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Intramural gastric abscess is a rare condition representing a localized form of suppurative gastritis, which was described in the time of Galen. Cases are usually diagnosed either with a combination of imaging modalities such as upper gastrointestinal series, ultrasound, computed tomography (CT), and endoscopic ultrasound or in conjunction with endoscopy and laparotomy. The authors describe a case of intramural gastric abscess in which the diagnosis was made preoperatively using axial, coronal, and sagittal reformations obtained with multidetector CT.

Adrenal injuries, although an uncommon consequence of abdominal trauma, are important to recognize. If bilateral, adrenal trauma could result in life-threatening adrenal insufficiency. Furthermore, in the setting of trauma, adrenal injury can point to other concomitant injuries and has been associated with overall increased morbidity and mortality. In the past, before the advent of computed tomography (CT), detection was difficult, and the diagnosis was often made only at surgery or postmortem. Today, the diagnosis of adrenal injuries can be quickly and accurately made with CT. This retrospective review was carried out to identify, describe, and analyze different CT appearances of adrenal injuries and correlated with associated injuries and observed clinical context and outcomes. A patient cohort of CT-detected adrenal injuries was identified through a radiology software research tool by searching for keywords in radiology reports. The identified CT scans were reviewed and correlated with the patients' available clinical chart data and follow-up. Between April 1995 and October 2004, 73 cases of CT-detected adrenal injuries were identified, including 48 men and 25 women, with an age range 6 to 90 years and a mean age of 42.7 years. Of the cases, 77% were right-sided, 15% were left-sided, and 8% were bilateral. The causes of injuries were motor vehicle collisions (75%), falls (14%), sports related (4%), and miscellaneous causes (7%). Associated trauma included injuries of the liver (43%), spleen (23%), lung (19%), and kidney (18%), as well as pneumothoraces/hemothoraces (22%). Skeletal injuries included fractures of the ribs, clavicles, and/or scapulae (39%), pelvis and hips (30%), and the spine (23%). Isolated adrenal trauma was seen in only 4% of the cases. The CT findings of adrenal trauma were focal hematoma (30%), indistinct (27%) or enlarged (18%) adrenal gland, gross (15%) or focal (7%) adrenal hemorrhage, and adrenal mass (11%). Associated CT findings included periadrenal fat stranding (93%), retroperitoneal hemorrhage (22%), and thickened diaphragmatic crura (10%). Active adrenal bleeding was seen in one case (1.4%). The incidence of adrenal trauma was estimated to be 0.86%. Surgical management was required only for the associated injuries. The most common CT manifestations of adrenal trauma include focal hematoma, indistinct or ill-defined adrenal gland, adrenal enlargement or mass, and gross or focal adrenal hemorrhage in a normal-sized gland. Periadrenal stranding is very common. Retroperitoneal hemorrhage and crural thickening are also important associated findings. Operative intervention is typically required only for the associated injuries, which commonly accompany adrenal trauma.

The purpose of this study was to analyze report addenda to assess the self-reported error rate in radiologic study interpretation, the types of errors that occur, and the distribution of error by image modality.Addenda to all diagnostic radiology reports were compiled over a 1-year period (n = 5568). The overall error rate was based on addenda frequency relative to the total number of studies performed. Addenda written over the most recent 2-month interval (n = 851) were classified into five major categories of predominant error type: underreading, overreading, poor communication, insufficient history, and poor technique. Each category was further divided into multiple subtypes.Diagnostic studies at our hospital had an error rate of 0.8%. Errors of poor communication occurred most frequently (44%), followed by underreading (7%), insufficient history (21%), overreading (8%), and poor technique (1%). Analyzed by imaging modality, most errors occurred in PET (19.45 per 1000 studies), followed by MRI (13.86 per 1000 studies) and CT (12.45 per 1000 studies).Through the use of report addenda to calculate error, discrepancy between individual radiologists is removed in a reproducible and widely applicable way. This approach to error typology eliminates sample bias and in a departure from previous analyses of difficult cases shows that errors of communication are most frequent, representing a clear area for targeted improvement.

To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings.This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics.Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P.0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P.0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics.Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.

The aim of this study is to describe the imaging findings of abdominal and pelvic injuries in victims of the Boston Marathon bombing. A retrospective review of 87 patients following the Boston Marathon bombing was performed to evaluate for abdominal and pelvic injuries on plain radiography or CT scans of the abdomen and pelvis. Imaging exams were evaluated for shrapnel, soft tissue injury, visceral damage, vascular disruption, and fractures. The injuries were classified as primary, secondary, tertiary, and quaternary blast injuries. Eleven of the 87 patients had positive findings in the abdomen or pelvis (M:F = 7:4, average age 34.6 years). There were 22 ball bearings, two nails, one screw, and two irregular metal fragments in the 11 patients with secondary blast (shrapnel) injuries. There was no peritoneal penetration or visceral injury seen in any of the patients. One patient had multiple transverse process fractures, representing tertiary blast injury. All but one patient had superficial penetrating abdominal or pelvic injuries secondary to shrapnel. There were no cases of bowel or solid visceral organ injuries due to the lack of peritoneal violation from the relatively low-powered explosions. Absence of peritoneal penetration by shrapnel indicates no need for laparotomy following low-powered explosions.

Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center.This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident.A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290).MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

To evaluate a new system for processing and performing inpatient STAT diagnostic imaging with respect to utilization and time-based performance metrics.This HIPAA-compliant study had institutional review board approval; informed consent was not required. The radiology information system of a large academic medical center was queried for all inpatient diagnostic imaging exams performed and interpreted from August 1, 2010, to October 31, 2012. Using customized software, data were evaluated based on order priority (non-STAT or STAT) and exam modality with respect to exam volume and time-based performance metrics (time-to-performance and preliminary interpretation time). Data were compared over 3 periods: August 1, 2010, to October 31, 2010 (preimplementation period); November 1, 2010, to October 31, 2011 (year 1 postimplementation); and November 1, 2011, to October 31, 2012 (year 2 postimplementation).In the first year after implementation of the new STAT policy, the percentage of inpatient exams ordered STAT significantly decreased from 22.1% to 5.4% (P0.001). This represented a proportional decrease of 26% (CT), 16% (MRI), 20% (US), and 24% (radiographs) relative to pre-STAT policy levels. The median time-to-performance and median preliminary interpretation time significantly decreased for all modalities after implementation of the policy (P0.05 for all modalities), decreasing by an average of 104 and 162 minutes, respectively. These changes persisted throughout year 2 postimplementation.A new institutional system for handling inpatient STAT diagnostic imaging results in a decreased number of STAT exams ordered and improved time-based performance metrics, thereby increasing workflow efficiency.

Intravenous contrast administration has been of great importance in diagnostic radiology, but it is not without risks either due to the local, systemic allergic reactions or due to subcutaneous extravasation of contrast media. Subcutaneous contrast medium extravasationis an infrequent, yet a well-recognized complication. However, most incidents are minor and can be managed conservatively, but there are a few cases that require immediate surgical intervention. This article discusses the risks factors, clinical manifestations, and conservative and surgical approaches of subcutaneous contrast media extravasation for both computed tomography and magnetic resonance imaging.

The aim of this study was to evaluate the imaging findings of head and neck injuries in patients from the Boston Marathon bombing. A total of 115 patients from the Boston Marathon bombing presenting to four hospitals who underwent imaging to evaluate for head and neck injuries were included in the study. Twelve patients with positive findings on radiography or cross-sectional imaging were included in the final analysis. The radiographic, computed tomography (CT), and magnetic resonance (MR) imaging features of these patients were evaluated for the presence of shrapnel and morphological abnormality. Head and neck injuries were seen in 12 out of 115 patients presenting to the four hospitals. There were secondary blast injuries to the head and neck in eight patients, indicated by the presence of shrapnel on imaging. In the four patients without shrapnel, there were two with subgaleal hematomas, one with facial contusion and one with mastoid injury. There were two patients with subarachnoid hemorrhage, one with brain contusion, one with cerebral laceration, and one with globe rupture. There was frontal bone, nasal bone, and orbital wall fracture in one patient each. Imaging identified 26 shrapnel fragments, 21 of which were ball bearings. Injuries to the head and neck region identified on imaging from the Boston Marathon bombing were not common. The injuries seen were predominantly secondary blast injuries from shrapnel, and did not result in calvarial penetration of the shrapnel fragments.

With the rise in the use of intravenous iodinated contrast media for both computed tomography scan and angiographic studies, there is a greater likelihood of complications. One of the most well-known adverse effects is contrast-induced media nephropathy, which is also called contrast-induced acute kidney injury. This is third most common cause of hospital acquired acute renal failure. It is associated with an increase in morbidity, mortality, and greater financial burden on healthcare system. Because of these factors, it is important for the radiologist to not only recognize risk factors, as well as the signs and symptoms, but also to know how to manage patients appropriately.

CT cystography has replaced conventional cystography in the evaluation of patients with suspected bladder rupture in most trauma centers. We performed this retrospective review to determine the accuracy of CT cystography and the role of multiplanar reformation in the diagnosis of bladder injury.The patient cohort was composed of trauma patients with clinically or CT-suspected bladder ruptures who were evaluated with CT cystography using two different MDCT scanners at our level 1 trauma center. The patients were identified through Folio, a radiology research tool software system. The CT cystography results were compared with the findings at surgery, clinical follow-up, or both.Between January 1, 2000, and December 31, 2004, 234 patients were examined in our level 1 trauma center with CT cystography. From the total of 234 examinations, 216 (92.3%) were interpreted as negative and 18 examinations (7.7%) were interpreted as positive. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Surgical bladder exploration and repair were performed in nine of the 18 cases. Seven (77.8%) of the nine cases had operative findings consistent with the CT cystogram findings. The overall sensitivity and specificity of CT cystography in diagnosing bladder rupture were each 100%. For extraperitoneal bladder rupture, the sensitivity and specificity were 92.8% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively.CT cystography is accurate for diagnosing bladder rupture. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture.

W441 of potential risks and complications, and the use of external and internal benchmarks are essential to achieve a high level of care in IR. The SIR Standards of Practice Committee guidelines for establishing a quality improvement (QI) program [1] are as follows: form a quality committee; identify QA standards; understand the system and define processes; establish metrics and set threshold values; collect and analyze data; and initiate QI projects. Although continuous assessment of IR procedures can be more challenging than assessment of diagnostic studies, IR practices should base their data collection on the QI publications standards of the SIR [2]. In evaluation of an IR service for procedural care auditing parameters, the following should be included: appropriateness, efficacy and safety, and evaluation with indicator thresholds for a specific procedure. When indication and success rates fall below a minimum threshold or when complication rates exceed a maximum threshold, a review should be performed to determine causes and to implement changes, if necessary [2].

The aim of this study was to retrospectively review the growth rate in emergency radiology volume at an urban academic trauma center from 1996 to 2012.The authors reviewed aggregated billing data, for which the requirement for institutional review board approval was waived, from 1,458,230 diagnostic radiologic examinations ordered for emergency department (ED) visits from 1996 to 2012. The growth rate was calculated as the average annual percentage change in imaging examinations per ED visits. The growth rates between 1996 to 2003 and 2004 to 2012 were statistically compared using a t test.ED patient visits showed continual growth at an average of 3% per year. Total imaging per ED visit grew from 1996 to 2003 at 4 ± 4% per year but significantly decreased from 2004 to 2012 at -2 ± 3% per year (P = .01). By modality, statistically significant decreased growth was observed in CT and MRI from 2004 to 2012. Ultrasound and x-ray showed unchanged growth from 1996 through 2012. ED physician ultrasound data available for 2002 to 2011 also showed increased growth.When adjusting ED imaging volume by ED visits, significantly decreased growth of overall ED imaging, specifically CT and MRI, was observed during the past 9 years. This may be due to slowing of new imaging indications, improved awareness of practice guidelines, and increased use of ultrasound. Although the national health care discussion focuses on continual imaging growth, these results demonstrate that long-term stability in ED imaging utilization is achievable.

Purpose The aim of this study was to evaluate radiologist compliance with institutional guidelines for nonroutine communication of diagnostic imaging results. Methods From July 2012 through September 2013, 7,401 completed advanced imaging cases were retrospectively reviewed by groups of 3 or more radiologists. The reviewing radiologists were asked to reach consensus on two questions related to nonroutine communication: (1) “Does the report describe a finding which requires nonroutine communication to the patient’s physicians?” and if so, (2) “Were the department’s guidelines for nonroutine communication followed?” Consensus judgments were aggregated and analyzed on the basis of subspecialty, level of acuity per the guidelines, and type of communication used. Results Of the 7,401 studies reviewed, 960 (13.0%) were deemed to require nonroutine results communication. The need for nonroutine communication was most frequent with CT (16.6%), followed by MRI (11.1%) and ultrasound (3.4%). For the divisions studied, nonroutine communication was most frequently needed in thoracic (37.9%), followed by neurologic (17.3%), emergency (15.8%), cardiac (13.7%), musculoskeletal (4.4%), and abdominal (0.7%) imaging. Of the cases requiring nonroutine communication, 39 (4%) yielded consensus that the guidelines were not appropriately followed: 21% (n = 8) involved level 1 findings (critical), 41% (n = 16) involved level 2 findings (acute), and 38% (n = 15) involved level 3 findings (nonacute). Failures of communication involving level 1 findings primarily involved neurologic imaging, including 4 cases of new cerebral infarct and 3 cases of new intracranial hemorrhage. Conclusions Established guidelines for nonroutine communication are appropriately applied and durable, underscoring the high yield of formalizing and implementing these guidelines across practice settings.

Part I. Trauma Section 1. Brain Section 2. Spine Section 3. Chest Section 4. Abdomen Section 5. Upper Extremity Section 6. Lower Extremity Part II. Non-trauma Section 1. Brain Section 2. Head, Neck, and Spine Section 3. Chest Section 4. Abdomen Part III. Pediatric Index of Cases

Recent advances in computed tomography (CT) technology allow for acquisition of two CT datasets with different X-ray spectra. There are different dual-energy computed tomography (DECT) technical approaches such as: the dual-source CT, the fast kilovoltage-switching method, and the sandwich detectors technique. There are various postprocessing algorithms that are available to provide clinically relevant spectral information. There are several clinical applications of DECT that are easily accessible in the emergency setting. In this review article, we aim to provide the emergency radiologist with a discussion on how this new technology works and how some of its applications can be useful in the emergency room setting.

A case of a mesocaval shunt placed urgently in a 52-year-old man to control life-threatening hemorrhage from esophageal varices is reported. The latter resulted from portal hypertension secondary to Laennec's cirrhosis. The patient suffered from acute and chronic alcoholism, but not alcoholic hepatitis. Twenty-three years later, the shunt is angiographically patent; the patient is alive and well. He has been free from encephalopathy with the exception of three episodes of gastrointestinal hemorrhage secondary to peptic ulcer disease. In each case, hepatic coma responded promptly to cathartics, enemas, and lactulose once bleeding ceased.

Purpose: To evaluate the degree to which the artifacts created by the radio-opaque components of a backboard obscure the findings on the initial trauma series chest radiograph (BBCXR). Methods: We reviewed 40 consecutive trauma victims admitted to our level I trauma center over a 3-month period who underwent a follow-up portable supine chest radiograph (PCXR) off the backboard no longer than 1 h after the initial trauma BBCXR. The original interpretation of the BBCXR was compared to the reading of the PCXR as well as to a retrospective analysis of the BBCXR performed by two radiologists blinded as to the findings on the original report. Results: The initial interpretation of the BBCXR failed to identify abnormalities reported in the follow-up PCXR of 10 individuals (25 %), most frequently bone fractures, misplaced hardware, and pleural effusions. Of these missed abnormalities, 80 % were identified retrospectively. Conversely, the initial reading of the BBCXR described a widened mediastinum in five cases, right upper lobe opacities in two, and cardiomegaly in one. Of these eight reported findings, only five (63 %) – the cardiomegaly and four of the mediastinal abnormalities – were also reported upon retrospective analysis, while the PCXR taken with the patient off the backboard confirmed widened mediastinum in only three cases. Conclusions: The initial, often hurried reading of a portable chest radiograph taken on a backboard as part of a trauma series often misses significant pathology, most of which can be detected upon more thorough examination of the original film. The backboard also tends to magnify mediastinal structures more than routine PCXR. Therefore, we advocate a more cautious analysis of the original BBCXR and routine utilization of a follow-up PCXR to confirm mediastinal abnormalities.

Purpose: In blunt trauma, CT of the thorax is often performed because of the limitations of plain film chest radiography in accurately depicting injuries to the thoracic aorta. The advent of helical CT has allowed the entire chest to be imaged more expeditiously. We will evaluate the extent to which this ability to rapidly obtain additional images of the thorax has increased the utilization of chest CT in blunt trauma. Methods: The radiologic records of all victims of blunt trauma who underwent total body CT (TBCT), which included abdomen, pelvis, and chest images, in the 10 months before and 10 months after our institution acquired helical CT (HCT), were retrospectively evaluated. Results: In the 10 months before we obtained HCT, 520 conventional CT of the abdomen and pelvis were completed, of which only 11 (2.1 %) included images of the full thorax. After HCT was instituted, 684 abdomen and pelvis CT were performed, of which 59 (8.6 %) were ordered with the entire chest. Of the 11 conventional TBCT, 6 (55 %) showed findings in the chest; in 2 of these cases (18 %) the abnormalities were confined exclusively to the thorax. Similarly, of the 59 helical TBCT, 31 (53 %) depicted traumatic abnormalities in the thorax, and in 23 of these cases (39 %) injuries were only within the chest. In 4 of the latter the injuries were mediastinal hematomas, 1 of which (25 %) was confirmed angiographically to represent an aortic laceration. Conclusion: The speed and ease with which additional images can be obtained by HCT has greatly increased utilization of cross-sectional imaging of the thorax after blunt trauma (approximately four-fold). Over half of these depict traumatic injuries.

The purpose of this study was to assess the utility of urgent abdominal computed tomography (CT) performed in a nontrauma setting on a predominantly elderly population. We retrospectively reviewed abdominal CT images of 170 patients (average age, 64 years); CT was performed on a “stat” basis to evaluate suspected acute abdominal pathology at a typical urban Veterans’ Affairs hospital. Imaging results were correlated with subsequent clinical intervention. Abdominal CT was most commonly ordered to assess abdominal pain (119 cases, 71%), suspected abdominal abscess (11 cases, 6.5%), suspected leaking abdominal aortic aneurysm (11 cases, 6.5%), and suspected acute pancreatitis (8 cases, 5%). Clinically relevant findings were recorded in 96 abdominal CT cases (56%), only 23 (13.5%) of which depicted acute pathology. This included nine patients with abscesses, four with diverticulitis, two with nonspecific enteric inflammation, and two with cholecystitis. Only 16 patients (9%) required urgent therapy. The most common clinically relevant findings not requiring prompt intervention were cholelithiasis (11 cases), chronic pancreatitis (9 cases), and liver metastases (6 cases). Of 13 patients with abdominal aortic aneurysm diagnosed on abdominal CT, 11 presented with abdominal pain, but none showed signs of rupture. Although, in a predominantly elderly population, urgent abdominal CT often reveals significant chronic disease, it seldom depicts pathology requiring prompt therapy. Therefore, a more focused use of this examination is warranted.

Although the apprenticeship model of medical training has been in use for centuries, there are several problems with its use. The fundamental ethical principle of nonmaleficence requires that no preventable harm come to patients involved in the training process. In addition, changing medical practice patterns with shorter hospital stays and duty-hour restrictions are making it difficult for trainees to be exposed to enough patients to prepare them to deal with the many possible scenarios they may face in practice. Despite these limitations, the apprenticeship model cannot be completely rejected because it is essential for trainees to perfect their technique by caring for real patients with the guidance of experienced practitioners. Simulation-based training can allow novices to learn from their mistakes in a safe environment and in accordance with the principles of deliberate practice, thus allowing simulation to be a bridge to help get trainees from the novice state, in which they have a higher risk of causing harm, to a more experienced state in which they are more likely to do what is needed for patients.

This study was designed to retrospectively evaluate transjugular intrahepatic portosystemic shunt (TIPS) performed on an emergency basis in patients with hemorrhagic shock from recurrent uncontrolled variceal bleeding. Over a 3.5-year period we reviewed the medical records as well as the imaging studies of 16 patients who had uncontrolled variceal bleeding and presented to our department for an emergent placement of TIPS. In our study the technical success was 88% (14/16 patients), the overall mortality was 36% (5/14 patients), and the shunt immediately reduced the portal venous pressure gradient by a mean of 64%. Given the poor outcome of other alternatives, aggressive treatment and placement of TIPS is justified regardless of the severity of the bleeding episode.

OBJECTIVE. The purpose of this article is to discuss nephrogenic systemic fibrosis (NSF) in detail regarding its history, possible pathophysiology, clinical and pathologic presentations, diagnosis, and implications for the radiology community. CONCLUSION. NSF is a potentially lethal disorder that occurs in patients with reduced kidney function. Current evidence suggests a strong association with gadolinium-based contrast agents—mostly used in MRI—in this patient group. This has urged the radiology community to emphasize careful screening for the presence of renal dysfunction among patients for whom gadolinium-enhanced MRI is contemplated. Appropriate selection of gadolinium-based contrast agent type, avoidance of nonstandard dosage, patient education, and informed consent have been recommended by authorities.

A novel 19-gauge, blunt-tipped, side cutting single throw, 70-cm long transjugular needle, specifically designed for transvenous kidney biopsy, was used in seven patients with high risk for bleeding. A mean of 4 device-passes (3-6) per patient resulted in a satisfactory specimen for pathological diagnosis. Immediate post-biopsy nonenhanced CT was performed to evaluate for bleeding at the biopsy site. All patients were observed for 2 hr after the procedure. No clinically significant immediate or late complication was noted.

To retrospectively determine the incidence of nephrogenic systemic fibrosis (NSF) in a large academic medical center after the adoption of restrictive gadolinium-based contrast agent (GBCA) administration guidelines.For this retrospective HIPAA-compliant study, institutional review board approval was obtained and the requirement for informed consent was waived. Restrictive GBCA guidelines were adopted in May 2007. The guidelines (a) require a recent serum creatinine level measurement in any patient who is aged 60 years or older and/or at risk for renal disease, (b) limit the maximal weight-based GBCA dose administered to any patient with an estimated glomerular filtration rate (eGFR) lower than 60 mL/min/m(2) to 20 mL, and (c) prohibit the administration of any GBCA in patients who have an eGFR lower than 30 mL/min/m(2) and/or are undergoing chronic dialysis treatment (except in emergency situations). The electronic medical records were searched for all contrast material-enhanced magnetic resonance (MR) imaging examinations performed during the post-guidelines adoption period between January 2008 and March 2010 and the pre-guidelines adoption and transitional period between January 2002 and December 2007. Separate pathology records were searched for biopsy-confirmed cases of NSF during the same study periods. The incidences of NSF during the pre-guidelines adoption and transitional period and post-guidelines adoption period were compared by using the paired Z test.A total of 52,954 contrast-enhanced MR examinations were performed during the post-guidelines adoption period. Of these 52,954 examinations, 46,464 (88%) were performed in adult patients with an eGFR of 60 mL/min/m(2) or higher or presumed normal renal function and 6454 (12%) were performed in patients with an eGFR of 30-59 mL/min/m(2). Thirty-six patients with an eGFR lower than 30 mL/min/m(2) underwent contrast-enhanced MR imaging for emergent indications. Review of the pathology records for January 2008 to September 2010 revealed no new cases of NSF resulting from GBCA exposure.After restrictive guidelines regarding GBCA administration were instituted, no new cases of NSF were identified among 52,954 contrast-enhanced MR examinations, including those performed in patients with an eGFR lower than 60 mL/min/m(2).

Purpose To assess the effect of automatically inserted technical details on the concordance of a radiology report header with the actual procedure performed. Methods and Materials The study was IRB approved and informed consent was waived. We obtained radiology report audit data from the hospital's compliance office from the period of January 2005 through December 2009 spanning a total of 20 financial quarters. A "discordance percentage" was defined as the percentage of total studies in which a procedure code change was made during auditing. Using Chi-square analysis we compared discordance percentages between reports with manually inserted technical details (MITD) and automatically inserted technical details (AITD). The second quarter data of 2007 was not included in the analysis as the switch from MITD to AITD occurred during this quarter. Results The hospital's compliance office audited 9,110 studies from 2005-2009. Excluding the 564 studies in the second quarter of 2007, we analyzed a total of 8,546 studies, 3,948 with MITD and 4,598 with AITD. The discordance percentage in the MITD group was 3.95% (156/3,948, range per quarter, 1.5- 6.1%). The AITD discordance percentage was 1.37% (63/4,598, range per quarter, 0.0-2.6%). A Chi-square analysis determined a statistically significant difference between the 2 groups ( P Conclusion There was a statistically significant improvement in the concordance of a radiology report header with the performed procedure using automatically inserted technical details compared to manually inserted details.

We report the case of an infant with congenital colonic stenosis in the ascending colon and review the literature regarding this uncommon condition.

Background Cervical spine injuries may have devastating neurological consequences, which makes accurate diagnosis of injury a key part of the trauma evaluation. Imaging plays a significant role in making the diagnosis and guiding management. Current American College of Radiology Appropriateness Criteria guidelines recommend computed tomography (CT) of the cervical spine with multi-planar reformats as the highest-rated imaging examination for patients meeting clinical criteria, without subsequent need for further imaging with a negative scan in a neurologically intact and non-obtunded patient. Although CT is fast and accurate for evaluation of bony injury, it may overlook ligamentous injury. Objective and Case Report We report a case in which ligamentous instability was demonstrated as subluxation with an out-of-collar lateral radiograph after a CT scan showed no subluxation or fracture in a patient without neurological deficits. Our Radiology Department routinely performs an out-of-collar lateral radiograph after a negative CT scan, and this case suggests that there may be an important role for this practice. Conclusion Magnetic resonance is the optimal study for soft tissue and ligamentous evaluation; however, a simple lateral out-of-collar radiograph after CT clearance, in an otherwise neurologically intact and non-obtunded patient, may be a quick and cost-effective means to assess for instability of the cervical spine.

Key performance indicators (KPIs) are financial and nonfinancial measures that are used to define and evaluate the success of an organization. KPIs differ, depending on the nature of the organization and the organizational strategy; they are devised to help evaluate the progress of an organization toward achieving its long-term goals and fulfilling its vision. In healthcare organizations, performance assessment is especially critical for the development of best practices that can lead to improved outcomes in patient care, and KPIs have been incorporated into many healthcare management systems. In the future, radiology-specific KPIs such as those in use at the authors' institution may help provide a framework for measuring performance in radiology practice.

The purpose of this study was to retrospectively assess the frequency, manifestations, and severity of acute adverse reactions associated with administration of two gadolinium-based contrast agents to patients who underwent MRI at a single large academic institution.Data from continuous quality assurance records on the number of administrations of and acute adverse reactions to gadopentetate dimeglumine and gadobenate dimeglumine at our institution October 2007 to December 2008 were tabulated and analyzed. During the investigation period, 32,659 administrations of gadolinium-based contrast agents were performed for MRI examinations. Of these, 27,956 administrations were gadopentetate dimeglumine, and 4,703 administrations were gadobenate dimeglumine. Data were collected on the frequency and severity of acute adverse reactions.A total of 51 acute adverse reactions occurred in 50 patients (16 men, 34 women; mean age, 48 years), accounting for 0.16% of all administrations (51/32,659). Thirty-eight reactions (38/27,956, 0.14%) were associated with gadopentetate dimeglumine, and 13 (13/4,703, 0.28%) were associated with gadobenate dimeglumine. Forty-three reactions were mild, six were moderate, and two were severe. The severe reactions occurred with the use of gadobenate dimeglumine.The rates of acute adverse reactions to gadopentetate dimeglumine and gadobenate dimeglumine were 0.14% and 0.28%, respectively. The overall adverse reaction rate was 0.16% in our patient sample. Direct comparison of adverse reaction rates of the two agents was not possible because of the retrospective uncontrolled study design.

To assess the discrepancy rate for the interpretation of abdominal and pelvic computed tomography (CT) examinations among experienced radiologists. Ninety abdominal and pelvic CT examinations reported by three experienced radiologists who specialize in abdominal imaging were randomly selected from the radiological database. The same radiologists, blinded to previous interpretation, were asked to re-interpret 60 examinations: 30 of their previous interpretations and 30 interpreted by others. All reports were assessed for the degree of discrepancy between initial and repeat interpretations according to a three-level scoring system: no discrepancy, minor, or major discrepancy. Inter- and intrareader discrepancy rates and causes were evaluated. CT examinations included in the investigation were performed on 90 patients (43 men, mean age 59 years, SD 14, range 19–88) for the following indications: follow-up/evaluation of malignancy (69/90, 77%), pancreatitis (5/90, 6%), urinary tract stone (4/90, 4%) or other (12/90, 13%). Interobserver and intraobserver major discrepancy rates were 26 and 32%, respectively. Major discrepancies were due to missed findings, different opinions regarding interval change of clinically significant findings, and the presence of recommendation. Major discrepancy of between 26 and 32% was observed in the interpretation of abdominal and pelvic CT examinations.

To retrospectively assess the association between gadopentetate dimeglumine exposure at magnetic resonance imaging and the development of nephrogenic systemic fibrosis (NSF).This HIPAA-compliant study had institutional review board approval. Informed consent was waived. A search of medical and pathologic records was performed to identify patients with NSF that was diagnosed between January 1998 and December 2007. Patients with known exposure to gadolinium-based contrast agents other than gadopentetate dimeglumine were excluded. Medical records were then reviewed for gadopentetate dimeglumine exposure, renal status, concomitant diseases, timing of NSF symptom onset, date of NSF diagnosis, and clinical outcome. Skin gadolinium deposition was assessed for those patients with adequate available tissue. Spearman rank correlations were estimated to assess the relationship between the dose of gadopentetate dimeglumine and the time to onset of NSF.Thirty-six patients (mean age, 62.6 years; range, 30-83 years) had been exposed to gadopentetate dimeglumine prior to NSF onset. All had stage 5 chronic kidney disease and all but one were undergoing dialysis at the time of exposure. NSF developed within 3 months after the last gadopentetate dimeglumine exposure (range, 1-59 months) in 21 (66%) of 32 patients. The patients had been exposed to median cumulative gadopentetate dimeglumine volumes of 35, 40, 85, and 117.5 mL over the 3, 12, and 24 months and up to 11 years preceding the onset of NSF, respectively. Patients who received higher cumulative and total gadopentetate dimeglumine doses had a higher risk of developing NSF than did those who received lower doses (odds ratio = 1.2). Twenty (56%) of 36 patients died, with a median interval of 18 months between NSF symptom onset and death.NSF develops in patients with renal impairment after exposure to gadopentetate dimeglumine in a dose- and time-dependent manner.http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.2531082160/-/DC1.

The aim of this study was to evaluate the uncertainty in computed tomographic pulmonary angiography (CTPA) radiology reports, manifested by descriptions of report limitations and image quality.CTPA reports between 2004 and 2006 were reviewed for patient demographic data (age, gender, pregnancy state), radiologist data (years of experience, subspecialty, final dictation by an attending radiologist vs a resident being present and dictating the report), the presence of pulmonary embolism (PE), and key words describing examination quality and limitations.There were 2151 CTPA reports. Patterns of reporting CTPA in the impression sections of radiology reports were as follows: (1) PE conclusively positive (10%), (2) PE conclusively negative (29%), (3) PE negative to segmental arteries (27%), (4) PE negative to central pulmonary arteries (21%), (5) PE negative but suboptimal examination (8%), and (6) nondiagnostic examination (5%). Among the last three categories, seven PEs were not initially diagnosed but were found on subsequent imaging examinations. Limitations in image quality, respiratory motion artifact, and contrast enhancement were most frequently mentioned as limitations in image quality (62% and 28% of all reports, respectively). Radiologists tended to report limitations in image quality if they were thoracic radiology subspecialists, had10 years of experience, or worked independently (P.001).Different patterns of reporting CTPA exist and vary on the basis of individual radiologists' subspecialties, experience, and whether they work independently or with residents. Certain wording regarding the presence of PE may falsely imply negativity of PE in a limited examination.

We report a case of disruption of the subclavian artery following dislocation of the first rib. The case report and mechanism of trama are discussed.

Objective The aim of this study was to determine the frequency of contrast-induced nephropathy (CIN) in patients undergoing repeat contrast-enhanced computed tomographic (CT) examinations within 24 hours, as well as associated risk factors. Materials and Methods Through a search of medical and radiologic records, patients who underwent 2 contrast-enhanced CT examinations within 24 hours during a 4-year period (2003-2006), with available serum creatinine measurements before and after CT imaging were included. Medical records were reviewed for demographic data, risk factors, renal status, and CT contrast volume. The frequency of CIN was calculated, and odds ratios of risk factors were determined. Results There were 164 patients (90 men, 74 women; mean age, 56.3 years), with an average baseline serum creatinine level of 1.02 ± 0.73 mg/dL (range, 0.3-6.6 mg/dL). Three hundred twenty-eight CT examinations were performed: 2 in each patient, at an average interval of 11.4 hours. The mean doses of contrast medium used for the first and second CT examinations were 126.2 and 123.4 mL, respectively. Twenty-one patients (12.8%) developed CIN. Comparing patients with and without CIN, the only statistically significant risk factor for CIN was an increase in serum creatinine between the first and second CT examinations, with an odds ratio of 18 ( P Conclusion The incidence of CIN in patients who underwent repeat contrast-enhanced CT examinations was 12.8%. An increase in serum creatinine between the first and second CT examinations was highly associated with CIN and may serve as a risk factor for developing CIN.

AJR 2015; 204:W607 0361–803X/15/2045–W607 © American Roentgen Ray Society Reply to “The ‘Abujudeh Curve’ in Radiology Quality and Safety Research” We appreciate the insight of Dr. Bruno [1] regarding our article [2]. Indeed, we believe that with big data, long-term quality improvement projects, and good analytics, it is likely that the pattern represented by this curve will be observed frequently. The first portion of the curve is characterized by an increase in adverse observations, an apparent worsening of the targeted problem. We believe this is likely caused by an increased awareness of the problem itself—a phenomenon known as the Hawthorne effect. This apparent worsening should not dissuade the quality improvement team from marching on with the project; it is a normal response. With time, the increase reaches a plateau. This plateau phase is characteristic of the second portion of the curve, and we believe that this point on the curve represents the closest point to the true incidence. The final portion of the curve is the decline, which (we would hope) represents the effect of the quality improvement initiatives if effective and done properly. Hani H. Abujudeh James H. Thrall Massachusetts General Hospital, Harvard Medical School, Boston, MA

AIDS patients are susceptible to opportunistic gastrointestinal infections including ascending cholangitis and cholecystitis, especially if CD4 count is200. Incidence of acalculous cholecystitis has not been reported previously.We aim to evaluate the incidence of acalculous cholecystitis in AIDS patients and to identify causative organisms and mortality rate following cholecystectomy.We reviewed the files of 46 patients in order to meet the objectives of this study.CD4 counts were200 in 31 patients and200 in 15 patients. HIDA imaging was performed in 31 patients; in 8, the CD4 count was200 and all had calculous cholecystitis. The gallbladder was visualized in 3 patients for a sensitivity of 63% and no organisms were found in the gallbladder specimens. In 23 patients, the CD4 count was200; the gallbladder was visualized in 5 patients for a HIDA sensitivity of 78%; 16 (52%) had acalculous cholecystitis; and 15 had calculous cholecystitis. In acalculous cholecystitis, Cryptosporidium was found in six cases, cytomegalovirus (CMV) in six cases, and fungus, yeast, tuberculosis, and mycobacterium avium intracellular each in one case. The thirty day mortality rate was 18%; 5 of 28 who underwent open cholecystectomy died within 30 days, 4 of them with a CD4 count200. There was no mortality in the 26 patients who underwent laparoscopic cholecystectomy.(1) Because of the high incidence of 52% of acalculous cholecystitis in AIDS patients with a CD4 count200, we recommend using intravenous cholecystokinin if the gallbladder is visualized on hepatobiliary scintigraphy in order to determine gallbladder ejection fraction and exclude acalculous cholecystitis. (2) Laparoscopic rather than open cholecystectomy should be the surgical procedure of choice in AIDS patients especially if the CD4 count is200.

1All authors: Department of Radiology, C320, UMDNJ-New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103. Address correspondence to H. Abujudeh (judehmd@yahoo.com). udd-Chiari syndrome (BCS) is caused by obstruction of the hepatic venous outflow tract resulting from obstruction of the hepatic vein, the inferior vena cava (IVC), or both. Most cases are due to thrombotic occlusion of the hepatic veins resulting from a hypercoagulable state [1]. BCS can manifest in an acute or chronic form; medical, surgical, and interventional treatments are available. A transjugular intrahepatic portosystemic shunt (TIPS) has been described to treat BCS. Most published reports discuss TIPS for treatment of the chronic form [2–9]. We present a rescue TIPS procedure in a patient who presented with acute BCS.