models were used to calculate the odds ratio (OR) and incident rate ratio (IRR). Results: Among 840 patients, 561 (72% males, age 39 ± 18) were included, and 168 patients (30%) were admitted to the ICU. Decreasing hematocrit trend [OR 2.54 (1.41-4.58), p = 0.002] and increasing lactate trend [OR 3.85 (1.35-11.01), p = 0.012] were associated with increased odds of ICU admission. LOS median was 2 (IQR: 1-5) days. Decreasing hematocrit trend [IRR 1.37 (1.13-1.66), p = 0.002] and increasing lactate trend [2.02 (1.43-2.85), p < 0.001] were associated with longer hospital LOS. Conclusion: Hematocrit and lactate trends may be helpful in predicting ICU admission and LOS in torso trauma independent of organ injuries on CT, age, or admission clinical parameters.

Utilization of a two-material decomposition from a single-source, dual-energy CT in acute traumatic vertebral fractures.

Purpose: The purpose of this study is to utilize a two-material decomposition to quantify bone marrow edema on a dual-energy computed tomography (DECT) scanner at the cervical, thoracic, and lumbar spine acute fractures in correlation with short tau inversion recovery (STIR) hyperintensity on magnetic resonance imaging (MRI) in comparison with the normal bone marrow. Materials and methods: This retrospective institutional review board-approved study gathered patients over 18 years old who had acute cervical, thoracic, or lumbar spinal fractures scanned on a DECT scanner. Those who had a spinal MRI done with bone marrow STIR hyperintensity within 3 weeks of the DECT were included. The water (calcium) and fat (calcium) density (mg/cm3) measurements of the region of interest of the bone marrow were obtained at a normal anatomic equivalent site and at the fracture site where STIR hyperintensity was noted on MRI. A statistical analysis was performed using the paired t-test and Wilcoxon signed rank test (p > 0.05). Results: A total of 20 patients met the inclusion criteria (males n = 17 males, females n = 3). A total of 32 fractures were analyzed: 19 cervical and 13 thoracolumbar. There were statistically significant differences in the water (43 ± 24 mg/cm3) and fat (36 ± 31 mg/cm3) density (mg/cm3) at the acute thoracic and lumbar spine fractures in correlation with edema on STIR images (both paired t-test <0.001, both Wilcoxon signed ranked test p < 0.01). There were no significant differences in the water (-10 ± 46 mg/cm3) or fat (+7 ± 50 mg/cm3) density (mg/cm3) at the cervical spine fractures. Conclusion: The DECT two-material decomposition using water (calcium) and fat (calcium) analyses has the ability to quantify a bone marrow edema at the acute fracture site in the thoracic and lumbar spine.

The Public Perception of CT Colonography Versus Colonoscopy via Sentiment Analysis of Social Media.

PURPOSE: The purpose of this study was to understand the public perception of CT colonography (CTC) in comparison with optical colonoscopy as a colorectal cancer screening technique. METHODS: In this observational study, all English-language tweets from January 1, 2015, until September 1, 2021, containing terms related to CTC and terms related to optical colonoscopy were collected. The tweets were given sentiment scores using Twitter-roBERTa-base, a natural language processing model. These scores were then used to classify tweets into positive, neutral, and negative categories. The numbers of negative, positive, and neutral tweets were tabulated. RESULTS: A total of 4,709 tweets from 2,194 users relating to CTC were collected. Of these tweets, 9.81% were negative, 68.52% were neutral, and 21.63% were positive. In comparison, a total of 445,969 tweets from 261,209 users were collected relating to optical colonoscopy. Of these tweets, 31.8% were negative, 51.3% were neutral, and 16.9% were positive. CONCLUSIONS: The public awareness of CTC remains limited in comparison with optical colonoscopy, with Twitter volume relating to CTC being about 1% the volume for optical colonoscopy. There was a higher proportion of negative tweets regarding colonoscopy. The lower proportion of negative tweets regarding CTC may be helpful in encouraging its use as an alternative to optical colonoscopy, with the aim of increasing uptake of colorectal cancer screening.

Social determinants of health and the prediction of missed breast imaging appointments.

BACKGROUND: Predictive models utilizing social determinants of health (SDH), demographic data, and local weather data were trained to predict missed imaging appointments (MIA) among breast imaging patients at the Boston Medical Center (BMC). Patients were characterized by many different variables, including social needs, demographics, imaging utilization, appointment features, and weather conditions on the date of the appointment. METHODS: This HIPAA compliant retrospective cohort study was IRB approved. Informed consent was waived. After data preprocessing steps, the dataset contained 9,970 patients and 36,606 appointments from 1/1/2015 to 12/31/2019. We identified 57 potentially impactful variables used in the initial prediction model and assessed each patient for MIA. We then developed a parsimonious model via recursive feature elimination, which identified the 25 most predictive variables. We utilized linear and non-linear models including support vector machines (SVM), logistic regression (LR), and random forest (RF) to predict MIA and compared their performance. RESULTS: The highest-performing full model is the nonlinear RF, achieving the highest Area Under the ROC Curve (AUC) of 76% and average F1 score of 85%. Models limited to the most predictive variables were able to attain AUC and F1 scores comparable to models with all variables included. The variables most predictive of missed appointments included timing, prior appointment history, referral department of origin, and socioeconomic factors such as household income and access to caregiving services. CONCLUSIONS: Prediction of MIA with the data available is inherently limited by the complex, multifactorial nature of MIA. However, the algorithms presented achieved acceptable performance and demonstrated that socioeconomic factors were useful predictors of MIA. In contrast with non-modifiable demographic factors, we can address SDH to decrease the incidence of MIA.

Use of MR in Pancreaticobiliary Emergencies.

This article presents the MR protocols, imaging features, diagnostic criteria, and complications of commonly encountered emergencies in pancreaticobiliary imaging, which include pancreatic trauma, bile leak, acute cholecystitis, biliary obstruction, and pancreatitis. Various classifications and complications that can arise with these conditions, as well as artifacts that may mimic pathology, are also included. Finally, the emerging utility of abbreviated MR protocols is discussed.

Quantification of bone marrow edema using dual-energy CT at fracture sites in trauma.

PURPOSE: The purpose of our study was to analyze the change in water and fat density within the bone marrow using the GE Revolution dual-energy computed tomography (DECT) platform using two-material decomposition analyses at extremity, spine, and pelvic fracture sites compared to normal bone marrow at equivalent anatomic sites in adult patients who sustained blunt trauma. METHODS: This retrospective study included 26 consecutive adults who sustained blunt torso trauma and an acute fracture of the thoracolumbar vertebral body, pelvis, or upper and lower extremities with a total of 32 fractures evaluated. Two-material decomposition images were analyzed for quantitative analysis. Statistical analysis was performed using the paired t-test and Shapiro-Wilk test for normality. RESULTS: There were statistically significant differences in the water and fat densities in the bone marrow at the site of an extremity, vertebral body, or pelvic fracture when compared to the normal anatomic equivalent (p < 0.01). CONCLUSION: In this preliminary study, DECT basis material images, using water (calcium) and fat (calcium) decomposition illustrated significant differences in water and fat content between fracture sites and normal bone in a variety of anatomical sites.

The Impact of Social Determinants of Health on Lung Cancer Screening Utilization.

PURPOSE: The purpose of this study was to understand how social determinants of health might influence lung cancer screening (LCS) adherence. METHODS: All LCS low-dose CT appointments scheduled at an urban, tertiary care academic medical center in the New England region between January 1, 2015, and December 31, 2018, were included. Demographics, insurance type, information on social determinants of health, and appointment status were obtained from the electronic medical records. Multivariate logistic regression was performed to evaluate the associations between the appointment status and the explanatory variables. RESULTS: During the study period, 2,797 patients had 4,747 scheduled LCS appointments. Forty-one percent of patients had at least one missed appointment, and 32.7% of all scheduled appointments were missed. The retention rate of patients after the baseline examination was approximately 50%. Self-reported Black race was independently associated with 1.5 times the odds of missing appointments compared with White race (P = .012). Patients with Medicaid had 6.1 times the odds of missing appointments compared with patients with private insurance and 4.6 times the odds of missing appointments compared with patients with Medicare (P < .0001). Housing insecurity was a risk factor for failing to follow up after the baseline examination, with an odds ratio of 5.3 (P = .0013). CONCLUSIONS: The high rate of missed LCS appointments underscores the need to improve screening compliance. The identification of specific social determinants of health that contribute to disparities in access to LCS could empower policymakers, hospital systems, and providers to use targeted interventions to promote more equitable access.

Acute cholecystitis: diagnostic value of dual-energy CT-derived iodine map and low-keV virtual monoenergetic images.

PURPOSE: To compare conventional and dual-energy CT (DECT) for the diagnosis of acute cholecystitis and gangrene. METHODS: Fifty-seven consecutive adult patients with abdominal pain who underwent IV contrast-enhanced abdominal DECT on a dual-layer (dlDECT) or rapid-switching (rsDECT) scanner from September, 2018 to April, 2021 with cholecystectomy and pathology-confirmed cholecystitis were retrospectively reviewed, and compared with 57 consecutive adult patients without cholecystitis from the same interval scanned with DECT. Images were reviewed independently by two abdominal radiologists with 12 and 16 years of experience in two sessions 4 weeks apart, blinded to clinical data. Initially, only blended reconstructions (simulating conventional single-energy CT images) were reviewed (CT). Subsequently, CT and DECT reconstructions including low-keV virtual monoenergetic images and iodine maps were reviewed. Gallbladder fossa hyperemia, pericholecystic fluid, subjective presence of gangrene, heterogeneous wall enhancement, sloughed membranes, intramural air, abscess, overall impression of the presence of acute cholecystitis, and intramural iodine density were assessed. RESULTS: Gallbladder fossa hyperemia was detected with increased sensitivity on DECT (R1, 61.4%; R2, 75.4%) vs. CT (R1, 22.8%; R2, 15.8%). DECT showed increased sensitivity for gangrene (R1, 24.6%; R2, 38.6%) vs. CT (R1, 5.3%; R2, 14%), heterogeneous wall enhancement (DECT: R1, 33.3%; R2, 63.2% vs. CT: R1, 7%; R2, 31.6%), and cholecystitis (DECT: R1, 86%; R2, 89.5% vs. CT: R1, 77.2%; R2, 70.2%). In addition, DECT was more sensitive for the detection of acute cholecystitis (R1, 86%; R2, 89.5%) vs. CT (R1, 77.2%; R2, 70.2%). Iodine density threshold of 1.2 mg/ml, 0.8 mg/mL, and 0.5 mg/mL showed specificity for gangrenous cholecystitis of 78.26%, 86.96%, and 95.65%, respectively, using the rsDECT platform. CONCLUSION: DECT showed improved sensitivity compared to conventional CT for detection of acute cholecystitis. Iodine density measurements may be helpful to diagnose gangrene.

American Society of Emergency Radiology Multicenter Blunt Splenic Trauma Study: CT and Clinical Findings.

Background Treatment of blunt splenic trauma (BST) continues to evolve with improved imaging for detection of splenic vascular injuries. Purpose To report on treatments for BST from 11 trauma centers, the frequency and clinical impact of splenic vascular injuries, and factors influencing treatment. Materials and Methods Patients were retrospectively identified as having BST between January 2011 and December 2018, and clinical, imaging, and outcome data were recorded. Patient data were summarized descriptively, both overall and stratified by initial treatment received (nonoperative management [NOM], angiography, or surgery). Regression analyses were used to examine the primary outcomes of interest, which were initial treatment received and length of stay (LOS). Results This study evaluated 1373 patients (mean age, 42 years ± 18; 845 men). Initial treatments included NOM in 849 patients, interventional radiology (IR) in 240 patients, and surgery in 284 patients. Rates from CT reporting were 22% (304 of 1373) for active splenic hemorrhage (ASH) and 20% (276 of 1373) for contained vascular injury (CVI). IR management of high-grade injuries increased 15.6%, from 28.6% (eight of 28) to 44.2% (57 of 129) (2011-2012 vs 2017-2018). Patients who were treated invasively had a higher injury severity score (odds ratio [OR], 1.04; 95% CI: 1.02, 1.05; P < .001), lower temperature (OR, 0.97; 95% CI: 0.97, 1.00; P = .03), and a lower hematocrit (OR, 0.96; 95% CI: 0.93, 0.99; P = .003) and were more likely to show ASH (OR, 8.05; 95% CI: 5.35, 12.26; P < .001) or CVI (OR, 2.70; 95% CI: 1.64, 4.44; P < .001) on CT images, have spleen-only injures (OR, 2.35; 95% CI: 1.45, 3.8; P < .001), and have been administered blood product for fewer than 24 hours (OR, 2.35; 95% CI: 1.58, 3.51; P < .001) compared with those chosen for NOM, after adjusting for key demographic and clinical variables. After adjustment, factors associated with a shorter LOS were female sex (OR, 0.84; 95% CI: 0.73, 0.96; P = .009), spleen-only injury (OR, 0.72; 95% CI: 0.6, 0.86; P < .001), higher admission hematocrit (OR, 0.98; 95% CI: 0.6, 0.86; P < .001), and presence of ASH at CT (OR, 0.74; 95% CI: 0.62, 0.88; P < .001). Conclusion Contained vascular injury and active splenic hemorrhage (ASH) were frequently reported, and rates of interventional radiologic management increased during the study period. ASH was associated with a shorter length of stay, and patients with ASH had eight times the odds of undergoing invasive treatment compared with undergoing nonoperative management. © RSNA, 2021 See also the editorial by Patlas in this issue.

Pancreatic Trauma: Imaging Review and Management Update.

Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ©RSNA, 2020 See discussion on this article by Patlas.

Liver trauma: hepatic vascular injury on computed tomography as a predictor of patient outcome.

OBJECTIVES: To evaluate hepatic vascular injury (HVI) on CT in blunt and penetrating trauma and assess its relationship to patient management and outcome. METHOD AND MATERIALS: This retrospective study was IRB approved and HIPAA compliant. Informed consent was waived. Included were patients ≥ 16 years old who sustained blunt or penetrating trauma with liver laceration seen on a CT performed at our institution within 24 h of presentation over the course of 10 years and 6 months (August 2007-February 2018). During this interval, 171 patients met inclusion criteria (123 males, 48 females; mean age 34; age range 17-80 years old). Presence of HVI was evaluated and liver injury was graded in a blinded fashion by two radiologists using the 1994 and 2018 American Association for the Surgery of Trauma (AAST) liver injury scales. Hospital length of stay and treatment (angioembolization or operative) were recorded from the electronic medical record. Multivariate linear regressions were used to determine our variables' impact on the length of stay, and logistic regressions were used for categorical outcomes. RESULTS: Of the included liver trauma patients, 25% had HVI. Patients with HVI had a 3.2-day longer length of hospital stay on average and had a 40.3-fold greater odds of getting angioembolization compared to those without. Patients with high-grade liver injury (AAST grades IV-V, 2018 criteria) had a 3.2-fold greater odds of failing non-operative management and a 14.3-fold greater odds of angioembolization compared to those without. CONCLUSION: HVI in liver trauma is common and is predictive of patient outcome and management. KEY POINTS: • Hepatic vascular injury occurs commonly (25%) with liver trauma. • Hepatic vascular injury is associated with increased length of hospital stay and angioembolization. • High-grade liver injury is associated with failure of non-operative management and with angioembolization.

Imaging of Gastrointestinal Tract Perforation.

Gastrointestinal tract perforation involving the stomach, duodenum, small intestine, or large bowel occurs as a result of full-thickness gastrointestinal wall injury with release of intraluminal contents into the peritoneal or retroperitoneal cavity. Most cases are associated with high mortality and morbidity, requiring urgent surgical evaluation. Initial patient presentations can be nonspecific with a broad differential, which can delay timely management. This article provides brief overviews of different causes of perforation. Various imaging modalities and protocols are discussed, along with direct and indirect imaging findings of perforation. Specific findings associated with different causes are also described to aid in the diagnosis.

Computed tomography (CT) in the evaluation of bladder and ureteral trauma: indications, technique, and diagnosis.

INTRODUCTION: Trauma to the genitourinary system includes blunt and penetrating injuries to bladder and ureters. These are rare injuries and are overlooked as other abdominal and pelvic injuries often take priority. Delayed diagnosis can lead to significant morbidity and mortality. Computed tomography has taken a central role in the imaging of the ureters and bladder. METHODS: This article reviews the anatomic relationships, mechanisms of injury, and clinical presentation to help physicians determine when bladder and ureteral injuries should be suspected and further imaging should be pursued. Radiologic evaluation of bladder and ureteral injury with CT cystography and CT urography, respectively, will be reviewed. CONCLUSION: CT cystography and CT urography are effective tools in identifying potentially serious injuries to the genitourinary system. Timely recognition of these injuries can be crucial for the overall management and prognosis.

Society of abdominal radiology gastrointestinal bleeding disease-focused panel consensus recommendations for CTA technical parameters in the evaluation of acute overt gastrointestinal bleeding.

PURPOSE: To formulate consensus recommendations for CT angiography technical parameters used to evaluate overt gastrointestinal (GI) bleeding. METHODS: An electronic questionnaire consisting of 17 questions was sent to a panel of 16 radiologists with expertise on the imaging of GI bleeding from the Society of Abdominal Radiology GI Bleeding disease-focused panel to obtain consensus agreement on issues related to CTA technical parameters for imaging overt GI bleeding. A multi-round Delphi method of voting was performed to obtain consensus which was defined as ≥ 80% agreement. RESULTS: Consensus agreement was reached in 15/17 (89%) of the questions including the technique for the administration of IV contrast, the number of phases, scan timing, and image reconstruction. CONCLUSIONS: A panel of experts on the imaging of GI bleeding from the Society of Abdominal Radiology was able to reach consensus on the majority of technical parameters used for CTA of overt GI bleeding. These recommendations should improve the quality of patient care by adopting these minimal technical requirements for optimal exam performance and lead to less variation in the performance of these exams which will facilitate collecting and comparing published data from different centers. These recommendations will need revisions as additional scientific data become available.

Small Bowel Obstruction and Ischemia.

Imaging evaluation of small bowel obstruction (SBO) is essential for determining the appropriate clinical treatment for a patient. The current recommendations for the evaluation of SBO, including protocols, are reviewed. A method for evaluating SBO including the criteria for diagnosis, finding the transition point, determining the cause, and identifying the presence of ischemia is discussed.

Imaging Acetabular Fractures.

Acetabular fractures are encountered by radiologists in a wide spectrum of practice settings. The radiologist's value in the acute and long-term management of acetabular fractures is augmented by familiarity with systematic computed tomography-based algorithms that streamline and simplify Judet-Letournel fracture typing, together with an appreciation of the role of imaging in initial triage, operative decision making, postoperative assessment, prognostication, and evaluation of complications. The steep increase in incidence of acetabular fractures in the elderly over the past several decades places special emphasis on familiarity with geriatric fracture patterns.

Diffusion-weighted imaging of the pericholecystic hepatic parenchyma for distinguishing acute and chronic cholecystitis.

PURPOSE: The purpose of this study is to measure the performance of restricted diffusion of the pericholecystic hepatic parenchyma for distinguishing between acute and chronic cholecystitis. METHODS: The institutional review board approved this HIPAA-compliant retrospective study. Two hundred sixty-six patients presenting with acute right upper quadrant pain between 10/3/2010 and 11/28/2012 undergoing MR within 48 h of equivocal utility of ultrasound (US) were included. Diffusion-weighted imaging (DWI) sequences (b = 0, 600 s/mm2, apparent diffusion coefficient (ADC) maps) were reviewed and graded in a blinded fashion by two abdominal fellowship-trained radiologists for the presence of restricted diffusion in the pericholecystic hepatic parenchyma and the gallbladder wall. Sensitivity, specificity, and inter-observer agreement for individual imaging signs were calculated using surgical pathology as the reference standard for acute cholecystitis. RESULTS: Of the 266 patients, 113 were treated conservatively and 153 underwent cholecystectomy. Restricted diffusion of the pericholecystic hepatic parenchyma showed low sensitivity (reviewer 1, 40%; reviewer 2, 30%) and moderately high specificity (reviewer 1, 84%; reviewer 2, 75%) for distinguishing acute and chronic cholecystitis. Restricted diffusion in the gallbladder wall showed low sensitivity (reviewer 1, 30%; reviewer 2, 7%) and high specificity (reviewer 1, 93%; reviewer 2, 97%) for distinguishing acute and chronic cholecystitis. CONCLUSION: Diffusion-weighted imaging of the pericholecystic hepatic parenchyma shows moderately high specificity for distinguishing between acute and chronic cholecystitis.

Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters.

PURPOSE: To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis. MATERIALS AND METHODS: Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n = 127) male and 56.9% female (n = 168), with mean age 51.9 years (range 18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parameters obtained from medical record review, and modified Hinchey classification with management outcomes. RESULTS: CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P = 0.0001), colonic fistula (13.2% vs. 0.4%, P = 0.0002), extraluminal air (26.4% vs. 9.3%, P = 0.0052), bowel obstruction (5.2% vs. 0.0%, P = 0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P = 0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2 mmHg vs. 128.2 mmHg, P = 0.0220). CONCLUSION: Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.