The role of imaging in the management of non-traumatic subarachnoid hemorrhage: a practical review.

The purpose of this review is to understand the role of imaging in the diagnosis and management of non-traumatic subarachnoid hemorrhage (SAH). SAH is a life-threatening emergency and a relatively common entity, the most common etiology being ruptured aneurysms. Multiple conundrums exist in literature at various steps of its imaging workup: diagnosis, management, and follow-up. We target our review to highlight the most effective practice and suggest efficient workup plans based on literature search, and describe in detail the clinical diagnostic and prognostic scales, role of CT scan, lumbar puncture, and MR, including angiography in the diagnosis and workup of SAH and its complications, and try to simplify the conundrums. Practical knowledge of imaging workup of SAH can help guide correct management of these patients, so as to reduce morbidity and mortality without resource overutilization.

Through-the-Glass Portable Radiography of Patients in Isolation Units: Experience During the COVID-19 Pandemic.

OBJECTIVE. To reduce staff exposure to infection and maintain operational efficiency, we have developed a protocol to image patients using portable chest radiography through the glass of an isolation room. This technique is safe and easy to implement. Images are of comparable quality to standard portable radiographs. CONCLUSION. This protocol, used routinely by our department during the COVID-19 pandemic, can be applied to any situation in which the patient is placed in isolation.

Digital tomosynthesis for detection of ingested foreign objects in the emergency department: a case of razor blade ingestion.

A 46-year-old schizophrenic male presented to the emergency department (ED) after deliberate ingestion of an undetermined number of open razor blades. Abdominal radiograph revealed one razor blade but raised suspicion of a second blade which was subsequently confirmed by digital tomosynthesis (DTS), seen as two razor blades superimposed upon each other placed at slightly different angles. A careful search was made during endoscopy and the two razor blades were retrieved from the stomach and duodenum, respectively. This case illustrates the use of digital tomosynthesis as a smart, timely, cost-effective, and low-dose alternative to conventional computed tomography (CT) that can be conveniently employed in the ED for foreign body localization.

Sedentary Behavior in the Workplace: A Potential Occupational Hazard for Radiologists.

In this study, we sought to quantify the sedentary worklife of the radiologist, a potential health risk. Radiologists of all training levels at our academic institution were surveyed to estimate the levels of at-work and out-of-work sitting. Fitbit One activity monitors were used to measure the at-work activity levels of radiology, pediatric, and internal medicine (IM) residents. Correlation between awareness and utilization of dynamic (sitting or standing, walking, or biking) picture archiving and communication system (PACS) workstations among radiology residents was assessed. Among surveyed radiologists (n = 89), 78% estimated sitting for at least 6 hours per workday. Estimated workplace sitting accounted for most of the total sitting for 81% of respondents. As measured by activity monitors, radiology residents (n = 27) took fewer steps per day (2683 vs 4602 vs 4967) and per hour (294 vs 419 vs 444) and experienced more sedentary time per hour (40.3 vs 36.2 vs 34.9min/h) than IM (n = 15) and pediatric (n = 9) residents. Activity experienced during reading room-based work and interventional work was compared by studying 4 additional radiology residents during both types of rotations. Reading-room activity was low, whereas activity on interventional rotations surpassed average levels for the pediatric and IM residents in our study. Radiology residents' (n = 28) awareness and utilization of dynamic PACS workstations varied among reading rooms, but were generally low-75% reported never or rarely using them. Resident utilization correlated with awareness of dynamic workstations available at our institution (R(2) = 0.64; P = 0.013). In conclusion, radiology residents in our study led more sedentary worklives compared with residents from other specialties and took minimal advantage of available tools to mitigate this. Potential health risks of inactivity justify individual and departmental efforts to limit workplace inactivity among radiologists.

Harlequin testicle and other uncommon pathologies masquerading at routine scrotal ultrasound.

Many scrotal conditions manifest similarly as pain, swelling, a palpable abnormality, or a combination of these symptoms. Most common scrotal pathologies have characteristic accompanying sonographic findings. Less common pathologies can have similar clinical presentations, and imaging with scrotal ultrasound is required to aid in proper diagnosis. This article focuses on several of these less commonly encountered scrotal pathologies--including testicular segmental infarction, scrotal filariasis, scrotal mesothelioma, seminiferous tubule fibrosis, and scrotal leiomyosarcoma--and compares and contrasts them to more routine diagnoses. Familiarity with both typical and atypical scrotal conditions is necessary to make accurate diagnoses at ultrasound to guide appropriate treatment and avoid unnecessary surgery.

The relationship between knee joint loading rate during walking and degenerative changes on magnetic resonance imaging.

BACKGROUND: While animal study and cadaveric study have demonstrated an association between knee joint loading rate and joint degeneration, the relationship between knee joint loading rate during walking and osteoarthritis has not yet been sufficiently studied in humans. METHODS: Twenty-eight participants (14 transfemoral amputees and 14 age and body mass matched controls) underwent knee MRI with subsequent assessment using the semiquantitative Whole-Organ Magnetic Resonance Image Score. Each subject also underwent gait analysis in order to determine knee adduction moment loading rate, peak, and impulse and an exploratory measure, knee adduction moment rate∗magnitude. FINDINGS: Significant correlations were found between medial tibiofemoral joint degeneration and knee adduction moment peak (slope=0.42 [SE 0.20]; P=.037), loading rate (slope=12.3 [SE 3.2]; P=.0004), and rate∗magnitude (slope=437 [SE 100]; P<.0001). These relationships continued to be significant after adjusting for body mass or subject type. The relationship between medial knee semiquantitative MRI score and knee adduction moment loading rate and rate∗magnitude continued to be significant even after adjusting for peak moment (P<.0001), however, the relationship between medial knee semiquantitative MRI score and peak moment was no longer significant after adjusting for either loading rate or rate∗magnitude (P>.2 in both cases). INTERPRETATION: This study suggests an independent relationship between knee adduction moment loading rate and medial tibiofemoral joint degeneration. Our results support the hypothesis that rate of loading, represented by the knee adduction moment loading rate, is strongly associated with medial tibiofemoral joint degeneration independent of knee adduction moment peak and impulse.

How radiologists get paid: resource-based relative value scale and the revenue cycle.

OBJECTIVE: To learn the impact of health care reform, it is important for radiologists to first understand basic administrative aspects of medicine. This article describes the processes of radiology billing, reimbursement, and the revenue cycle, which includes the importance of proper coding, the resource-based relative value scale, and accounts receivable. CONCLUSION: An understanding of the basics of medical practice management can help radiologists effectively provide optimal patient care. This article provides an overview of one component of this topic--the current radiology reimbursement system.

Business of radiology: financial fundamentals for radiologists.

OBJECTIVE: The purposes of this article are to provide a primer on financial statements and to review several financial concepts that are at the foundation of the business of medicine. CONCLUSION: For radiologists to effectively contribute to the leadership and management of their practices, it is imperative that they understand the business aspects of radiology. Radiologists' understanding and participation in practice management may also facilitate job satisfaction and assist the provision of optimal patient care.

Craniocervical hyperpneumatization with concurrent pneumorrhachis, pneumomediastinum, and subcutaneous emphysema in a weightlifter.

BACKGROUND CONTEXT: Acquired hyperpneumatization of the skull base and upper cervical vertebrae is extremely rare and is thought to occur in patients who habitually perform the Valsalva maneuver or engage in repetitive positive pressure activities such as scuba diving or free diving. Craniocervical hyperpneumatization has been reported to cause intracranial and extracranial pneumatoceles but is not generally considered as a cause of pneumorrhachis (air in the spinal canal). Pneumorrhachis is relatively rare, and usually occurs in a localized form, either in the cervical spine secondary to skull base fractures or in the thoracic spine secondary to pneumomediastinum or pneumothorax. Here, we report a case of extensive pneumorrhachis extending from the skull base to the thoracolumbar junction in association with marked axio-atlanto-occipital hyperpneumatization and pneumomediastinum. This unique constellation of findings likely resulted from complications of the Valsalva maneuver during strenuous exercise. PURPOSE: To present a unique case of axio-atlanto-occipital hyperpneumatization with concurrent marked cervicothoracic pneumorrhachis, subcutaneous emphysema, and pneumomediastinum and to provide a review of the relevant literature, pathophysiology, and treatment strategies related to hyperpneumatization and pneumorrhachis. STUDY DESIGN/SETTING: A unique case report from an urban medical center. PATIENT SAMPLE: A single case. OUTCOME MEASURES: Imaging findings and clinical history. METHODS: Imaging data from a picture archiving and communication system and clinical data from an electronic medical record system were analyzed. RESULTS: A 58-year-old previously healthy man presented with 3 to 4 weeks of neck pain, shoulder pain, and intermittent hand and finger numbness that developed after weightlifting. On physical examination, he had mild hyperreflexia and decreased pinprick sensation within the T5-T8 dermatomes. Initial radiographic and computed tomography (CT) studies demonstrated extensive craniocervical hyperpneumatization involving the occipital bone, clivus, and C1 and C2 vertebral bodies. There was also pneumorrhachis extending throughout the entire cervical and thoracic spine, which caused moderate dural compression. Pneumomediastinum and subcutaneous emphysema were present. Maxillofacial CT showed dehiscent bone involving the dens, atlas, and occipital bone, with adjacent soft-tissue gas and pneumorrhachis. He was managed conservatively and advised to stop performing the Valsalva maneuver during weightlifting. His symptoms resolved, and follow-up imaging showed complete resolution of pneumorrhachis and partial reversal of hyperpneumatization. CONCLUSIONS: Craniocervical hyperpneumatization is a rare complication of the Valsalva maneuver. Most reported cases have involved only the skull base, or the skull base and C1, and many have been further complicated by microfractures leading to pneumocephalus or extracranial pneumatoceles. We present a unique case of extensive craniocervical hyperpneumatization that extended to the level of C2 and was complicated by microfractures causing severe pneumorrhachis. Concurrent pneumomediastinum in this case may have been an independent complication of the Valsalva maneuver, which could have contributed to pneumorrhachis. Alternatively, pneumomediastinum may have been caused by migration of gas through the neural foramen from the epidural space, driven by positive pressure generated by the one-way valve effect of the Eustachian tube during periods of exertion.

Advanced medical imaging protocol workflow-a flexible electronic solution to optimize process efficiency, care quality and patient safety in the National VA Enterprise.

Radiologists routinely make decisions with only limited information when assigning protocol instructions for the performance of advanced medical imaging examinations. Opportunity exists to simultaneously improve the safety, quality and efficiency of this workflow through the application of an electronic solution leveraging health system resources to provide concise, tailored information and decision support in real-time. Such a system has been developed using an open source, open standards design for use within the Veterans Health Administration. The Radiology Protocol Tool Recorder (RAPTOR) project identified key process attributes as well as inherent weaknesses of paper processes and electronic emulators of paper processes to guide the development of its optimized electronic solution. The design provides a kernel that can be expanded to create an integrated radiology environment. RAPTOR has implications relevant to the greater health care community, and serves as a case model for modernization of legacy government health information systems.

ACR white paper: New practice models--hospital employment of radiologists: a report from the ACR Future Trends Committee.

In response to the current era of rapid evolution of health care delivery and financing, radiologists are increasingly considering, as well as confronting, new practice models. Hospital employment is one such opportunity. Within this report to the ACR membership, the potential advantages and risks for radiologists considering hospital employment are examined.

Business of radiology 101: the state of radiology business practice and health care policy curricula at US radiology residency programs.

PURPOSE: The aim of this study was to assess the prevalence, content, and perceptions of curricula focused on radiology business practice and health care policy at US radiology residency training programs. METHODS: The desired survey population was trainees and faculty members of radiology residency programs in the United States. Three anonymous survey instruments were distributed, including an e-mail survey to the membership of the ACR RFS, a paper survey to ACR RFS delegates attending the 2010 AMCLC, and an e-mail survey to the membership of the Association of Program Directors in Radiology (APDR). RESULTS: Response rates for the surveys were 12%, 25%, and 21%, respectively. Members of the APDR and RFS agreed that understanding and competency in business practice and health care policy topics are important to the future careers of residents (total favorable sentiment >86% for APDR members and >96% for RFS members). Most survey respondents' home institutions offer some form of a noninterpretive curriculum (91% of APDR respondents, 74% of RFS respondents), but the breadth of topics addressed and educational time devoted to these curricula were quite variable. Subjective effectiveness of curricula was infrequently rated as very effective by 12% of APDR respondents and 6% of RFS respondents. CONCLUSIONS: Despite the perceived importance of radiology business practice and health care policy education, and residency training requirements in competencies related to these subjects that have been in place for more than a decade, curricula addressing these items still seem to be in a stage of acceptance and development. Further commitment to and innovation within these curricula are requisite in educating our future radiologists.

Lateral approach for radiocarpal wrist arthrography.

OBJECTIVE: We describe a technique of radiocarpal arthrography using the lateral approach. This technique may be used as an alternative to conventional dorsal techniques. CONCLUSION: Radiocarpal injection using the lateral approach can be considered as an alternative to conventional dorsal approaches in the evaluation of wrist pain and instability.

Imaging appearance of swine-origin influenza A (novel 2009 H1N1) pneumonia in an immunocompromised patient.

The Centers for Disease Control (CDC) predicted a resurgence of Swine-origin Influenza A (novel 2009 H1N1) pneumonia, hospitalizations and deaths during the 2009-2010 flu season. Immunocompromised patients are at higher risk to contract it and may present (atypically) with greater morbidity and mortality. We report the first radiographic description of CDC-confirmed swine-origin influenza A (novel 2009 H1N1) in a 32-year-old immunocompromised man. At presentation, chest radiographs demonstrated bilateral, ill-defined nodular airspace opacities. Chest CT showed upper-lobe-predominant, patchy ground-glass opacities with areas of consolidation and a thick-walled cavity.

Intrapancreatic accessory spleen.

Accessory spleens are common, usually asymptomatic, incidentally discovered congenital foci of splenic tissue. They occur most commonly near the splenic hilum, with almost 20% in or near the pancreatic tail. On contrast-enhanced computed tomography (CT), differentiation of an intrapancreatic accessory splenule (IPAS) from other pancreatic tail lesions such as islet cell tumors and metastatic disease can present a diagnostic challenge. A high index of suspicion on the part of the radiologist, based on the classic location with typical imaging features and a combination of cross-sectional imaging studies such as ultrasound, computed tomograph (CT), or magnetic resonance imaging (MRI) with nuclear medicine examinations, can confirm the diagnosis of intrapancreatic accessory splenule and prevent unnecessary biopsy and/or surgery.