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Purpose The goal of this study was to examine emergency department (ED) ordering practices in patients receiving both chest radiography (CXR) and chest CT (CCT). Methods Consecutive ED patients receiving both CXR and CCT in a single ED visit from January 2009 to December 2013 were included. For each examination, the time of order entry, time of study completion, and time of final interpretation were recorded and analyzed. Results A total of 3,627 patients met the inclusion criteria. In 3,437 (94.8%) patients, the CXR was ordered first; in 43 (1.2%), the CCT was ordered first; and in 91 (2.5%), the CCT and CXR were ordered simultaneously. In 50.3% (1,826 of 3,627) of all cases, imaging in the second modality (whether CCT or CXR) was ordered before final report availability of the first exam. In 9.8% (n = 354 of 3,627) of all cases, imaging in the second modality (whether CCT or CXR) was ordered before image availability from the first examination. Conclusions These results suggest inefficient resource usage, for which targeted technology solutions may be helpful.

Clinical features Cardiotoxicity is a rare but serious side effect of clozapine. We present a case of a psychiatric patient on chronic clozapine 75 mg daily, who presented with congestive heart failure secondary to the cardiotoxic effects of the psychiatric medication. Therapeutic challenge Conventional heart failure treatment failed to improve symptoms. Solution A course of 40 mg of intravenous immunoglobulin and 125 mg of steroids was implemented, after which the patient made a full recovery. We hope to raise awareness of concurrent clozapine-induced pericarditis and myocarditis and propose a role of intravenous immunoglobulin and steroids in the treatment of drug-induced cardiomyopathy.

Based on its intrinsic mass and velocity, a bullet has an upper limit of wounding potential. Actual wound severity is a function of the bullet construction and trajectory, as well as the properties of the tissues traversed. Interpreting physicians must evaluate the bullet trajectory and describe patterns of injury resulting from the effect of energy transfer from the projectile into living tissue. A basic understanding of firearms, projectiles, and wound ballistics can help the interpreting physicians in conceptualizing these injuries and interpreting these cases.

Introduction This review article illustrates a spectrum of arterial pseudoaneurysms that may occur in various locations throughout the thoracoabdominal region. This article discusses the common etiologies and typical clinical presentations of arterial pseudoaneurysms as well as the imaging modalities employed in their diagnosis and potential treatment options. Objective The goal of this review article is to familiarize radiologists with the diagnosis of thoracoabdominal arterial pseudoaneurysms, the prompt identification and treatment of which are crucial in this patient population. Conclusion In summary, a thorough understanding of the etiologies, imaging characteristics, and clinical implications of pseudoaneurysms can help optimize identification and management of this spectrum of disease.

Introduction: The number of citations an article receives is an important indication of its impact and its contribution to academia. There is a paucity of literature concerning top article citations in diabetes. The main objective of this investigation was to bridge this gap and to provide readers with a practical guide in evaluating diabetes literature. Methods: Scopus Library was searched to determine the citations of all published diabetes articles. A total of 100 articles were included in our investigation under the subject category ‘Diabetes, diabetes mellitus, and diabetics’. Two databases were used to extract citations. We did not apply any time restriction in our search. The top 100 cited articles were selected and analyzed by two independent investigators. We extracted immediacy index from ResearchGate. Results: The journal with the highest number of top 100 cited articles was The New England Journal of Medicine with 23, followed by 22 in Diabetes Care. The top article on the list received 17,779 citations. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles ( p < 0.005). The United States had the highest number of articles (59). Contrary to bibliometric analyses published in other medical fields, the largest subset of the diabetes articles ( n = 54) were published in the 10-year period between 2000 and 2009. Conclusion: Our analysis provides an insight on the citation frequency of top cited articles published in diabetes to help recognize the quality of the works, discoveries and the trends steering the study of diabetes.

The number of citations an article receives is an important indication of its impact and contribution to the clinical world. There is a paucity of literature concerning top article citations in cardiology. The main objective of this investigation was to bridge this gap and to provide readers a practical guide in evaluating the cardiovascular literature. Scopus Library database was searched to determine the citations of all published cardiovascular articles. One hundred two journals were included in our investigation under the Institute of Science Information Web of Science subject category "cardiology, cardiovascular, and heart." We did not apply any time or study-type restriction in our search. The top 100 cited articles were selected and analyzed by 2 independent investigators. The journal with the highest number of top 100 cited articles was Circulation with 36, followed by 28 in the European Heart Journal. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles (p

Odontogenic infections leading to a simple dentoalveolar abscess (DA) are a common, non-traumatic dental condition (NTDC) encountered in emergency departments (ED). Simple DA is classified into two main types; the endodontic (periapical) abscess and the periodontal abscess. Endodontic abscess forms secondary to dental caries, after the necrosis of the dental pulp and subsequent infection of the root canal. In a periodontal abscess, the infection originates from the periodontal tissues or the gingiva.1 The ED sometimes serves as the primary care setting for the workup of simple DA, instead of outpatient dental clinics. This trend has resulted in an increase in the dental related ED visits, as a percentage of all ED visits.1 Published literature has advocated the use of the simple, cheap, and familiar technique of panoramic radiographs as the standard radiological technique in evaluating simple DA.2 However, in most ED settings, facial computed tomography (CT) has superseded the use of panoramic radiographs, because of its availability, easy access, and potential to offer greater anatomic detail. There are, however, issues associated with the routine use of CT in terms of increased turnaround time (TAT), radiation exposure, and technical/professional fees associated with routinely utilizing facial CT in the workup of DA. Okunseri et al3 state that patients who present to the ED with an NTDC would be better managed in an outpatient dental office setting, given the availability of definitive care and the likelihood of continuity of patient care. While there is extensive variability in the management and diagnostic algorithms applied to suspected simple DA in the ED setting across the country, advanced imaging has become much more common in the age of widely available multidetector CTs. Inappropriate and continuous use of the ED for NTDC burdens the health care system by lending to overcrowding, increasing care cost, longer wait times for patients with other urgent health conditions, and increased exposure to ionizing radiation.1,3 Though outpatient dental treatment would be ideal, in the event that these patients present to the ED, rapid, efficient, and effective care delivery is of the utmost importance. Our investigation examined the diagnostic utility of facial CT in patients with suspected simple DA, as well as the TAT, radiation exposure, and associated financial costs. The central hypothesis of this investigation was that facial CT rarely results in a change of patient management in the clinical setting of suspected simple DA.

Previous literature on the impact of scribe programs varies and has mostly been reported from academic institutions or other clinics. We report the implementation of the scribe program in the emergency room of a community hospital and its impact on patient throughput, physician productivity, and patient satisfaction. We performed a quasi-experimental, before-and-after study measuring patient throughput metrics, physician productivity, and patient satisfaction. The intervention measuring the scribe implementation was divided into pre- and post-implementation periods. Patient throughput metrics were (1) door-to-room time, (2) room-to-doc time, (3) door-to-doc time, (4) doc-to-disposition time, and (5) length of stay for discharged/admitted patients. Our secondary outcome was physician productivity, which was calculated by measuring total patients seen per hour and work relative value units per hour. Additionally, we calculated the time-motion analysis in minutes to measure the emergency department physician’s efficiency by recording the following: (1) chart preparation, (2) chart review, (3) doctor–patient interaction, (4) physical examination, and (5) post-visit documentation. Finally, we measured patient satisfaction as provided by Press Ganey surveys. Data analysis was conducted in 12,721 patient encounters in the pre-scribe cohort, and 13,598 patient encounters in the post-scribe cohort. All the patient throughput metrics were statistically significant (p < 0.0001). The patients per hour increased from 2.3 ± 0.3 pre-scribe to 3.2 ± 0.6 post-scribe cohorts (p < 0.001). Total work relative value units per hour increased from 241(3.1 ± 1.5 per hour) pre-scribe cohort to 336 (5.2 ± 1.4 per hour) post-scribe cohort (p < 0.001). The pre-scribe patient satisfaction was high and remained high in the post-scribe cohort. There was a significant increase in the clinician providing satisfactory feedback from the pre-scribe (3.9 ± 0.3) to the post-scribe (4.7 ± 0.1) cohorts (p < 0.01). We describe a prospective trial of medical scribe use in the emergency department setting to improve patient throughput, physician productivity, and patient satisfaction. We illustrate that scribe use in community emergency department is feasible and results in improvement in all three metrics.

The organ injury scale grading system proposed by the American Association for the Surgery of Trauma provides guidelines for operative versus nonoperative management in solid organ injuries; however, major shortcomings of the American Association for the Surgery of Trauma injury scale may become apparent with low-grade injuries, in which conservative management may fail. Nonoperative management of common intra-abdominal solid organ injuries relies increasingly on computed tomographic findings and other clinical factors, including patient age, presence of concurrent injuries, and serial clinical assessments. Familiarity with characteristic imaging features is essential for the prompt diagnosis and appropriate treatment of blunt abdominal trauma. In this pictorial essay, the spectrum of the American Association for the Surgery of Trauma organ injury scale grading system is illustrated, and a multidisciplinary management algorithm for common intra-abdominal solid organ injuries is proposed.

To examine the added diagnostic value of emergent contrast enhanced CT head (CECTH) in patients who present to the emergency department (ED) with acute non-traumatic symptoms referable to the brain, and to assess the financial implications of CECTH in the emergent setting.We queried healthcare data for head CTs ordered by our ED between January 2008 and December 2010. Those who presented to the ED with non-traumatic neurologic disturbances were included. All traumatic head injury cases were excluded. Two board certified radiologists with fellowship training who were blinded to patient history and physical findings, independently reviewed all non-contrast computed tomography of the head (NCTH) and CECTH images. CECTH's were read following abnormal NCTH's, and findings were recorded as normal or abnormal.In our investigation, 379 patients-210 (55 %) females and 169 (45 %) males-met the inclusion criteria. Common indications for head CT included: headache 183 (48 %); dizziness 73 (19 %); altered mental status 49 (13 %); and seizure 38 (10 %). The mean age of study subjects was 47 (±29) years. Two hundred sixty-one (69 %) of all patients scanned showed no abnormality. One hundred eighteen (31 %) of 379 patients had abnormal scans. We encountered 1 abnormal CECTH on which NCTH was normal. Cost of CECTH was $465 and NCTH was $385.Head CT in ED non-traumatic neurological presentations with CECTH is not generally indicated and represents a calculable cost savings in the management of these patients.

Social media is rapidly being incorporated into medical education. We created a small group, reflective practice sessions by integrating specific medical cases to improve awareness about professionalism on social media. Medical scenarios were generated for reflective practice sessions on social media professionalism. Anonymous pre/post-session surveys evaluated residents' use of social media and gathered their opinions on the session. Thirty-eight of 48 (79 %) residents replied to the presession survey with 50 % (19/38) reporting daily digital media use, 76 % (29/38) witnessed unprofessional postings on social media, and 21 % (8/38) posted unprofessional content themselves. Of the 79 % (30/38) residents who attended the session, 74 % (28/38) completed the post-session survey. Residents reported the session added to the longevity of their professional career 4.11, 95 % CI (3.89–4.36). As a result of the session, they were more conscious of using the social media more professionally 3.47, 95 % CI (2.88–3.96) and would be proactive in protecting patient privacy and confidentiality on social media sites 3.96, 95 % CI (3.50–4.37). In summary, reflective practice-based sessions regarding the impact of social media on professionalism in surgery was well favored by the residents. The majority agreed that it had important implications for the longevity of their professional career. Participants reported having an increased awareness to protect patient privacy and utilize social media more professionally.

OBJECTIVE. The aim of this article is to illustrate the imaging findings and analyze the spectrum of findings seen in patients with acute aortic syndrome. We also will discuss the overlaps in pathophysiologic and imaging findings among aortic syndromes. CONCLUSION. Acute aortic syndrome includes acute aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. The most common clinical presentation is severely painful and potentially life-threatening abnormalities of the aorta. Differentiating among these aortic diseases is impossible by symptoms or physical evaluation. Therefore, any clinical suspicion should prompt immediate action including confirmatory noninvasive imaging. Prognosis of acute aortic syndromes is clearly related to prompt diagnosis and appropriate management. Accurate imaging interpretation can modify the natural history of acute aortic syndrome and improve prognosis.

The purpose of this study was to reiterate the predominance of CT in evaluating ventriculoperitoneal shunt malfunction in terms of cost-effectiveness, reduction of radiation exposure, and turnaround time as the measurement parameters.This retrospective study included patients 18 years and older with a history of ventriculoperitoneal shunt insertion who presented to the emergency department with symptoms of shunt malfunction and underwent shunt series radiography and head CT within 12 hours. Shunt revision occurring contemporaneously with imaging was defined as revision within 48 hours of the original imaging report. The effective radiation dose was calculated by multiplying dose-length product from the scanner with the standard conversion coefficient k (k = 0.0021 mSv/mGy × cm). The turnaround time for patients who underwent both head CT and shunt series radiography was calculated from time of the first study to the time of completion of the last study.There were 16 shunt revisions in 239 patients. The sensitivity of CT was 87.5%; specificity, 91.4%; positive predictive value, 42.4%; and negative predictive value, 99%. The sensitivity of shunt series radiography was 18.7%; specificity, 90.9%; positive predictive value, 13%; and negative predictive value, 93.9%. There were 223 observations of CT radiation dose per patient (mean, 1.87 ± 0.45). There also were 223 observations of shunt radiography radiation dose per patient (mean, 1.57 ± 0.60). The median turnaround time among patients undergoing CT and shunt radiography was 109 ± 84 minutes.Shunt series radiography is a low-yield diagnostic imaging modality for identifying shunt malfunction and prolongs turnaround time, increases medical cost, and exposes patients to unnecessary radiation.

Zika virus (ZKV) is an arbovirus of the Flaviviridae family, which includes West Nile, dengue fever, yellow fever, and Japanese encephalitis virus. It is transmitted by the Aedes genus of mosquitoes. Before 2015, ZKV outbreaks occurred in areas of Africa, the Pacific Islands, and Southeast Asia. The current large outbreak, which began in Brazil, has also emerged throughout a large part of South/Central America, a number of islands in the Caribbean, including Puerto Rico, the Virgin Islands, and Mexico. A sudden rise in the numbers of infants reported born with microcephaly in Brazil, and the detection of the single-stranded positive RNA virus in the amniotic fluid of affected newborns, has captured medical, mainstream media, and global political attention, causing considerable concern in a post-Ebola global community considerably more focused on the threat of internationally transmissible diseases. The goal of this article is to provide an overview of ZKV for clinicians, with the emphasis on pathogenesis, clinical manifestations, diagnosis, and treatment/preventive measures.

Injuries to the foot are a common cause for presentation to the emergency department (ED), and imaging is often used to aid in the diagnosis. The foot can be divided into three distinct anatomic regions: the forefoot, midfoot and hindfoot. Our manuscripts comprise a three-part imaging review in which we address the use of radiography as well as advanced imaging modalities. We provide pearls to radiographic interpretation and discuss prognostic implications and classification systems. Part 1 addressed forefoot injuries, Part 2 reviews midfoot injuries and Part 3 covers the hindfoot.

Injuries to the foot are a common cause for presentation to the emergency department, and imaging is often used to aid in the diagnosis. The foot can be divided into three distinct anatomic regions: the forefoot, midfoot and hindfoot. Our manuscripts comprise a three-part imaging review in which we address the use of radiography as well as advanced imaging modalities. We provide pearls to radiographic interpretation and discuss prognostic implications and classification systems. Part 1 addresses forefoot injuries, part 2 reviews midfoot injuries and part 3 covers the hindfoot.

Acute altered mental status can be caused by a broad range of etiologies, including cerebrovascular, neurologic, traumatic, metabolic, infectious, psychiatric, medications, etc. We present a case of a 53-year-old healthcare professional with an acute altered mental status after a trip to Africa. The patient was extensively worked up for infectious, cardiovascular, and neurologic etiologies, and all results were within normal limits. Further history revealed an overdose of a self-medicated hypnotic (zolpidem) for insomnia. The patient was conservatively managed and discharged on trazadone for insomnia.

Background: Citation classics have been published in almost all medical fields. The main objective of this study was to provide the readers with a complete updated guide using two different citation tracking sources in assessing respiratory literature published in respiratory specific or general medical journals.Methods: Scopus Library database (www.scopus.com) was used to determine the 50 most cited articles regarding respiratory medicine using the subject category “respiratory system.” The results from the database were sorted using the option “Times cited.”Results: The top 50 articles were published during the time period 1987–2008, with most articles (n = 22) published from 1996 to 2000.The topic that had the highest number of articles (n = 15) was chronic obstructive pulmonary disorders (COPD) followed by asthma (n = 10).Conclusion: A periodic evaluation of the top cited articles can help researchers identify the quality of work in respiratory system and pinpoint subtopics which have not been given d...

The incorporation of an electronic medical record into patient care is a priority in developed countries, but faces significant obstacles for adoption in developing countries. The goal of our study was to define and assess the efficiency of a personalized intervention on village physicians’ use of electronic medical records in rural community health services of underprivileged areas. Six towns were selected with two bordering local health stations from each town. One was randomly given to the intervention group and the other to the control group. A structured on-site intervention was provided to village physicians in the intervention group, for 7 months. The results showed that in the intervention group, the percentage of households with complete records increased. The percentage of clinic medical records and complete child vaccination in the intervention group also increased from 2 to 14 percent (p =

Injuries to the foot are a common cause for presentation to the ED, and imaging is often used to aid in the diagnosis. The foot can be divided into three distinct anatomical regions: the forefoot, midfoot and hindfoot. Our manuscripts comprise a three-part imaging review in which we address the use of radiography as well as advanced imaging modalities. We provide pearls to radiographic interpretation and discuss prognostic implications and classification systems. Part 1 addresses forefoot injuries, part 2 reviews midfoot injuries and part 3 covers the hindfoot.

Introduction Our objective was to identify trends and examine the characteristics of the top 100 cited articles in emergency medicine (EM) journals. Methods Scopus Library database was queried to determine the citations of the top 100 EM articles. A second database (Google Scholar) was used to gather the following information: number of authors, publication year, journal name, impact factor, country of origin, and article type (original article, review article, conference paper, or editorial). The top 100 cited articles were selected and analyzed by 2 independent investigators. Results We identified 100 top-cited articles published in 6 EM journals, led by Annals of Emergency Medicine (65) and American Journal of Emergency Medicine (15). All top-cited articles were published between 1980 and 2009. The common areas of study were categorized as cardiovascular medicine, emergency department administration, toxicology, pain medicine, pediatrics, traumatology, and resuscitation. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles ( P Conclusion The top-cited articles published in EM journals help us recognize the quality of the works, discoveries, and trends steering EM. Our analysis provides an insight to the prevalent areas of study being cited within our field of practice.

Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. Bb, the active fragment of complement factor B (fB), has been reported to be a predictor of preeclampsia. However, conflicting results have been found by some investigators. We hypothesized that the disagreement in findings may be due to the racial/ethnic differences among various study groups, and that fB activation is significant in women of an ethnic minority with preeclampsia. We investigated the maternal and fetal levels of Bb (the activated fB fragment) in pregnant women of an ethnic minority with or without preeclampsia. We enrolled 291 pregnant women (96% of an ethnic minority, including 78% African-American). Thirteen percent of these were diagnosed with preeclampsia. Maternal venous blood was collected from all participants together with fetal umbilical cord blood samples from 154 deliveries in the 291 women. The results were analyzed using the Mann-Whitney U test and multivariate analyses. Maternal Bb levels were significantly higher in the preeclamptic group than in the nonpreeclamptic group. Levels of Bb in fetal cord blood were similar in both groups. Subgroup analyses of African-American patients' results confirmed the study hypothesis that there would be a significant increase in Bb in the maternal blood of the preeclamptic group and no increase in Bb in the fetal cord blood of this group. These results suggest that a maternal immune response through complement fB might play a role in the development of preeclampsia, particularly in African-American patients.

Objectives Despite evidence demonstrating equivalent accuracy of sonography and computed tomography (CT) in the workup of mild/uncomplicated acute diverticulitis, CT is overwhelmingly performed as the initial diagnostic test, particularly in the acute setting. Our study evaluated potential radiation and turnaround time savings associated with performing sonography instead of CT as the initial diagnostic examination in the workup of suspected uncomplicated acute diverticulitis. Methods We retrospectively reviewed medical records from January 2010 to December 2012 for patients presenting with clinical symptoms of acute diverticulitis. Patients were categorized as a whole and subgrouped by age (>40 and 40 years and 121

OBJECTIVE. Colorectal emergencies are a common presentation in the emergency medicine setting and their timely diagnosis plays a crucial role in avoiding dreaded complications. The quintessential role of a radiologist lies in identifying the cause, narrowing the differential diagnosis according to imaging features, and, most importantly, identifying the associated complications. CONCLUSION. This review focuses on imaging features of the spectrum of colitides and the complications related to colitides.

OBJECTIVE. In this article, we illustrate imaging findings of colorectal emergencies encountered in the acute setting that are primarily noninfectious and noninflammatory in origin. Our review should enable the reader to identify and understand common colorectal emergencies and related complications in clinical practice. CONCLUSION. The diagnosis of colorectal emergencies is mostly straightforward, but it can be challenging because of the overlap of presenting symptoms and imaging findings. Therefore, it is essential to clarify the cause, narrow the differential diagnosis, and identify associated complications.

Aim. To determine absorbed radiation dose (ARD) in radiosensitive organs during prospective and full phase dose modulation using ECG-gated MDCTA scanner under 64- and 320-row detector modes.Methods. Female phantom was used to measure organ radiation dose. Five DP-3 radiation detectors were used to measure ARD to lungs, breast, and thyroid using the Aquilion ONE scanner in 64- and 320-row modes using both prospective and dose modulation in full phase acquisition. Five measurements were made using three tube voltages: 100, 120, and 135 kVp at 400 mA at heart rate (HR) of 60 and 75 bpm for each protocol. Mean acquisition was recorded in milligrays (mGy).Results. Mean ARD was less for 320-row versus 64-row mode for each imaging protocol. Prospective EKG-gated imaging protocol resulted in a statistically lower ARD using 320-row versus 64-row modes for midbreast (6.728 versus 19.687 mGy,P<0.001), lung (6.102 versus 21.841 mGy,P<0.001), and thyroid gland (0.208 versus 0.913 mGy;P<0.001). Retrospective imaging using 320- versus 64-row modes showed lower ARD for midbreast (10.839 versus 43.169 mGy,P<0.001), lung (8.848 versus 47.877 mGy,P<0.001), and thyroid gland (0.057 versus 2.091 mGy;P<0.001). ARD reduction was observed at lower kVp and heart rate.Conclusions. Dose reduction to radiosensitive organs is achieved using 320-row compared to 64-row modes for both prospective and retrospective gating, whereas 64-row mode is equivalent to the same model 64-row MDCT scanner.

As musculoskeletal disorders are a common cause of emergency department visits in the United States, it is vital for nurses and nurse practitioners to understand the decision rules for ordering imaging tests when triaging patients with musculoskeletal complaints. Proper knowledge and command of selecting the most appropriate imaging for these frequent emergency department presentations will help reduce costs, decrease ionizing radiation exposure, and increase patient throughput. This article reviews the current evidence-based literature for musculoskeletal imaging in the emergency department and discusses the epidemiology, etiology, management, and prevention of the most common musculoskeletal disorders.

Headache is a common complaint. This disorder affects 46% of the world’s adult population. The importance of treating traumatic headaches is widely known. It is debated whether similar perseverance should be used when managing patients with nontraumatic headaches (NTHs). According to the 2012 Annual Report of the Centers for Disease Control and Prevention, 3.3% of adult patients visit emergency departments seeking treatment for headaches. Headaches may be the manifestation of easily recognizable states or that of vague conditions, such as cerebral venous sinus thrombosis. These variabilities make the diagnosis of NTH challenging, particularly in the ED setting. Clinical algorithms advocate the use of neuroimaging, such as computed tomography (CT) scans of the head, to evaluate patients presenting to emergency departments

INTRODUCTION Faculty awards provide an incentive to encourage higher standards of personal performance, which closely reflects the quality of health care. We report the development and implementation of the first medical faculty award program in the region. MATERIAL AND METHODS Anonymous preaward survey evaluated responses to understand the overall state of our institution. Five awards were celebrated. An anonymous postaward survey gathered responses to evaluate the effectiveness of the program. RESULTS A total of 60% (307/509) of preaward survey responses were collected. Among those, 92% (283/307) felt that employee recognition was important and 78% (240/307) felt that performance should be the deciding criteria for employee recognition. A 24% (20/85) of the faculty received the decade of excellence award and 13% (11/85) received the compassionate physician award. Best service award was granted to 7% (6/85) of the nominees. Postaward survey showed 68% (170/250) agreed that the award ceremony incentivized them to increase quality of personal performance. CONCLUSION In summary, we feel that this transparent, objective, and peer-nominated awards program could serve as an incentivized model for health care providers to elevate the standards of personal performance, which in turn will benefit the advancement of patient care.

A broad spectrum of congenital coronary anomalies may be discovered on imaging and sometimes in the emergency setting on computed tomography (CT). Most coronary artery anomalies are of academic interest; however, a minority can cause morbidity and mortality and symptoms such as angina, myocardial infarction, or arrhythmias. These anomalies are usually discovered as an incidental finding on CT examinations as part of the diagnostic workup for other pathology or on dedicated coronary computed tomography angiography (CCTA) as part of the evaluation for a coronary cause of chest pain. The purpose of this pictorial review is to demonstrate the types of coronary anomalies and to enhance the clinicians’ understanding of the imaging classifications and clinical implications.

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

OBJECTIVE. The aim of this article is to illustrate the imaging findings and spectrum of disease entities affecting the aorta. The clinical presentation and assessment of acute aortic pathology can be elusive or deceptive, making the diagnosis challenging. The widespread availability of advanced cross-sectional imaging technology in the emergency setting puts the radiologist at the forefront of accurate and timely diagnosis. CONCLUSION. Cross-sectional imaging plays a pivotal role in the diagnosis and delineation of aortic pathology. Awareness of the imaging findings and complications can help in swift and accurate diagnosis.

Background Bedside ultrasonography has become a valuable tool in the emergent care setting for triage and rapid evaluation of patients who are acutely ill. Given the cross-sectional nature of ultrasound technology, incidental findings are frequently encountered during imaging. These can impact clinical management and can pose a diagnostic dilemma for emergency medicine (EM) physicians and EM residents. Purpose Our retrospective study was designed to evaluate the prevalence and detection rate of incidental findings on bedside ultrasound examinations performed by EM residents. We also sought to identify types of incidental findings encountered and the diagnostic accuracy of those findings. Materials and Methods Board-certified radiologists retrospectively reviewed bedside ultrasonography examinations performed and interpreted by EM residents at a large urban academic hospital. Our sample included patients who presented with traumatic and nontraumatic symptoms in the acute setting. Findings were defined as incidental only if they were previously unknown and not related to a patients presenting symptoms. The results were corroborated with electronic medical records and additional pertinent imaging when available. Results Of 196 examinations analysed, EM residents identified incidental findings on 26% of the studies, which mostly involved the renal and biliary system. Radiologist review detected incidental findings in 20.9% but was more accurate when supplemental imaging was available. EM residents detected incidental findings at rates similar to that published previously and had moderate interobserver agreement with radiologist review. Worrisome and indeterminate findings were confirmed by additional work-up and further imaging. Conclusion Incidental findings are frequently encountered on bedside ultrasonography and have the potential to alter clinical management. Expertise in detection and knowledge of the presence and spectrum of these incidental findings is essential for appropriate triage, patient management, and follow-up.

Award incentives encourage higher standards of personal performance, which closely reflects the quality of patient care. We report the development, implementation, and success of our internal medicine department awards program. An anonymous pre award survey collected responses to understand the need for an awards program in our department. Five awards were celebrated. An anonymous post award survey collected responses to evaluate the effectiveness of the program. A total of 69 % (175/253) of pre award survey responses were collected. Among those, 100 % (175/175) agreed that employee recognition was important. 68 % (119/175) felt that performance should be the deciding criteria for employee recognition. There was a winner in each award category. Post award survey showed 78 % (102/130) agreed that the award ceremony incentivized them to increase quality of personal performance. In summary, we feel that this transparent, objective, and peer-nominated awards program could serve as an incentivized model for healthcare providers to elevate the standards of personal performance, which in turn will benefit the advancement of patient care.

The aim of this study was to identify the risk factors associated with noncompliance of recommendations made by emergency radiologists. Between March 2012 and August 2012, our team retrospectively reviewed 20,000 consecutive emergency department (ED) patients receiving imaging to assess how often emergency radiologists made recommendations, how often they were followed, and what factors were associated with noncompliance. Faculty (Radiology or Emergency Medicine) were considered senior if they had been practicing for >5 years post residency/fellowship training. Faculty practicing

Purpose:To date there is extensive data on the radiation dose for assessing coronary artery calcium scores (CACS) with 4-64 row multidetector MDCT. However with the advent of 320 row MDCT, the entire heart can be imaged in one beat and thus potentially reduce the radiation dose. The aim of this study was to evaluate radiation dose for CACS on low-dose prospective EKG-triggered 320 row MDCT.Materials and Methods: Informed consent for this retrospective HIPAA-compliant study was waived and approved by our institution’s institutional review board IRB. One hundred and sixty eight consecutive patients (Male 133 (79%): female 35 (21%), mean body mass index BMI 29±5 and mean heart rate 58± bpm) underwent coronary calcium scoring with prospective gating. The scan parameters were 300 mA, 120 kVp, volume scan length (VSL) 160 mm, gantry rotation 0.350 msec and 320 x 0.5 mm detectors at 320 MDCT. Beta blockers were given to patients in a case heart rate HR > 65 bpm. The effective dose (ED) estimates were calculated for all patients from the dose length product and the conversion factor k (0.014 mSv/mGy/cm) as recommended by current guidelines.Results: The mean SD radiation was 1.89±0.79 mSv. Overall the range varied from 0.28-2.48 mSv. The radiation was significantly less in females as compared to males (2.02±0.73 vs. 1.41±0.87, p=60 bpm (1.87±0.79 vs. 1.77±0.84 mSv, p=0.45). On the other hand a higher radiation was noted among obese individuals as compared to those with BMIConclusion: Radiation dose obtained from 320-MDCT is similar to those obtained with 4-64 row MDCT. Further studies are needed to assess the feasibility of further lowering the tube current and tube voltage.------------------------------------------------Cite this article as:Khosa F, Khan A, Shuaib W, Clouse M, Budoff M, Blankstein R, Nasir K. Radiation exposure for coronary artery calcium score at prospective 320 row multi-detector computed tomography. Int J Cancer Ther Oncol 2013; 1(2):01023.DOI: http://dx.doi.org/10.14319/ijcto.0102.3

Rib series rarely add information to the posteroanterior (PA) film for the diagnosis of rib fractures. In this investigation, we evaluated the utility of rib X-rays using turnaround time (TAT), radiation exposure, and cost-efficiency as the key parameters. This investigation was conducted from January 2008 to December 2012. We included patients who had rib series performed for suspected rib fractures. TAT for patients was calculated from the time exam was ordered by the emergency department (ED) physician/staff to time the report was finalized by the attending radiologist. Effective radiation dose for rib series was calculated as a summation of radiation dose from the standard rib series images for each patient. Cost-efficiency was determined based on the number of interventions that took place as a result of a complicated study. Our investigation consisted of 422 patients, 208 females aged (57 ± 20.8) and 214 males aged (48 ± 17.3). A total of 74(17.5 %) abnormal findings were noted, out of which only 1(0.23 %) underwent management change. The mean turnaround time for patients undergoing rib series had a value of 133.5 (±129.8) min as opposed to a single chest PA of 61.8(± 64) min. Average effective radiation dose for a rib series was 0.105 (±0.04) mSv, whereas average effective radiation dose of a single chest PA was 0.02 mSv. Dedicated rib series has a low-yield diagnostic value as it pertains to management change. The overall impact on patient care based on our findings is small when compared to the risks associated with prolonged TAT, repeated exposure to radiation, and extensive medical costs.