Turning around cancer: Oncology imaging and implications for emergency department radiology workflow.

PURPOSE: Oncologic imaging in the emergency department (ED) is frequently encountered, including non-acute scans known as "metastatic workups" or "staging" (referred to as "cancer staging computed tomography (CT) exams"). This study examines the impact of oncologic staging CT exams on ED imaging turnaround time (TAT), defined as the time from the end of the CT exam to a final signed radiologist report, as well as order to scan completion time. METHODS: A retrospective review was conducted of all adult patients presenting to an urban, quaternary academic medical center ED from February 2016 to September 2017, who had CT imaging ordered, performed, and interpreted in the ED imaging department. CT exams containing institution-specific cancer descriptors were included. After excluding all acute exams, cancer staging CT exams were compared to a matched cohort of non-oncologic ED CT exams to evaluate median TAT and order to scan completion time using a log transformed multivariable linear regression. RESULTS: Adjusting for age and CT body part, cancer staging CT exams were associated with an independently statistically significant increased median log TAT compared to non-oncologic ED CT exams (114.5 min [IQR 112] versus 69 min [IQR 67], respectively, p < .0001) and an independently statistically significant increased median log initial order to scan completion time (166 min [IQR: 89] vs 119 min [IQR: 93], p < .0001). CONCLUSION: Oncology patients receiving non-acute metastatic workup scans in the ED have a significantly longer TAT compared to non-oncologic ED CT exams as well as longer order to scan completion times.

Assessment of Pediatric Neurotrauma Imaging Appropriateness at a Level I Pediatric Trauma Center.

PURPOSE: The aim of this study was to assess the prevalence of appropriate neuroimaging on the basis of the ACR Appropriateness Criteria among pediatric patients presenting after head trauma to a level I emergency department. METHODS: A retrospective emergency department record review was performed for patients <18 years of age undergoing head CT or MRI for the indication "head trauma" between January 2013 and December 2014. Clinical history and symptoms were compared with the ACR Appropriateness Criteria; the indication was deemed appropriate for ratings of ≥7. Patients were analyzed by age, gender, presentation, imaging obtained, follow-up, treatment, and outcomes. RESULTS: Among 207 patients, 120 (58%) were imaged with CT and 107 (52%) with MRI; 20 patients underwent both CT and MRI. One hundred eighty-seven patients (90.3%) were appropriately imaged, with 90.0% of CT studies (108 of 120) deemed appropriate and 91.6% of MRI studies (98 of 107) deemed appropriate. Younger patients were more likely to be inappropriately imaged with CT or MRI than older patients (P = .02 and P < .01, respectively). Patients undergoing CT were older (mean age 9.9 ± 5.8 years) and more likely to be male (85.2%) than those undergoing MRI (5.6 ± 5.6 years and 55.1%, respectively) (P < .01 and P < .001, respectively). The diagnostic yield of positive imaging findings for intracranial trauma was significantly lower in the MRI group (P < .01), and patients undergoing MRI were significantly more likely to return to baseline with conservative management (P < .01). CONCLUSIONS: Most pediatric patients undergoing neuroimaging for head trauma did so appropriately per ACR guidelines and had symptom resolution with conservative management. The minority not imaged appropriately represent a target for quality improvement efforts.

Low back pain in the emergency department-are the ACR Appropriateness Criteria being followed?

PURPOSE: To assess the prevalence of appropriate imaging among emergency department (ED) patients with low back pain. METHODS: Our level-1 ED records were retrospectively searched for patients with a chief compliant of "low back pain" from January to April 2013. Of 624 patients, 100 were randomly selected and analyzed for their demographics, presentation, imaging, treatment, and outcomes. The study indication for imaging was compared with the ACR Appropriateness Criteria, and the indication was deemed appropriate if it received a rating of ≥5. RESULTS: The mean age of the study population was 48 years (50% women, 50% men). The majority presented with acute or acute on chronic low back pain (94 patients), and half had a precipitating event (50 patients). A total of 28 (28%) patients underwent imaging in the ED; 24 (24%) had outpatient imaging; 54 (54%) had neither ED nor outpatient imaging. In all, 96% (27 of 28) of patients imaged in the ED, and 96% (23 of 24) imaged as outpatients, were appropriately imaged. Of patients who did not undergo imaging, 96% (52 of 54) were appropriately not imaged. A total of 76 patients (76%) had follow-up after discharge: of these, 42 (55%) had resolution or return of pain to baseline with conservative management; 18 (24%) had improvement with intervention (epidural steroid injection or kyphoplasty); 8 (10%) improved with surgery; and 8 had persistent pain (11%). CONCLUSIONS: The majority of patients presenting to the ED with low back pain did not undergo imaging. The vast majority of those who underwent imaging were appropriately imaged, based on the ACR Appropriateness Criteria.

Rapidly evolving large extracranial vertebral artery pseudoaneurysm in Behçet's disease: Case report and review of the literature.

Behçet's disease is a multisystem chronic autoimmune disease of unknown etiology with a wide spectrum of symptoms and organ system involvement. Arterial manifestations, particularly of the extracranial vertebral arteries, are rare. We report an unusual case of an African American patient with Behçet's disease, who presented with bilateral spontaneous vertebral artery pseudoaneurysms. The patient underwent successful endovascular parent vessel occlusion with detachable coils and on follow-up had complete clinical and angiographic signs of recovery.

E-portfolio competency metadata: pilot study for a call to action.

The six competency domains required by the Accreditation Council for Graduate Medical Education (ACGME) have led to a proliferation of measurement tools, assessment methods, and all forms of data from paper to electronic. The need exists to develop a standardized electronic (e)-portfolio to provide the aggregate data to improve education and patient care. This process requires a sound methodology using XML metadata to allow portability of e-portfolio data. We surveyed publicly available metadata and developed an e-portfolio system for the Henry Ford Hospital General Surgery Residency Program. Based on our implementation of e-portfolios for 70 physicians, we call upon the ACGME, the Residency Review Committees, and the American Board of Medical Specialties to establish a method to formalize and develop a standard for residency competency metadata. Using an approach similar to that of our study can streamline data and lead to improved medical education and ultimately better patient care.