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OBJECTIVES: To investigate whether high concentration iodinated contrast media (CM), compared with low concentration CM, could reduce pain and discomfort levels in patients who had level II and III venous conditions. METHODS: This prospective, single-center study enrolled patients who had level II and III venous conditions and underwent abdominal contrast-enhanced CT scan between July 2021 and February 2022. The venous condition to establish peripheral venous access for CM injection was graded using the Intravenous Access Scoring system, of which level II and III indicated poor venous condition and difficult venous access. Patients received iomeprol 400 in high concentration group and ioversol 320 in low group at an identical iodine delivery rate of 1.12 gI/s. The primary outcomes were pain and comfort levels. The secondary outcomes included adverse events and image quality. Patients rated pain intensity via Numerical Rating Scale and comfort level via Visual Analogue Scale with higher scores indicating higher levels of pain and discomfort. Quantitative and qualitative image assessment were compared between two groups. Continuous variables were compared using Student's t test or Mann-Whitney U test. Categorical variables were compared using χ2 test, χ2 test for trend or Fisher's exact test. RESULTS: A total of 206 patients (mean age, 60.13 ± 12.14 years; 81 males) were included with 99 in the high concentration group and 107 in the low concentration group. The high group had significantly lower pain scores (median 1 [IQR: 0-2] vs 2 (IQR 2-4), p < 0.001) and comfort scores (1 [IQR: 0-3] vs 3 [IQR: 2-5], p < 0.001) than the low group. Incidence of CM extravasation did not significantly differ (1.0 % vs 4.5 %, p = 0.214). No hypersensitivity reaction was observed. Qualitative assessment showed higher clarity scores of intrahepatic hepatic artery and portal vein in the high group. Quantitative assessment results were comparable between two groups. CONCLUSION: High concentration iodinated CM could lower pain intensity and improve comfort levels without comprising image quality of CT scan. High concentration CM is a preferable choice in patients with poor venous conditions during contrast-enhanced CT scan.

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The esophagus is rarely affected by Mycobacterium A 75-y-old man presented with upper abdominal pain and significant weight loss for 2 mo. Contrast-enhanced CT, upper gastrointestinal endoscopy, and abdominal vessel angiography gave normal results. To clarify the facts, 18F-FDG PET/CT was performed, revealing an 18F-FDG-avid lesion in the posterior wall of the lower thoracic esophagus. On endoscopic ultrasound-guided fine-needle aspiration of this lesion, puslike material was released. On microscopic examination, acid-fast bacilli were noted. The patient then began receiving standard antitubercular therapy.

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BACKGROUND: Computed tomography (CT) is frequently performed in the patients who admitted to the emergency department (ED), discharged but returned to ED within 72 h. It is unknown whether the main complaints of patients assist physicians to use CT effectively. This study aimed to find the association between chief complaints and the CT results. METHODS: This three-year retrospective cohort study was conducted in the ED of a tertiary medical center. Adult patients who returned to the ED after the index visit were included from 2019 to 2021. Demographics, pre-existing diseases, chief complaints, and CT region were recorded by independent ED physicians. A logistic regression model with an odds ratio (OR) and 95% confidence interval (CI) was used to determine the relationship between chief complaints and positive CT results. RESULTS: In total, 7,699 patients revisited ED after the index visit; 1,202 (15.6%) received CT. The top chief complaints in patients who received CT were abdominal pain, dizziness, and muscle weakness. Patients with abdominal pain or gastrointestinal symptoms had a significantly higher rate of positive abdominopelvic CT than those without it (OR 2.83, 95% CI 1.98-4.05, p < 0.001), while the central nervous system and cardiopulmonary chief complaints were not associated (or negatively associated) with new positive CT findings. CONCLUSION: Chief complaints of patients on revisit to the ED are associated with different yields of new findings when CT scans of the chest, abdomen and head are performed. Physicians should consider these differential likelihoods of new positive findings based on these data.

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Introduction: During the coronavirus 2019 pandemic, hospitals in the United States experienced a shortage of contrast agent, much of which is manufactured in China. As a result, there was a significantly decreased amount of intravenous (IV) contrast available. We sought to determine the effect of restricting the use of IV contrast on emergency department (ED) length of stay (LOS). Methods: We conducted a single-institution, retrospective cohort study on adult patients presenting with abdominal pain to the ED from March 7-July 5, 2022. Of 26,122 patient encounters reviewed, 3,028 (11.6%) included abdominopelvic CT with a complaint including "abdominal pain." We excluded patients with outside imaging and non-ED scans. Routine IV contrast agent was administered to approximately 74.6% of patients between March 7-May 6, 2022, when we altered usage guidelines due to a nationwide shortage. Between May 6-July 5, 2022, 32.8% of patients received IV contrast after institutional recommendations were made to limit contrast use. We compared patient demographics and clinical characteristics between groups with chi-square test for frequency data. We analyzed ED LOS with nonparametric Wilcoxon rank-sum test for continuous measures with focus before and after new ED protocols. We also used statistical process control charts and plotted the 1, 2 and 3 sigma control limits to visualize the variation in ED LOS over time. The charts include the average (mean) of the data and upper and lower control limits, corresponding to the number of standard deviations away from the mean. Results: After use of routine IV contrast was discontinued, ED LOS (229.0 vs 212.5 minutes, P = <0.001) declined by 16.5 minutes (95% confidence interval -10, -22). Conclusion: Intravenous contrast adds significantly to ED LOS. Decreased use of routine IV contrast in the ED accelerates time to CT completion. A policy change to limit IV contrast during a national shortage significantly decreased ED LOS.

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PURPOSE: Radiologists with diverse training, specialization, and habits interpret imaging in the Emergency Department. It is necessary to understand if their variation predicts differential value. The purpose of this study was to determine whether attending radiologist variation predicts major clinical outcomes in adult Emergency Department patients imaged with ultrasound for right upper quadrant pain. METHODS: Consecutive ED patients imaged with ultrasound for RUQ pain from 10/8/2016 to 8/10/2022 were included (N = 7097). The primary outcome was prediction of hospital admission by signing attending radiologist. Secondary outcomes included: ED and hospital length of stay (LOS), 30-day mortality, 30-day re-presentation rate, subspecialty consultation, advanced imaging follow up (HIDA, MRI, CT), and intervention (ERCP, drainage or surgery). Sample size was determined a priori (detectable effect size: w = 0.06). Data were adjusted for demographic data, Elixhauser comorbidities, number of ED visits in prior year, clinical data, and system factors (38 covariates). P-values were corrected for multiple comparisons (false discovery rate-adjusted p-values). RESULTS: The included ultrasounds were read by 35 radiologists (median exams/radiologist: 145 [74.5-241.5]). Signing radiologist did not predict hospitalization (p = 0.85), abdominopelvic surgery or intervention within 30 days, re-presentation to the Emergency Department within 30 days, or subspecialty consultation. Radiologist did predict difference in Emergency Department length of stay (p < 0.001) although this difference was small and imprecise. HIDA was mentioned variably by radiologists (range 0-19%, p < 0.001), and mention of HIDA in the ultrasound report increased 10-fold the odds of HIDA being performed in the next 72 h (odds ratio 10.4 [8.0-13.4], p < 0.001). CONCLUSION: Radiologist variability did not predict meaningful outcome differences for patients with right upper quadrant pain undergoing ultrasound in the Emergency Department, but when radiologists mention HIDA in their reports, it predicts a 10-fold increase in the odds a HIDA is performed. Radiologists are relied on for interpretation that shapes subsequent patient care, and it is important to consider how radiologist variability can influence both outcome and resource utilization.

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This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.

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BACKGROUND: Abdominal pain is common in patients visiting the emergency department (ED). The aim of this study was to assess the diagnostic contribution of point-of-care ultrasound (POCUS) in patients presenting to the ED with acute abdominal pain. METHODS: We designed an interventional randomized, controlled, open label, parallel-group, trial in two French EDs. We included adult patients presenting to the ED with acute abdominal pain. Exclusion criteria were a documented end-of-life, an immediate need of life-support therapy and pregnant or breast-feeding women. Patients were randomized in the experimental group (i.e., workup including POCUS) or control group (usual care). The primary objective of the study was to assess the added value of POCUS on diagnostic pathway in the ED, according to the diagnostic established a posteriori by an adjudication committee. The primary endpoint was the proportion of exact preliminary diagnosis between the 2 groups. The preliminary diagnosis made after clinical examination and biological results with POCUS (intervention arm) or without POCUS (usual care) was considered exact if it was similar to the adjudication committee diagnosis. RESULTS: Between June 2021 11th and June 2022 23th, 256 patients were randomized, but five were not included in the primary analysis, leaving 125 patients in the POCUS group and 126 patients in the usual care group (130 women and 121 men, median [Q1-Q3] age: 42 [30;57]). There was no difference for exact diagnosis between the two groups (POCUS 70/125, 56% versus control 78/126 (62%), RD 1.23 [95% CI 0.74-2.04]). There was no difference in the accuracy for the diagnosis of non-specific abdominal pain nor number of biological or radiological exams. Diagnostic delays and length of stay in the ED were also similar. CONCLUSIONS: In this trial, systematic POCUS did not improve the rate of diagnostic accuracy in unselected patients presenting to the ED with acute abdominal pain. However, as it was a safe procedure, further research should focus on patients with suspected etiologies where POCUS is particularly useful. TRIAL REGISTRATION:  This trial was registered on ClinicalTrials.gov on 2022/07/20 ( https://clinicaltrials.gov/study/NCT04912206?id=NCT04912206&rank=1 ) (NCT04912206).

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OBJECTIVE: Our objective was to determine if there was a significant change in computed tomography (CT) utilization or length of stay (LOS) among patients evaluated for acute appendicitis after implementation of an appendicitis evaluation algorithm. METHODS: We conducted a retrospective chart review of patients aged 3-18 years in an urban, tertiary pediatric emergency department with acute abdominal pain, evaluated for appendicitis. Data were collected for 6 months preimplementation and postimplementation of the evaluation algorithm with a 3-month washout period between September 2018 and November 2019. Main outcomes were rate of CT utilization and LOS preimplementation and postimplementation and were analyzed using χ 2 test and Mann-Whitney U test, respectively. Descriptive analysis of demographics was performed, in addition to logistic regression to assess differences between the 2 study periods. RESULTS: A total of 2872 charts were identified with a chief complaint inclusive of "abdominal pain." Of these, 1510 met age requirements but did not meet at least 1 inclusion criteria; 229 more were excluded upon chart review for a final study sample of 1133 patients. Of these, 648 (57.2%) were female, 747 (65.9%) were White, and 988 (87.2%) were non-Hispanic. The majority of patients (770, 68%) were discharged home from the emergency department without a diagnosis of acute appendicitis. Neither CT (25.7% to 24.8%; P = 0.794) nor ultrasound (59.5% to 59.7%; P = 1.000) utilization significantly changed postimplementation. Total ED median LOS increased significantly (333.50 to 362.00 minutes; P = 0.011). Significant factors associated with CT utilization included fever, migration of pain, and right lower quadrant tenderness. Significant factors associated with appendicitis diagnosis included right lower quadrant pain, nausea/vomiting, migration of pain, and peritoneal signs. CONCLUSIONS: Overall, the appendicitis evaluation algorithm did not significantly decrease CT utilization or LOS. Equivocal grade 2 or 3 ultrasound finding rates were high, likely leading to higher rates of CT utilization and increasing LOS.

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INTRODUCTION: Agenesis of the right hepatic lobe is a rare congenital anomaly. Developmental anomalies of the right lobe of the liver were first reported in 1870 by Heller [6]. Anatomical variations of the liver are common, occur during the normal development of the organ, and correspond to variations in the distribution of liver territories. Agenesis of the right lobe of the liver is an incidental finding revealed by the popularization of ultrasonography, computed tomography, or magnetic resonance imaging due to the condition being asymptomatic. CASE PRESENTATION: A 35-year-old Ethiopian female patient presented to the outpatient clinic with a complaint of right upper abdominal pain for 1 year, along with symptoms of fatty meal intolerance and long-standing epigastric burning pain. Her examination was unremarkable, and imaging investigations were suggestive of right hepatic lobe agenesis with multiple gallstones. Therefore, the patient was operated on and discharged with no perioperative complications. CONCLUSION: Surgical understanding of such anatomical anomalies is necessary for surgical planning, the appropriate interpretation of intraoperative surgical findings, and the design of postoperative therapy. Here we report a case of right hepatic lobe agenesis with cholelithiasis and cholidocholithiasis and a brief review of right lobe agenesis in the literature.

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59-year-old man, smoker, diabetic and hypertensive. He went to the ER due to fixed abdominal pain in the epigastrium, diaphoresis, dizziness, nausea, and "coffee grounds" vomiting. On examination he presented abdominal distension and pain on palpation in the epigastrium, without peritonism. He had a BP of 235/100 mmHg and in the blood-tests, leukocytosis with neutrophilia and normal hemoglobin. An urgent abdominal CT scan was performed, identifying a 5x6 cm nodular lesion of homogeneous density attached to the wall of the second and third duodenal portions that compressed the lumen, with two vessels with active bleeding within it. Therefore, percutaneous embolization of the gastroduodenal artery was performed. Subsequently, the patient suffered an episode of severe acute pancreatitis that required ICU admission. Finally, he presented a good clinical evolution with ceasing of pain, complete reabsorption of the hematoma and resolution of the obstructive symptoms.

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