Imaging

Case

A 54-year-old woman with history of active multiple sclerosis (MS) presented to the ED with left wrist pain after sustaining a mechanical fall 9 days earlier. On physical examination, the patient had minimal left wrist swelling with circumferential tenderness to palpation at both the distal radius and distal ulna, as well as snuff-box tenderness. Posterioranterior and lateral radiographs of the wrist were obtained (Figures 1 and 2).

What is the diagnosis?

Radiographs of the left wrist demonstrated cortically based sclerosis of the ulna, triquetrum, and hamate; no fracture or dislocation was seen. This pattern of cortical bone formation, described as the “dripping candle wax” sign, is characteristic for melorheostosis, a rare nonhereditary mixed sclerosing bone dysplasia.

Sclerosing bone dysplasias include a wide range of both hereditary and nonhereditary skeletal abnormalities that result from a disturbance in the bone ossification pathway. These dysplasias can be categorized as disruptions in endochondral bone formation, disruptions in intramembranous bone formation, or mixed. First described by Leri and Joanny in 1922, there have been approximately 400 reported cases of melorheostosis since its initial identification.^1,2

In melorheostosis, the distribution of lesions follows sclerotomes, skeletal regions supplied by a single spinal sensory nerve. The condition manifests as cortical and medullary hyperostosis involving one side of the bone (eg, medial or lateral) with a clear distinction between affected bone and the adjacent normal bone. As in this case, the radiographic appearance of melorheostosis is almost always sufficient for diagnosis.

Melorheostosis has no gender predilection and is usually diagnosed in late adolescence or early adulthood.5 While the etiology is unknown, genetic analyses have found a common loss-of-function mutation on chromosome 12q (LEMD3) associated with several sclerosing bone dysplasias, including melorheostosis, suggesting a common etiology.3 In addition, since melorheostosis typically has a sclerotomal distribution, some theories postulate that it represents an acquired defect of the spinal sensory nerves.¹

Patients generally present with pain, stiffness, and occasionally joint swelling in the involved regions. Although any bone can be involved, the extremities are most often affected, with the disease frequently polyostotic, but rarely bilateral.^4,5 In hyperostosis involving a joint, muscular atrophy, tendon and ligament shortening, and muscle contractures may be seen, which can limit range of motion.⁶ Some cases of leg-length discrepancy have also been described. Skeletal lesions may progress, but there is no reported risk of pathological fracture or malignant degeneration.⁷

Treatment is dependent on the patient’s age, location of involved bone, and specific symptoms. The major goals of treatment are pain relief and preserving or restoring full range of motion. Therapy is generally focused on conservative techniques such as analgesics, braces, and physical therapy. Occasionally, surgical treatment is necessary, including soft-tissue release, fasciotomy, tendon lengthening, and arthroplasty.⁸

In the ED setting, it is important to recognize melorheostosis as the source of pain as this condition may be confused with osseous neoplasm. Based on this patient’s underlying partially treated MS flare and the potential for recurring fall, admission was recommended for intravenous corticosteroids. The patient, however, was only amenable to a wrist splint and refused further treatment.

Dr Escalon is second-year postgraduate resident, the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York.

Dr Loftus is an assistant professor of radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York.

Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College in New York City. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

Case

A 54-year-old woman with history of active multiple sclerosis (MS) presented to the ED with left wrist pain after sustaining a mechanical fall 9 days earlier. On physical examination, the patient had minimal left wrist swelling with circumferential tenderness to palpation at both the distal radius and distal ulna, as well as snuff-box tenderness. Posterioranterior and lateral radiographs of the wrist were obtained (Figures 1 and 2).

What is the diagnosis?

Radiographs of the left wrist demonstrated cortically based sclerosis of the ulna, triquetrum, and hamate; no fracture or dislocation was seen. This pattern of cortical bone formation, described as the “dripping candle wax” sign, is characteristic for melorheostosis, a rare nonhereditary mixed sclerosing bone dysplasia.

Sclerosing bone dysplasias include a wide range of both hereditary and nonhereditary skeletal abnormalities that result from a disturbance in the bone ossification pathway. These dysplasias can be categorized as disruptions in endochondral bone formation, disruptions in intramembranous bone formation, or mixed. First described by Leri and Joanny in 1922, there have been approximately 400 reported cases of melorheostosis since its initial identification.^1,2

In melorheostosis, the distribution of lesions follows sclerotomes, skeletal regions supplied by a single spinal sensory nerve. The condition manifests as cortical and medullary hyperostosis involving one side of the bone (eg, medial or lateral) with a clear distinction between affected bone and the adjacent normal bone. As in this case, the radiographic appearance of melorheostosis is almost always sufficient for diagnosis.

Melorheostosis has no gender predilection and is usually diagnosed in late adolescence or early adulthood.5 While the etiology is unknown, genetic analyses have found a common loss-of-function mutation on chromosome 12q (LEMD3) associated with several sclerosing bone dysplasias, including melorheostosis, suggesting a common etiology.3 In addition, since melorheostosis typically has a sclerotomal distribution, some theories postulate that it represents an acquired defect of the spinal sensory nerves.¹

Patients generally present with pain, stiffness, and occasionally joint swelling in the involved regions. Although any bone can be involved, the extremities are most often affected, with the disease frequently polyostotic, but rarely bilateral.^4,5 In hyperostosis involving a joint, muscular atrophy, tendon and ligament shortening, and muscle contractures may be seen, which can limit range of motion.⁶ Some cases of leg-length discrepancy have also been described. Skeletal lesions may progress, but there is no reported risk of pathological fracture or malignant degeneration.⁷

Treatment is dependent on the patient’s age, location of involved bone, and specific symptoms. The major goals of treatment are pain relief and preserving or restoring full range of motion. Therapy is generally focused on conservative techniques such as analgesics, braces, and physical therapy. Occasionally, surgical treatment is necessary, including soft-tissue release, fasciotomy, tendon lengthening, and arthroplasty.⁸

In the ED setting, it is important to recognize melorheostosis as the source of pain as this condition may be confused with osseous neoplasm. Based on this patient’s underlying partially treated MS flare and the potential for recurring fall, admission was recommended for intravenous corticosteroids. The patient, however, was only amenable to a wrist splint and refused further treatment.

Dr Escalon is second-year postgraduate resident, the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York.

Dr Loftus is an assistant professor of radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York.

Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College in New York City. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

Case

A 54-year-old woman with history of active multiple sclerosis (MS) presented to the ED with left wrist pain after sustaining a mechanical fall 9 days earlier. On physical examination, the patient had minimal left wrist swelling with circumferential tenderness to palpation at both the distal radius and distal ulna, as well as snuff-box tenderness. Posterioranterior and lateral radiographs of the wrist were obtained (Figures 1 and 2).

What is the diagnosis?

Radiographs of the left wrist demonstrated cortically based sclerosis of the ulna, triquetrum, and hamate; no fracture or dislocation was seen. This pattern of cortical bone formation, described as the “dripping candle wax” sign, is characteristic for melorheostosis, a rare nonhereditary mixed sclerosing bone dysplasia.

Sclerosing bone dysplasias include a wide range of both hereditary and nonhereditary skeletal abnormalities that result from a disturbance in the bone ossification pathway. These dysplasias can be categorized as disruptions in endochondral bone formation, disruptions in intramembranous bone formation, or mixed. First described by Leri and Joanny in 1922, there have been approximately 400 reported cases of melorheostosis since its initial identification.^1,2

In melorheostosis, the distribution of lesions follows sclerotomes, skeletal regions supplied by a single spinal sensory nerve. The condition manifests as cortical and medullary hyperostosis involving one side of the bone (eg, medial or lateral) with a clear distinction between affected bone and the adjacent normal bone. As in this case, the radiographic appearance of melorheostosis is almost always sufficient for diagnosis.

Melorheostosis has no gender predilection and is usually diagnosed in late adolescence or early adulthood.5 While the etiology is unknown, genetic analyses have found a common loss-of-function mutation on chromosome 12q (LEMD3) associated with several sclerosing bone dysplasias, including melorheostosis, suggesting a common etiology.3 In addition, since melorheostosis typically has a sclerotomal distribution, some theories postulate that it represents an acquired defect of the spinal sensory nerves.¹

Patients generally present with pain, stiffness, and occasionally joint swelling in the involved regions. Although any bone can be involved, the extremities are most often affected, with the disease frequently polyostotic, but rarely bilateral.^4,5 In hyperostosis involving a joint, muscular atrophy, tendon and ligament shortening, and muscle contractures may be seen, which can limit range of motion.⁶ Some cases of leg-length discrepancy have also been described. Skeletal lesions may progress, but there is no reported risk of pathological fracture or malignant degeneration.⁷

Treatment is dependent on the patient’s age, location of involved bone, and specific symptoms. The major goals of treatment are pain relief and preserving or restoring full range of motion. Therapy is generally focused on conservative techniques such as analgesics, braces, and physical therapy. Occasionally, surgical treatment is necessary, including soft-tissue release, fasciotomy, tendon lengthening, and arthroplasty.⁸

In the ED setting, it is important to recognize melorheostosis as the source of pain as this condition may be confused with osseous neoplasm. Based on this patient’s underlying partially treated MS flare and the potential for recurring fall, admission was recommended for intravenous corticosteroids. The patient, however, was only amenable to a wrist splint and refused further treatment.

Dr Escalon is second-year postgraduate resident, the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York.

Dr Loftus is an assistant professor of radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, New York.

Dr Hentel is an associate professor of clinical radiology, Weill Cornell Medical College in New York City. He is also chief of emergency/musculoskeletal imaging and executive vice-chairman for the department of radiology, New York-Presbyterian Hospital/Weill Cornell Medical Center. He is associate editor, imaging, of the EMERGENCY MEDICINE editorial board.

NAPLES, FLA. – They sizzle, they buzz, they vibrate. And they’re sending some children to the emergency department.

"One of the newest things we’re seeing a fair amount of are magnets, those sizzle magnets," reported Karen Macauley, DHA, R.N., trauma program director, All Children’s Hospital, St. Petersburg, Fla., and secretary of the Society of Trauma Nurses.

So-called "sizzle" magnets make a sound when they connect and are being sold as novelty toys, jewelry, and even for purported health benefits. One website specializing in gifts for the visually impaired notes that the magnetic field of these hematite magnets is "so strong," they’ll stay put if placed on the front and back of hands or ear lobes.

That strong magnetic force, however, can create havoc if children ingest magnets of any kind, Dr. Macauley said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

"If the magnets stay in a string, they’re probably okay; but if they swallow one and wait a little while and swallow another, you can start to imagine what happens as it starts to pass through," she said. "One magnet stays, another comes in another part of the bowel, and they sizzle together. Now all of a sudden you have magnets that aren’t moving and cause a lot of necrosis. They’re actually very dangerous, and we don’t think too much about how dangerous they can be."

Between 2009 and 2011, an estimated 1,700 emergency department visits occurred because of magnet ingestion, with more than 70% of those cases involving children between age 4 and 12 years, according to researchers at the U.S. Public Interest Research Group, which highlighted magnets in its most recent annual toy safety survey.

Dr. Macauley also cautioned that button-size batteries, now in everything from remote controls to Grandma’s singing greeting card and hearing aid, are also a concern because they can cause burns or erode through tissue if ingested or put into body orifices.

"These batteries are everywhere, and kids do crazy stuff with them," she said.

Hemera/iStockphotos.com

The National Capital Poison Center, which operates a 24-hour National Battery Ingestion Hotline (202-625-3333)* for swallowed battery cases, estimates 3,500 Americans of all ages swallow miniature disc or button batteries each year.

The problem has been recognized for some time, but what few parents or providers realize is how quickly burns can occur, Dr. Macauley said.

She described a case involving a 6-year-old girl who picked up a small battery off the playground and amazed her friends by making it disappear in her ear. The child complained of severe pain overnight and presented to the emergency department in the morning, where surgery to remove the battery revealed third-degree burns to the ear canal and 65% perforation of the eardrum.

"It seemed like it should have been nothing; it was in there maybe 12 hours, but she had very severe injuries to her ear," Dr. Macauley said. "She’s been in the operating room probably a total of six different times trying to get that repaired, has a fair amount of hearing loss that stays, and ended up at a specialist hospital, out of network, to get a graft put in that ear."

Greeting card makers such as Hallmark have taken steps to secure button batteries, such as enclosing them underneath metal caps or in modules in which the cap is secured with screws. And the card makers warn consumers to properly dispose of old batteries after they’ve been replaced.

Dr. Macauley reported having no financial disclosures.

[email protected]

Correction, 3/5/2014: An earlier version of this article misstated the phone number for the Battery Ingestion hotline.

NAPLES, FLA. – They sizzle, they buzz, they vibrate. And they’re sending some children to the emergency department.

"One of the newest things we’re seeing a fair amount of are magnets, those sizzle magnets," reported Karen Macauley, DHA, R.N., trauma program director, All Children’s Hospital, St. Petersburg, Fla., and secretary of the Society of Trauma Nurses.

So-called "sizzle" magnets make a sound when they connect and are being sold as novelty toys, jewelry, and even for purported health benefits. One website specializing in gifts for the visually impaired notes that the magnetic field of these hematite magnets is "so strong," they’ll stay put if placed on the front and back of hands or ear lobes.

That strong magnetic force, however, can create havoc if children ingest magnets of any kind, Dr. Macauley said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

"If the magnets stay in a string, they’re probably okay; but if they swallow one and wait a little while and swallow another, you can start to imagine what happens as it starts to pass through," she said. "One magnet stays, another comes in another part of the bowel, and they sizzle together. Now all of a sudden you have magnets that aren’t moving and cause a lot of necrosis. They’re actually very dangerous, and we don’t think too much about how dangerous they can be."

Between 2009 and 2011, an estimated 1,700 emergency department visits occurred because of magnet ingestion, with more than 70% of those cases involving children between age 4 and 12 years, according to researchers at the U.S. Public Interest Research Group, which highlighted magnets in its most recent annual toy safety survey.

Dr. Macauley also cautioned that button-size batteries, now in everything from remote controls to Grandma’s singing greeting card and hearing aid, are also a concern because they can cause burns or erode through tissue if ingested or put into body orifices.

"These batteries are everywhere, and kids do crazy stuff with them," she said.

Hemera/iStockphotos.com

The National Capital Poison Center, which operates a 24-hour National Battery Ingestion Hotline (202-625-3333)* for swallowed battery cases, estimates 3,500 Americans of all ages swallow miniature disc or button batteries each year.

The problem has been recognized for some time, but what few parents or providers realize is how quickly burns can occur, Dr. Macauley said.

She described a case involving a 6-year-old girl who picked up a small battery off the playground and amazed her friends by making it disappear in her ear. The child complained of severe pain overnight and presented to the emergency department in the morning, where surgery to remove the battery revealed third-degree burns to the ear canal and 65% perforation of the eardrum.

"It seemed like it should have been nothing; it was in there maybe 12 hours, but she had very severe injuries to her ear," Dr. Macauley said. "She’s been in the operating room probably a total of six different times trying to get that repaired, has a fair amount of hearing loss that stays, and ended up at a specialist hospital, out of network, to get a graft put in that ear."

Greeting card makers such as Hallmark have taken steps to secure button batteries, such as enclosing them underneath metal caps or in modules in which the cap is secured with screws. And the card makers warn consumers to properly dispose of old batteries after they’ve been replaced.

Dr. Macauley reported having no financial disclosures.

[email protected]

Correction, 3/5/2014: An earlier version of this article misstated the phone number for the Battery Ingestion hotline.

NAPLES, FLA. – They sizzle, they buzz, they vibrate. And they’re sending some children to the emergency department.

"One of the newest things we’re seeing a fair amount of are magnets, those sizzle magnets," reported Karen Macauley, DHA, R.N., trauma program director, All Children’s Hospital, St. Petersburg, Fla., and secretary of the Society of Trauma Nurses.

So-called "sizzle" magnets make a sound when they connect and are being sold as novelty toys, jewelry, and even for purported health benefits. One website specializing in gifts for the visually impaired notes that the magnetic field of these hematite magnets is "so strong," they’ll stay put if placed on the front and back of hands or ear lobes.

That strong magnetic force, however, can create havoc if children ingest magnets of any kind, Dr. Macauley said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

"If the magnets stay in a string, they’re probably okay; but if they swallow one and wait a little while and swallow another, you can start to imagine what happens as it starts to pass through," she said. "One magnet stays, another comes in another part of the bowel, and they sizzle together. Now all of a sudden you have magnets that aren’t moving and cause a lot of necrosis. They’re actually very dangerous, and we don’t think too much about how dangerous they can be."

Between 2009 and 2011, an estimated 1,700 emergency department visits occurred because of magnet ingestion, with more than 70% of those cases involving children between age 4 and 12 years, according to researchers at the U.S. Public Interest Research Group, which highlighted magnets in its most recent annual toy safety survey.

Dr. Macauley also cautioned that button-size batteries, now in everything from remote controls to Grandma’s singing greeting card and hearing aid, are also a concern because they can cause burns or erode through tissue if ingested or put into body orifices.

"These batteries are everywhere, and kids do crazy stuff with them," she said.

Hemera/iStockphotos.com

The National Capital Poison Center, which operates a 24-hour National Battery Ingestion Hotline (202-625-3333)* for swallowed battery cases, estimates 3,500 Americans of all ages swallow miniature disc or button batteries each year.

The problem has been recognized for some time, but what few parents or providers realize is how quickly burns can occur, Dr. Macauley said.

She described a case involving a 6-year-old girl who picked up a small battery off the playground and amazed her friends by making it disappear in her ear. The child complained of severe pain overnight and presented to the emergency department in the morning, where surgery to remove the battery revealed third-degree burns to the ear canal and 65% perforation of the eardrum.

"It seemed like it should have been nothing; it was in there maybe 12 hours, but she had very severe injuries to her ear," Dr. Macauley said. "She’s been in the operating room probably a total of six different times trying to get that repaired, has a fair amount of hearing loss that stays, and ended up at a specialist hospital, out of network, to get a graft put in that ear."

Greeting card makers such as Hallmark have taken steps to secure button batteries, such as enclosing them underneath metal caps or in modules in which the cap is secured with screws. And the card makers warn consumers to properly dispose of old batteries after they’ve been replaced.

Dr. Macauley reported having no financial disclosures.

[email protected]

Correction, 3/5/2014: An earlier version of this article misstated the phone number for the Battery Ingestion hotline.

SNOWMASS, COLO. – Detection of myocardial midwall fibrosis via cardiovascular magnetic resonance in patients with nonischemic dilated cardiomyopathy provides prognostic information independent of left ventricular ejection fraction.

"Low LVEF and fibrosis uniquely identify the need for an ICD [implantable cardioverter-defibrillator]. This is new information that helps refine our understanding of whom it is that’s uniquely at risk. We’ve always had these troublesome questions in patients with nonischemic heart failure," Dr. Clyde W. Yancy observed at the Annual Cardiovascular Conference at Snowmass.

He highlighted what he called "very provocative data" in a recent study led by Dr. Sanjay K. Prasad of Royal Brompton Hospital in London. The investigators evaluated 472 consecutive patients with nonischemic dilated cardiomyopathy using late gadolinium cardiovascular magnetic resonance (CMR). Thirty percent of them were found to have midwall fibrosis. Their all-cause mortality rate during a median 5.3 years of prospective follow-up was 26.8%, compared with 10.6% in the 330 patients without fibrosis. An arrhythmic composite event comprising sudden cardiac death (SCD), aborted SCD, or sustained ventricular tachycardia occurred in 29.6% of the group with fibrosis vs. 7% of patients without fibrosis.

In a multivariate analysis adjusted for LVEF and other prognostic factors, the presence of midwall fibrosis was independently associated with a 2.43-fold increased risk of all-cause mortality, a 3.2-fold greater risk of cardiovascular mortality or heart transplantation, a 4.6-fold increase in SCD or aborted SCD, and a 1.6-fold increased likelihood of a composite of heart failure hospitalization, mortality from heart failure, or cardiac transplantation (JAMA 2013;309:896-908).

Dr. Yancy, who chaired the writing committee for the 2013 ACC/AHA Guideline for the Management of Heart Failure, noted that the guidelines grant a strong Class I/Level of Evidence B recommendation for implantation of an ICD for primary prevention in nonischemic dilated cardiomyopathy patients who are in New York Heart Association functional class II or III and have an LVEF of 35% or less. But there is a pressing need for refined implantation criteria. Basing the ICD decision on only these criteria results in a low rate of appropriate shocks, a high frequency of inappropriate shocks, and exclusion from device therapy of a group of patients with a high relative risk of SCD.

The British study provides reason for optimism in this regard. Using a greater than 15% estimated SCD risk based upon LVEF plus midwall fibrosis as a proposed indication for ICD implantation, the investigators found that an additional 12 patients in their cohort would receive an ICD and 43 others would now avoid ICD implantation, noted Dr. Yancy, professor of medicine and of medical social sciences and chief of cardiology at Northwestern University, Chicago.

He reported having no financial conflicts.

[email protected]

SNOWMASS, COLO. – Detection of myocardial midwall fibrosis via cardiovascular magnetic resonance in patients with nonischemic dilated cardiomyopathy provides prognostic information independent of left ventricular ejection fraction.

"Low LVEF and fibrosis uniquely identify the need for an ICD [implantable cardioverter-defibrillator]. This is new information that helps refine our understanding of whom it is that’s uniquely at risk. We’ve always had these troublesome questions in patients with nonischemic heart failure," Dr. Clyde W. Yancy observed at the Annual Cardiovascular Conference at Snowmass.

He highlighted what he called "very provocative data" in a recent study led by Dr. Sanjay K. Prasad of Royal Brompton Hospital in London. The investigators evaluated 472 consecutive patients with nonischemic dilated cardiomyopathy using late gadolinium cardiovascular magnetic resonance (CMR). Thirty percent of them were found to have midwall fibrosis. Their all-cause mortality rate during a median 5.3 years of prospective follow-up was 26.8%, compared with 10.6% in the 330 patients without fibrosis. An arrhythmic composite event comprising sudden cardiac death (SCD), aborted SCD, or sustained ventricular tachycardia occurred in 29.6% of the group with fibrosis vs. 7% of patients without fibrosis.

In a multivariate analysis adjusted for LVEF and other prognostic factors, the presence of midwall fibrosis was independently associated with a 2.43-fold increased risk of all-cause mortality, a 3.2-fold greater risk of cardiovascular mortality or heart transplantation, a 4.6-fold increase in SCD or aborted SCD, and a 1.6-fold increased likelihood of a composite of heart failure hospitalization, mortality from heart failure, or cardiac transplantation (JAMA 2013;309:896-908).

Dr. Yancy, who chaired the writing committee for the 2013 ACC/AHA Guideline for the Management of Heart Failure, noted that the guidelines grant a strong Class I/Level of Evidence B recommendation for implantation of an ICD for primary prevention in nonischemic dilated cardiomyopathy patients who are in New York Heart Association functional class II or III and have an LVEF of 35% or less. But there is a pressing need for refined implantation criteria. Basing the ICD decision on only these criteria results in a low rate of appropriate shocks, a high frequency of inappropriate shocks, and exclusion from device therapy of a group of patients with a high relative risk of SCD.

The British study provides reason for optimism in this regard. Using a greater than 15% estimated SCD risk based upon LVEF plus midwall fibrosis as a proposed indication for ICD implantation, the investigators found that an additional 12 patients in their cohort would receive an ICD and 43 others would now avoid ICD implantation, noted Dr. Yancy, professor of medicine and of medical social sciences and chief of cardiology at Northwestern University, Chicago.

He reported having no financial conflicts.

[email protected]

SNOWMASS, COLO. – Detection of myocardial midwall fibrosis via cardiovascular magnetic resonance in patients with nonischemic dilated cardiomyopathy provides prognostic information independent of left ventricular ejection fraction.

"Low LVEF and fibrosis uniquely identify the need for an ICD [implantable cardioverter-defibrillator]. This is new information that helps refine our understanding of whom it is that’s uniquely at risk. We’ve always had these troublesome questions in patients with nonischemic heart failure," Dr. Clyde W. Yancy observed at the Annual Cardiovascular Conference at Snowmass.

He highlighted what he called "very provocative data" in a recent study led by Dr. Sanjay K. Prasad of Royal Brompton Hospital in London. The investigators evaluated 472 consecutive patients with nonischemic dilated cardiomyopathy using late gadolinium cardiovascular magnetic resonance (CMR). Thirty percent of them were found to have midwall fibrosis. Their all-cause mortality rate during a median 5.3 years of prospective follow-up was 26.8%, compared with 10.6% in the 330 patients without fibrosis. An arrhythmic composite event comprising sudden cardiac death (SCD), aborted SCD, or sustained ventricular tachycardia occurred in 29.6% of the group with fibrosis vs. 7% of patients without fibrosis.

In a multivariate analysis adjusted for LVEF and other prognostic factors, the presence of midwall fibrosis was independently associated with a 2.43-fold increased risk of all-cause mortality, a 3.2-fold greater risk of cardiovascular mortality or heart transplantation, a 4.6-fold increase in SCD or aborted SCD, and a 1.6-fold increased likelihood of a composite of heart failure hospitalization, mortality from heart failure, or cardiac transplantation (JAMA 2013;309:896-908).

Dr. Yancy, who chaired the writing committee for the 2013 ACC/AHA Guideline for the Management of Heart Failure, noted that the guidelines grant a strong Class I/Level of Evidence B recommendation for implantation of an ICD for primary prevention in nonischemic dilated cardiomyopathy patients who are in New York Heart Association functional class II or III and have an LVEF of 35% or less. But there is a pressing need for refined implantation criteria. Basing the ICD decision on only these criteria results in a low rate of appropriate shocks, a high frequency of inappropriate shocks, and exclusion from device therapy of a group of patients with a high relative risk of SCD.

The British study provides reason for optimism in this regard. Using a greater than 15% estimated SCD risk based upon LVEF plus midwall fibrosis as a proposed indication for ICD implantation, the investigators found that an additional 12 patients in their cohort would receive an ICD and 43 others would now avoid ICD implantation, noted Dr. Yancy, professor of medicine and of medical social sciences and chief of cardiology at Northwestern University, Chicago.

He reported having no financial conflicts.

[email protected]

But it’s how the emergency medicine list’s creators developed it that may prove most valuable in future efforts to reduce unnecessary tests throughout medicine.

Several specialty societies have developed Top-5 lists of avoidable tests or procedures to comply with the American Board of Internal Medicine’s Choosing Wisely campaign. The lists are "a new idea to engage clinicians in resource stewardship and to address rising health care costs," said Dr. Jeremiah D. Schuur of the department of emergency medicine, Brigham and Women’s Hospital, Boston, and his associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed/2013.12688]).

To create the emergency medicine list, Dr. Jeremiah D. Schuur and his associates took the traditional Choosing Wisely approach, then added a consensus-based twist.

They convened a technical expert panel that included the chiefs of the two academic hospital emergency departments (EDs) and four community hospital EDs in their health care system, which covers more than 320,000 ED visits annually in eastern Massachusetts. The panel also included an emergency physician with expertise in affordability, another with expertise in diagnostic imaging, and a third with expertise in hospital admissions and transfers, as well as a chief resident in emergency medicine.

The panel devised a preliminary list of 64 "low-value clinical decisions that were under the control of emergency clinicians and were thought to have a potential for cost savings."

Then came the twist: A total of 283 frontline emergency clinicians from the health system’s six emergency departments then were invited to complete a Web-based survey tool measuring their opinions of the potential benefit or harm to patients if clinicians discontinued the top 17 potentially avoidable items on the list.

The panel reviewed results from the 174 clinicians who completed the survey, and it then distilled them into a list of the Top-5 unnecessary tests and procedures:

• Do not order CT of the cervical spine for trauma patients who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.

• Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability).

• Do not order MRI of the lumbar spine for patients with low-back pain without high-risk features.

• Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.

• Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (for example, with anticoagulation therapy or clinical coagulopathy).

Every item on this list "received similar ratings by different groups of ED clinicians, including physicians and midlevel practitioners, clinicians in academic and community-hospital EDs, and practitioners with experience ranging from less than 3 years to more than 10 years," the authors explained. That suggests that emergency health care clinicians in other locations, as well as members of other specialty societies, also can achieve such consensus, Dr. Schuur and his associates noted.

Emergency medicine "is under immense pressure" to improve the value of services, they added.

"Some emergency physicians may be hesitant to embrace stewardship efforts, such as Choosing Wisely, for fear of losing autonomy and the medicolegal risk," the investigators noted. "However, if emergency physicians, who best understand the clinical evidence and unique needs of our patients, do not define measures of overuse for our specialty, others will."

But it’s how the emergency medicine list’s creators developed it that may prove most valuable in future efforts to reduce unnecessary tests throughout medicine.

Several specialty societies have developed Top-5 lists of avoidable tests or procedures to comply with the American Board of Internal Medicine’s Choosing Wisely campaign. The lists are "a new idea to engage clinicians in resource stewardship and to address rising health care costs," said Dr. Jeremiah D. Schuur of the department of emergency medicine, Brigham and Women’s Hospital, Boston, and his associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed/2013.12688]).

To create the emergency medicine list, Dr. Jeremiah D. Schuur and his associates took the traditional Choosing Wisely approach, then added a consensus-based twist.

They convened a technical expert panel that included the chiefs of the two academic hospital emergency departments (EDs) and four community hospital EDs in their health care system, which covers more than 320,000 ED visits annually in eastern Massachusetts. The panel also included an emergency physician with expertise in affordability, another with expertise in diagnostic imaging, and a third with expertise in hospital admissions and transfers, as well as a chief resident in emergency medicine.

The panel devised a preliminary list of 64 "low-value clinical decisions that were under the control of emergency clinicians and were thought to have a potential for cost savings."

Then came the twist: A total of 283 frontline emergency clinicians from the health system’s six emergency departments then were invited to complete a Web-based survey tool measuring their opinions of the potential benefit or harm to patients if clinicians discontinued the top 17 potentially avoidable items on the list.

The panel reviewed results from the 174 clinicians who completed the survey, and it then distilled them into a list of the Top-5 unnecessary tests and procedures:

• Do not order CT of the cervical spine for trauma patients who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.

• Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability).

• Do not order MRI of the lumbar spine for patients with low-back pain without high-risk features.

• Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.

• Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (for example, with anticoagulation therapy or clinical coagulopathy).

Every item on this list "received similar ratings by different groups of ED clinicians, including physicians and midlevel practitioners, clinicians in academic and community-hospital EDs, and practitioners with experience ranging from less than 3 years to more than 10 years," the authors explained. That suggests that emergency health care clinicians in other locations, as well as members of other specialty societies, also can achieve such consensus, Dr. Schuur and his associates noted.

Emergency medicine "is under immense pressure" to improve the value of services, they added.

"Some emergency physicians may be hesitant to embrace stewardship efforts, such as Choosing Wisely, for fear of losing autonomy and the medicolegal risk," the investigators noted. "However, if emergency physicians, who best understand the clinical evidence and unique needs of our patients, do not define measures of overuse for our specialty, others will."

But it’s how the emergency medicine list’s creators developed it that may prove most valuable in future efforts to reduce unnecessary tests throughout medicine.

Several specialty societies have developed Top-5 lists of avoidable tests or procedures to comply with the American Board of Internal Medicine’s Choosing Wisely campaign. The lists are "a new idea to engage clinicians in resource stewardship and to address rising health care costs," said Dr. Jeremiah D. Schuur of the department of emergency medicine, Brigham and Women’s Hospital, Boston, and his associates (JAMA Intern. Med. 2014 [doi:10.1001/jamainternmed/2013.12688]).

To create the emergency medicine list, Dr. Jeremiah D. Schuur and his associates took the traditional Choosing Wisely approach, then added a consensus-based twist.

They convened a technical expert panel that included the chiefs of the two academic hospital emergency departments (EDs) and four community hospital EDs in their health care system, which covers more than 320,000 ED visits annually in eastern Massachusetts. The panel also included an emergency physician with expertise in affordability, another with expertise in diagnostic imaging, and a third with expertise in hospital admissions and transfers, as well as a chief resident in emergency medicine.

The panel devised a preliminary list of 64 "low-value clinical decisions that were under the control of emergency clinicians and were thought to have a potential for cost savings."

Then came the twist: A total of 283 frontline emergency clinicians from the health system’s six emergency departments then were invited to complete a Web-based survey tool measuring their opinions of the potential benefit or harm to patients if clinicians discontinued the top 17 potentially avoidable items on the list.

The panel reviewed results from the 174 clinicians who completed the survey, and it then distilled them into a list of the Top-5 unnecessary tests and procedures:

• Do not order CT of the cervical spine for trauma patients who do not meet the National Emergency X-ray Utilization Study (NEXUS) low-risk criteria or the Canadian C-Spine Rule.

• Do not order CT to diagnose pulmonary embolism without first risk stratifying for pulmonary embolism (pretest probability and D-dimer tests if low probability).

• Do not order MRI of the lumbar spine for patients with low-back pain without high-risk features.

• Do not order CT of the head for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule.

• Do not order coagulation studies for patients without hemorrhage or suspected coagulopathy (for example, with anticoagulation therapy or clinical coagulopathy).

Every item on this list "received similar ratings by different groups of ED clinicians, including physicians and midlevel practitioners, clinicians in academic and community-hospital EDs, and practitioners with experience ranging from less than 3 years to more than 10 years," the authors explained. That suggests that emergency health care clinicians in other locations, as well as members of other specialty societies, also can achieve such consensus, Dr. Schuur and his associates noted.

Emergency medicine "is under immense pressure" to improve the value of services, they added.

"Some emergency physicians may be hesitant to embrace stewardship efforts, such as Choosing Wisely, for fear of losing autonomy and the medicolegal risk," the investigators noted. "However, if emergency physicians, who best understand the clinical evidence and unique needs of our patients, do not define measures of overuse for our specialty, others will."

Noninvasive cardiovascular imaging in U.S. medical practice today raises two policy challenges, according to a statement released on Feb. 17 by the American College of Cardiology and 13 collaborating medical groups: fostering a volume of imaging that balances patient needs with responsible use of societal resources, and continued improvement in the quality of care based on noninvasive cardiovascular imaging.

"The purpose of this document is to provide a brief exposition of the issues involved [in usage volume of noninvasive cardiovascular imaging] and the possible ways in which the medical care system can balance responsible use of imaging with patient safety concerns while maintaining or even enhancing quality of care," wrote the 20-member panel in a health policy statement (J. Am. Coll. Cardiol. 2014;63:698-721). "Policy makers must take into account the complex interplay between medical care quality (of which proper use of diagnostic testing is an integral part), patient health outcomes, and medical costs," said the statement’s panel, which included representatives from the American Society of Nuclear Cardiology, the American Society of Echocardiography, the Radiological Society of North America, and six other imaging groups.

"The current situation in noninvasive cardiovascular imaging is pretty much unsatisfactory from everyone’s point of view," said Dr. Daniel B. Mark, a cardiologist and professor of medicine at Duke University in Durham, N.C., who chaired the statement-writing committee."However, it is encouraging that we now have much more knowledge and several new informatics tools that can be used to help us apply that knowledge. We have many of the ingredients needed to create a more responsible, cost-conscious approach to imaging that still preserves – at its core – patient-physician decision making," said Dr. Mark in a written statement.

Over the past 20 years, U.S. health care payers implemented three main strategies to control expenditures for diagnostic imaging, the statement said: requiring prior authorization from a radiology benefits manager; requiring prior notification before performing selected, advanced diagnostic imaging methods like MRI and PET; and reduced payments for imaging. The statement characterized all three as "blunt instruments,’ and added these can lead to "limited patient access to necessary services and greater administrative inefficiencies."

One approach that would likely improve imaging-use policy is an "iterative process" that uses high-quality data to guide development of policy interventions with the potential to reduce imaging overuse, underuse, and misuse. Another approach the panel endorsed is integration of appropriate-use software into the process of care. "Development of computerized appropriate-use tools would be efficient and also greatly enhance transparency," the panel said. "Validated patient-specific point-of-care/referral appropriateness tools and other decision-support tools are examples of innovations that could support a higher-quality, more accountable use of cardiovascular imaging."

Recent data show that growth of advanced cardiovascular imaging has substantially slowed since 2006, likely because of a combination of professional society and payer initiatives. "Many clinicians and patients fear that imaging policy decisions will continue to be driven primarily, if not exclusively, by cost considerations without adequate consideration of clinical benefit and value," said the statement.

"The complexity of our current health care system and the competing macro-forces that push it in myriad different directions can make responsible imaging use seem impossibly daunting. What we need is a convergence of will from all key stakeholders to make it happen. This statement is hopefully a step in that direction," Dr. Mark said.

Dr. Mark said that he had no disclosures.

[email protected]

On Twitter @mitchelzoler

Noninvasive cardiovascular imaging in U.S. medical practice today raises two policy challenges, according to a statement released on Feb. 17 by the American College of Cardiology and 13 collaborating medical groups: fostering a volume of imaging that balances patient needs with responsible use of societal resources, and continued improvement in the quality of care based on noninvasive cardiovascular imaging.

"The purpose of this document is to provide a brief exposition of the issues involved [in usage volume of noninvasive cardiovascular imaging] and the possible ways in which the medical care system can balance responsible use of imaging with patient safety concerns while maintaining or even enhancing quality of care," wrote the 20-member panel in a health policy statement (J. Am. Coll. Cardiol. 2014;63:698-721). "Policy makers must take into account the complex interplay between medical care quality (of which proper use of diagnostic testing is an integral part), patient health outcomes, and medical costs," said the statement’s panel, which included representatives from the American Society of Nuclear Cardiology, the American Society of Echocardiography, the Radiological Society of North America, and six other imaging groups.

"The current situation in noninvasive cardiovascular imaging is pretty much unsatisfactory from everyone’s point of view," said Dr. Daniel B. Mark, a cardiologist and professor of medicine at Duke University in Durham, N.C., who chaired the statement-writing committee."However, it is encouraging that we now have much more knowledge and several new informatics tools that can be used to help us apply that knowledge. We have many of the ingredients needed to create a more responsible, cost-conscious approach to imaging that still preserves – at its core – patient-physician decision making," said Dr. Mark in a written statement.

Over the past 20 years, U.S. health care payers implemented three main strategies to control expenditures for diagnostic imaging, the statement said: requiring prior authorization from a radiology benefits manager; requiring prior notification before performing selected, advanced diagnostic imaging methods like MRI and PET; and reduced payments for imaging. The statement characterized all three as "blunt instruments,’ and added these can lead to "limited patient access to necessary services and greater administrative inefficiencies."

One approach that would likely improve imaging-use policy is an "iterative process" that uses high-quality data to guide development of policy interventions with the potential to reduce imaging overuse, underuse, and misuse. Another approach the panel endorsed is integration of appropriate-use software into the process of care. "Development of computerized appropriate-use tools would be efficient and also greatly enhance transparency," the panel said. "Validated patient-specific point-of-care/referral appropriateness tools and other decision-support tools are examples of innovations that could support a higher-quality, more accountable use of cardiovascular imaging."

Recent data show that growth of advanced cardiovascular imaging has substantially slowed since 2006, likely because of a combination of professional society and payer initiatives. "Many clinicians and patients fear that imaging policy decisions will continue to be driven primarily, if not exclusively, by cost considerations without adequate consideration of clinical benefit and value," said the statement.

"The complexity of our current health care system and the competing macro-forces that push it in myriad different directions can make responsible imaging use seem impossibly daunting. What we need is a convergence of will from all key stakeholders to make it happen. This statement is hopefully a step in that direction," Dr. Mark said.

Dr. Mark said that he had no disclosures.

[email protected]

On Twitter @mitchelzoler

Noninvasive cardiovascular imaging in U.S. medical practice today raises two policy challenges, according to a statement released on Feb. 17 by the American College of Cardiology and 13 collaborating medical groups: fostering a volume of imaging that balances patient needs with responsible use of societal resources, and continued improvement in the quality of care based on noninvasive cardiovascular imaging.

"The purpose of this document is to provide a brief exposition of the issues involved [in usage volume of noninvasive cardiovascular imaging] and the possible ways in which the medical care system can balance responsible use of imaging with patient safety concerns while maintaining or even enhancing quality of care," wrote the 20-member panel in a health policy statement (J. Am. Coll. Cardiol. 2014;63:698-721). "Policy makers must take into account the complex interplay between medical care quality (of which proper use of diagnostic testing is an integral part), patient health outcomes, and medical costs," said the statement’s panel, which included representatives from the American Society of Nuclear Cardiology, the American Society of Echocardiography, the Radiological Society of North America, and six other imaging groups.

"The current situation in noninvasive cardiovascular imaging is pretty much unsatisfactory from everyone’s point of view," said Dr. Daniel B. Mark, a cardiologist and professor of medicine at Duke University in Durham, N.C., who chaired the statement-writing committee."However, it is encouraging that we now have much more knowledge and several new informatics tools that can be used to help us apply that knowledge. We have many of the ingredients needed to create a more responsible, cost-conscious approach to imaging that still preserves – at its core – patient-physician decision making," said Dr. Mark in a written statement.

Over the past 20 years, U.S. health care payers implemented three main strategies to control expenditures for diagnostic imaging, the statement said: requiring prior authorization from a radiology benefits manager; requiring prior notification before performing selected, advanced diagnostic imaging methods like MRI and PET; and reduced payments for imaging. The statement characterized all three as "blunt instruments,’ and added these can lead to "limited patient access to necessary services and greater administrative inefficiencies."

One approach that would likely improve imaging-use policy is an "iterative process" that uses high-quality data to guide development of policy interventions with the potential to reduce imaging overuse, underuse, and misuse. Another approach the panel endorsed is integration of appropriate-use software into the process of care. "Development of computerized appropriate-use tools would be efficient and also greatly enhance transparency," the panel said. "Validated patient-specific point-of-care/referral appropriateness tools and other decision-support tools are examples of innovations that could support a higher-quality, more accountable use of cardiovascular imaging."

Recent data show that growth of advanced cardiovascular imaging has substantially slowed since 2006, likely because of a combination of professional society and payer initiatives. "Many clinicians and patients fear that imaging policy decisions will continue to be driven primarily, if not exclusively, by cost considerations without adequate consideration of clinical benefit and value," said the statement.

"The complexity of our current health care system and the competing macro-forces that push it in myriad different directions can make responsible imaging use seem impossibly daunting. What we need is a convergence of will from all key stakeholders to make it happen. This statement is hopefully a step in that direction," Dr. Mark said.

Dr. Mark said that he had no disclosures.

[email protected]

On Twitter @mitchelzoler

Dr Patterson, editor of “Challenges in Sports Medicine and Orthopedics,” is a sports medicine physician at Florida Sports Injury in Clermont, Florida. Dr Patterson is board certified in family medicine and spinal cord injury medicine, and is a member of the faculty of sports and exercise medicine of the Royal College of Surgeons in Ireland.

A 5-year-old boy presented to the ED after sustaining an injury to his left leg during play with a friend. He was unable to bear weight on the left foot and had a visible deformity to his lower extremity. The left foot was neurovascularly intact. Radiographs were completed (Figures 1 and 2). 

What is your interpretation of the following radiographs? 

Answer

The radiographs revealed a 20˚ anteriorly (apex posterior) angulated fracture through the metaphysis of the distal tibia and fibula. Angulated distal tibia fractures in adults are usually fixed with surgery; however, in children, displaced or angulated fractures to long bones such as the tibia stimulate a significant amount of growth. In treating pediatric patients, there is a greater amount of acceptable angulation the closer a fracture is to the end of bone.¹

The patient in this case was placed in a long leg cast, and the fractures were reduced with three-point fixation technique. He remained in the cast for 5 weeks; thereafter, a below-the-knee orthopedic walking boot was placed for 3 weeks. The radiographs in Figures 3 and 4, taken 8 weeks after initiation of treatment, show a healed distal tibia and fibula fracture with an acceptable 7˚ of anterior angulation.

Dr Patterson, editor of “Challenges in Sports Medicine and Orthopedics,” is a sports medicine physician at Florida Sports Injury in Clermont, Florida. Dr Patterson is board certified in family medicine and spinal cord injury medicine, and is a member of the faculty of sports and exercise medicine of the Royal College of Surgeons in Ireland.

A 5-year-old boy presented to the ED after sustaining an injury to his left leg during play with a friend. He was unable to bear weight on the left foot and had a visible deformity to his lower extremity. The left foot was neurovascularly intact. Radiographs were completed (Figures 1 and 2). 

What is your interpretation of the following radiographs? 

Answer

The radiographs revealed a 20˚ anteriorly (apex posterior) angulated fracture through the metaphysis of the distal tibia and fibula. Angulated distal tibia fractures in adults are usually fixed with surgery; however, in children, displaced or angulated fractures to long bones such as the tibia stimulate a significant amount of growth. In treating pediatric patients, there is a greater amount of acceptable angulation the closer a fracture is to the end of bone.¹

The patient in this case was placed in a long leg cast, and the fractures were reduced with three-point fixation technique. He remained in the cast for 5 weeks; thereafter, a below-the-knee orthopedic walking boot was placed for 3 weeks. The radiographs in Figures 3 and 4, taken 8 weeks after initiation of treatment, show a healed distal tibia and fibula fracture with an acceptable 7˚ of anterior angulation.

Dr Patterson, editor of “Challenges in Sports Medicine and Orthopedics,” is a sports medicine physician at Florida Sports Injury in Clermont, Florida. Dr Patterson is board certified in family medicine and spinal cord injury medicine, and is a member of the faculty of sports and exercise medicine of the Royal College of Surgeons in Ireland.

A 5-year-old boy presented to the ED after sustaining an injury to his left leg during play with a friend. He was unable to bear weight on the left foot and had a visible deformity to his lower extremity. The left foot was neurovascularly intact. Radiographs were completed (Figures 1 and 2). 

What is your interpretation of the following radiographs? 

Answer

The radiographs revealed a 20˚ anteriorly (apex posterior) angulated fracture through the metaphysis of the distal tibia and fibula. Angulated distal tibia fractures in adults are usually fixed with surgery; however, in children, displaced or angulated fractures to long bones such as the tibia stimulate a significant amount of growth. In treating pediatric patients, there is a greater amount of acceptable angulation the closer a fracture is to the end of bone.¹

The patient in this case was placed in a long leg cast, and the fractures were reduced with three-point fixation technique. He remained in the cast for 5 weeks; thereafter, a below-the-knee orthopedic walking boot was placed for 3 weeks. The radiographs in Figures 3 and 4, taken 8 weeks after initiation of treatment, show a healed distal tibia and fibula fracture with an acceptable 7˚ of anterior angulation.

NAPLES, FLA. – Implementing a cloud-based network for sharing radiological images reduced radiation exposure and costs at a Level 1 tertiary care trauma center.

The number of trauma patients who underwent the exact same imaging study decreased significantly from 62% to 47% in the 6 months after the network was available (P less than .01).

This resulted in a significant 19.2% decline in radiation exposure (mean 8.39 mSv vs. 7.23 mSv; P less than .01), Dr. Mayur Narayan reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

"I think it’s a potential game changer," he said. "... The concept is important. The way we’re doing business currently is not sustainable."

Patients transferred within a regional trauma system to a tertiary care referral center frequently have prior radiology studies, but often undergo repeat imaging because of poor image quality, incompatible imaging software, or misplaced imaging discs. This can delay patient management, bring unwelcome radiation, and raise health care costs, explained Dr. Narayan, with the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore.

To reverse this trend, the center set up a secure, electronic (lifeIMAGE) network that uses a single platform for all medical image exchanges. Physicians can retrieve outside exams via the cloud or merge any or all picture archiving and communication system (PACS) data into their own PACS.

Patrice Wendling/Frontline Medical News

Ten hospitals are now on board and prospective data have been analyzed for 1,950 patients transferred to the trauma center between Jan. 1 and June 30, 2011, (pre-network) and between Jan. 1 and June 30, 2012, (post-network). About 8,500 patients are transferred to the trauma center annually from across the state. Patients in both time periods had similar demographics and Injury Severity Scores (mean 12).

In the 6 months after the network was implemented, the cost of imaging per patient dropped 18.7% ($413 vs. $333; P less than .01), while total imaging costs declined from $401,765 to $326,756 during the same period, Dr. Narayan said.

The most common repeat study in the analysis was an abdominal pelvic CT scan.

Inexplicably, hospital length of stay also declined from 4.4 days to 3.8 days (P = .07), he said. In-hospital mortality was unchanged (3.8% vs. 4.4%; P = .52).

The network cost Cowley Shock Trauma about $30,000 to set up, but other hospital groups are working to provide similar software for free, Dr. Narayan noted.

"The upfront costs should go away," he said.

During a discussion of the poster, one attendee said they set up a similar cloud-based system for their region, but no one used it. "I think it’s because small hospitals don’t see a lot of trauma. They have one or two patients maybe a month that would require transfer and with different people at the CT scanner every night, there’s no uniformity on how to do it," he said.

Others, however, noted that image sharing between hospitals has been fully integrated into their transfer algorithm, prompting calls between hospital radiology units, so that PAC files and patient record numbers have already been merged before the patient ever arrives in the trauma bay.

The Radiological Society of North America has also harnessed cloud-based computing to allow consumers to share their images and interpretations with any provider, regardless of institutional affiliation. According to 20-month follow-up data reported in late 2013, four out of five patients and 9 out of 10 physicians were satisfied with the RSNA Image Share network. A full 90% of patients were comfortable with the amount of privacy provided by the network, though some criticized the site for being "clunky" to navigate.

Dr. Narayan reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Implementing a cloud-based network for sharing radiological images reduced radiation exposure and costs at a Level 1 tertiary care trauma center.

The number of trauma patients who underwent the exact same imaging study decreased significantly from 62% to 47% in the 6 months after the network was available (P less than .01).

This resulted in a significant 19.2% decline in radiation exposure (mean 8.39 mSv vs. 7.23 mSv; P less than .01), Dr. Mayur Narayan reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

"I think it’s a potential game changer," he said. "... The concept is important. The way we’re doing business currently is not sustainable."

Patients transferred within a regional trauma system to a tertiary care referral center frequently have prior radiology studies, but often undergo repeat imaging because of poor image quality, incompatible imaging software, or misplaced imaging discs. This can delay patient management, bring unwelcome radiation, and raise health care costs, explained Dr. Narayan, with the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore.

To reverse this trend, the center set up a secure, electronic (lifeIMAGE) network that uses a single platform for all medical image exchanges. Physicians can retrieve outside exams via the cloud or merge any or all picture archiving and communication system (PACS) data into their own PACS.

Patrice Wendling/Frontline Medical News

Ten hospitals are now on board and prospective data have been analyzed for 1,950 patients transferred to the trauma center between Jan. 1 and June 30, 2011, (pre-network) and between Jan. 1 and June 30, 2012, (post-network). About 8,500 patients are transferred to the trauma center annually from across the state. Patients in both time periods had similar demographics and Injury Severity Scores (mean 12).

In the 6 months after the network was implemented, the cost of imaging per patient dropped 18.7% ($413 vs. $333; P less than .01), while total imaging costs declined from $401,765 to $326,756 during the same period, Dr. Narayan said.

The most common repeat study in the analysis was an abdominal pelvic CT scan.

Inexplicably, hospital length of stay also declined from 4.4 days to 3.8 days (P = .07), he said. In-hospital mortality was unchanged (3.8% vs. 4.4%; P = .52).

The network cost Cowley Shock Trauma about $30,000 to set up, but other hospital groups are working to provide similar software for free, Dr. Narayan noted.

"The upfront costs should go away," he said.

During a discussion of the poster, one attendee said they set up a similar cloud-based system for their region, but no one used it. "I think it’s because small hospitals don’t see a lot of trauma. They have one or two patients maybe a month that would require transfer and with different people at the CT scanner every night, there’s no uniformity on how to do it," he said.

Others, however, noted that image sharing between hospitals has been fully integrated into their transfer algorithm, prompting calls between hospital radiology units, so that PAC files and patient record numbers have already been merged before the patient ever arrives in the trauma bay.

The Radiological Society of North America has also harnessed cloud-based computing to allow consumers to share their images and interpretations with any provider, regardless of institutional affiliation. According to 20-month follow-up data reported in late 2013, four out of five patients and 9 out of 10 physicians were satisfied with the RSNA Image Share network. A full 90% of patients were comfortable with the amount of privacy provided by the network, though some criticized the site for being "clunky" to navigate.

Dr. Narayan reported having no financial disclosures.

[email protected]

NAPLES, FLA. – Implementing a cloud-based network for sharing radiological images reduced radiation exposure and costs at a Level 1 tertiary care trauma center.

The number of trauma patients who underwent the exact same imaging study decreased significantly from 62% to 47% in the 6 months after the network was available (P less than .01).

This resulted in a significant 19.2% decline in radiation exposure (mean 8.39 mSv vs. 7.23 mSv; P less than .01), Dr. Mayur Narayan reported at the annual meeting of the Eastern Association for the Surgery of Trauma.

"I think it’s a potential game changer," he said. "... The concept is important. The way we’re doing business currently is not sustainable."

Patients transferred within a regional trauma system to a tertiary care referral center frequently have prior radiology studies, but often undergo repeat imaging because of poor image quality, incompatible imaging software, or misplaced imaging discs. This can delay patient management, bring unwelcome radiation, and raise health care costs, explained Dr. Narayan, with the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore.

To reverse this trend, the center set up a secure, electronic (lifeIMAGE) network that uses a single platform for all medical image exchanges. Physicians can retrieve outside exams via the cloud or merge any or all picture archiving and communication system (PACS) data into their own PACS.

Patrice Wendling/Frontline Medical News

Ten hospitals are now on board and prospective data have been analyzed for 1,950 patients transferred to the trauma center between Jan. 1 and June 30, 2011, (pre-network) and between Jan. 1 and June 30, 2012, (post-network). About 8,500 patients are transferred to the trauma center annually from across the state. Patients in both time periods had similar demographics and Injury Severity Scores (mean 12).

In the 6 months after the network was implemented, the cost of imaging per patient dropped 18.7% ($413 vs. $333; P less than .01), while total imaging costs declined from $401,765 to $326,756 during the same period, Dr. Narayan said.

The most common repeat study in the analysis was an abdominal pelvic CT scan.

Inexplicably, hospital length of stay also declined from 4.4 days to 3.8 days (P = .07), he said. In-hospital mortality was unchanged (3.8% vs. 4.4%; P = .52).

The network cost Cowley Shock Trauma about $30,000 to set up, but other hospital groups are working to provide similar software for free, Dr. Narayan noted.

"The upfront costs should go away," he said.

During a discussion of the poster, one attendee said they set up a similar cloud-based system for their region, but no one used it. "I think it’s because small hospitals don’t see a lot of trauma. They have one or two patients maybe a month that would require transfer and with different people at the CT scanner every night, there’s no uniformity on how to do it," he said.

Others, however, noted that image sharing between hospitals has been fully integrated into their transfer algorithm, prompting calls between hospital radiology units, so that PAC files and patient record numbers have already been merged before the patient ever arrives in the trauma bay.

The Radiological Society of North America has also harnessed cloud-based computing to allow consumers to share their images and interpretations with any provider, regardless of institutional affiliation. According to 20-month follow-up data reported in late 2013, four out of five patients and 9 out of 10 physicians were satisfied with the RSNA Image Share network. A full 90% of patients were comfortable with the amount of privacy provided by the network, though some criticized the site for being "clunky" to navigate.

Dr. Narayan reported having no financial disclosures.

[email protected]

Using computed tomographic imaging (CT scans) based only on a child’s method of injury in blunt trauma cases incurs more risks than benefits, according to a recent study.

The ionizing radiation from CT scanning has been linked to long-term risk of cancer, with an estimated risk of one cancer case per 10,000 CT scans, and the U.S. Environmental Protection Agency attributes 25% of all radiation in the United States to CT scanning.

"The benefit of identifying or excluding life-threatening injuries with a high sensitivity is an invaluable tool," wrote Dr. Hunter B. Moore and his colleagues at the University of Colorado at Denver, Aurora, in the Journal of Trauma and Acute Care Surgery. "However, application in the more radiosensitive pediatric population requires critical analysis."

Dr. Moore’s team found that the only clinically significant factor in determining the value of using CT scans was an abnormal Glasgow Coma Score (GCS). The GCS neurological scale rates patients from 3 to 14 on their level of consciousness; the highest score (14 on the original scale, 15 on the revised scale) refers to normal verbal, motor, and eye functioning. This study used the original scale, according to corresponding author Denis Bensard.

"Most concerning was that injured children imaged based on the mechanism of injury alone yielded no significant findings on CT imaging," the researchers wrote (J. Trauma Acute Care Surg. 2013;75:995-1001). "When anatomic or physiologic abnormalities were present, a serious CT finding was observed in more than 20% of the children imaged."

The researchers classified 174 patients, all meeting trauma team activation criteria at a Level 2 pediatric trauma center, into four groups to study the clinical value of CT scanning based on the children’s mechanism of injury. The patients, with a mean age of 7 years and a mean Injury Severity Score of 10, were admitted from January 2006 through December 2011.

The first group had normal GCS scores and normal vital signs and physical examinations. CT scanning for this group was considered to be done based on mechanism of injury alone. The second group had abnormal GCS scores but normal vital signs and physical exams. The third group had normal GCS scores but abnormal vital signs or exam findings. The fourth group had both abnormal GCS scores and abnormal findings in vital signs and/or exams.

Across all groups, motor vehicle collisions accounted for the most common injury causes, followed by being struck by autos as pedestrians, and falls. Positive CT scan findings included extra axial blood or parenchymal injury in the head; bony, vascular injury in the neck; great vessel injury in the chest; or solid organ or hollow visceral injury in the abdomen.

Of the 54 patients (82% of 66 children) in the group with normal exams, vital signs, and GCS scores who received CT scans, the patients were exposed to an average 17 mSv through an average 1.7 scans per child. The annual environmental dose limit for radiation is established at 1 mSv per year. "Remarkably, no patient imaged, based on [injury] mechanism alone, had a serious or life-threatening finding on CT scan," the researchers wrote.

All 25 patients in the group with abnormal GCS scores but normal exams and vital signs were scanned, with an average of 3.1 scans and 29 mSv of radiation per child. While 22% of the scans revealed a serious injury, the only surgeries required were one craniotomy and one nephrectomy.

Among the 57 children with normal GCS scores but abnormal exams or vital signs, 49 of them (86%) were scanned, with an average of two scans and 20 mSv per child. One splenectomy resulted from among the 23% of scans revealing significant findings.

All but 1 of the 26 children with abnormal GCS scores and abnormal vital signs or exams were scanned, with an average of 2.8 scans and 27 mSv per child. A quarter of the scans revealed significant findings, and two children required emergency craniotomies.

"We found that only one in four CT scans found a serious finding, but emergent operative interventions were required in less than 3% of injured children imaged," the researchers wrote. "Focused assessment with sonography for trauma [FAST] examination for the cohort was found to have a high specificity of 98%, but low sensitivity of 30%."

They determined the low sensitivity to result from the scans’ inability to identify injuries in solid organs without "detectable blood or retroperitoneal injury," though CT scans did appear valuable for identifying intra-abdominal hemorrhage. Abdominal CT scans were most likely to identify serious injuries when initial exams revealed anatomic or physiologic abnormalities, but chest scans had little to no utility.

The authors noted that current cancer risk estimates from CT scan radiation may be low because of the time it can take for cancers to manifest (up to 40 years) and the short time span (10 years) of the retrospective study that validated the 1 in 10,000 per CT scan risk. "Commentary on this article cautions that these preliminary data are similar to atomic bomb survivors, and the true incidence of cancer from CT scanning may be 10 times more after more time elapses following CT scans," they wrote.

The researchers did not use external funding. They reported no disclosures

Using computed tomographic imaging (CT scans) based only on a child’s method of injury in blunt trauma cases incurs more risks than benefits, according to a recent study.

The ionizing radiation from CT scanning has been linked to long-term risk of cancer, with an estimated risk of one cancer case per 10,000 CT scans, and the U.S. Environmental Protection Agency attributes 25% of all radiation in the United States to CT scanning.

"The benefit of identifying or excluding life-threatening injuries with a high sensitivity is an invaluable tool," wrote Dr. Hunter B. Moore and his colleagues at the University of Colorado at Denver, Aurora, in the Journal of Trauma and Acute Care Surgery. "However, application in the more radiosensitive pediatric population requires critical analysis."

Dr. Moore’s team found that the only clinically significant factor in determining the value of using CT scans was an abnormal Glasgow Coma Score (GCS). The GCS neurological scale rates patients from 3 to 14 on their level of consciousness; the highest score (14 on the original scale, 15 on the revised scale) refers to normal verbal, motor, and eye functioning. This study used the original scale, according to corresponding author Denis Bensard.

"Most concerning was that injured children imaged based on the mechanism of injury alone yielded no significant findings on CT imaging," the researchers wrote (J. Trauma Acute Care Surg. 2013;75:995-1001). "When anatomic or physiologic abnormalities were present, a serious CT finding was observed in more than 20% of the children imaged."

The researchers classified 174 patients, all meeting trauma team activation criteria at a Level 2 pediatric trauma center, into four groups to study the clinical value of CT scanning based on the children’s mechanism of injury. The patients, with a mean age of 7 years and a mean Injury Severity Score of 10, were admitted from January 2006 through December 2011.

The first group had normal GCS scores and normal vital signs and physical examinations. CT scanning for this group was considered to be done based on mechanism of injury alone. The second group had abnormal GCS scores but normal vital signs and physical exams. The third group had normal GCS scores but abnormal vital signs or exam findings. The fourth group had both abnormal GCS scores and abnormal findings in vital signs and/or exams.

Across all groups, motor vehicle collisions accounted for the most common injury causes, followed by being struck by autos as pedestrians, and falls. Positive CT scan findings included extra axial blood or parenchymal injury in the head; bony, vascular injury in the neck; great vessel injury in the chest; or solid organ or hollow visceral injury in the abdomen.

Of the 54 patients (82% of 66 children) in the group with normal exams, vital signs, and GCS scores who received CT scans, the patients were exposed to an average 17 mSv through an average 1.7 scans per child. The annual environmental dose limit for radiation is established at 1 mSv per year. "Remarkably, no patient imaged, based on [injury] mechanism alone, had a serious or life-threatening finding on CT scan," the researchers wrote.

All 25 patients in the group with abnormal GCS scores but normal exams and vital signs were scanned, with an average of 3.1 scans and 29 mSv of radiation per child. While 22% of the scans revealed a serious injury, the only surgeries required were one craniotomy and one nephrectomy.

Among the 57 children with normal GCS scores but abnormal exams or vital signs, 49 of them (86%) were scanned, with an average of two scans and 20 mSv per child. One splenectomy resulted from among the 23% of scans revealing significant findings.

All but 1 of the 26 children with abnormal GCS scores and abnormal vital signs or exams were scanned, with an average of 2.8 scans and 27 mSv per child. A quarter of the scans revealed significant findings, and two children required emergency craniotomies.

"We found that only one in four CT scans found a serious finding, but emergent operative interventions were required in less than 3% of injured children imaged," the researchers wrote. "Focused assessment with sonography for trauma [FAST] examination for the cohort was found to have a high specificity of 98%, but low sensitivity of 30%."

They determined the low sensitivity to result from the scans’ inability to identify injuries in solid organs without "detectable blood or retroperitoneal injury," though CT scans did appear valuable for identifying intra-abdominal hemorrhage. Abdominal CT scans were most likely to identify serious injuries when initial exams revealed anatomic or physiologic abnormalities, but chest scans had little to no utility.

The authors noted that current cancer risk estimates from CT scan radiation may be low because of the time it can take for cancers to manifest (up to 40 years) and the short time span (10 years) of the retrospective study that validated the 1 in 10,000 per CT scan risk. "Commentary on this article cautions that these preliminary data are similar to atomic bomb survivors, and the true incidence of cancer from CT scanning may be 10 times more after more time elapses following CT scans," they wrote.

The researchers did not use external funding. They reported no disclosures

Using computed tomographic imaging (CT scans) based only on a child’s method of injury in blunt trauma cases incurs more risks than benefits, according to a recent study.

The ionizing radiation from CT scanning has been linked to long-term risk of cancer, with an estimated risk of one cancer case per 10,000 CT scans, and the U.S. Environmental Protection Agency attributes 25% of all radiation in the United States to CT scanning.

"The benefit of identifying or excluding life-threatening injuries with a high sensitivity is an invaluable tool," wrote Dr. Hunter B. Moore and his colleagues at the University of Colorado at Denver, Aurora, in the Journal of Trauma and Acute Care Surgery. "However, application in the more radiosensitive pediatric population requires critical analysis."

Dr. Moore’s team found that the only clinically significant factor in determining the value of using CT scans was an abnormal Glasgow Coma Score (GCS). The GCS neurological scale rates patients from 3 to 14 on their level of consciousness; the highest score (14 on the original scale, 15 on the revised scale) refers to normal verbal, motor, and eye functioning. This study used the original scale, according to corresponding author Denis Bensard.

"Most concerning was that injured children imaged based on the mechanism of injury alone yielded no significant findings on CT imaging," the researchers wrote (J. Trauma Acute Care Surg. 2013;75:995-1001). "When anatomic or physiologic abnormalities were present, a serious CT finding was observed in more than 20% of the children imaged."

The researchers classified 174 patients, all meeting trauma team activation criteria at a Level 2 pediatric trauma center, into four groups to study the clinical value of CT scanning based on the children’s mechanism of injury. The patients, with a mean age of 7 years and a mean Injury Severity Score of 10, were admitted from January 2006 through December 2011.

The first group had normal GCS scores and normal vital signs and physical examinations. CT scanning for this group was considered to be done based on mechanism of injury alone. The second group had abnormal GCS scores but normal vital signs and physical exams. The third group had normal GCS scores but abnormal vital signs or exam findings. The fourth group had both abnormal GCS scores and abnormal findings in vital signs and/or exams.

Across all groups, motor vehicle collisions accounted for the most common injury causes, followed by being struck by autos as pedestrians, and falls. Positive CT scan findings included extra axial blood or parenchymal injury in the head; bony, vascular injury in the neck; great vessel injury in the chest; or solid organ or hollow visceral injury in the abdomen.

Of the 54 patients (82% of 66 children) in the group with normal exams, vital signs, and GCS scores who received CT scans, the patients were exposed to an average 17 mSv through an average 1.7 scans per child. The annual environmental dose limit for radiation is established at 1 mSv per year. "Remarkably, no patient imaged, based on [injury] mechanism alone, had a serious or life-threatening finding on CT scan," the researchers wrote.

All 25 patients in the group with abnormal GCS scores but normal exams and vital signs were scanned, with an average of 3.1 scans and 29 mSv of radiation per child. While 22% of the scans revealed a serious injury, the only surgeries required were one craniotomy and one nephrectomy.

Among the 57 children with normal GCS scores but abnormal exams or vital signs, 49 of them (86%) were scanned, with an average of two scans and 20 mSv per child. One splenectomy resulted from among the 23% of scans revealing significant findings.

All but 1 of the 26 children with abnormal GCS scores and abnormal vital signs or exams were scanned, with an average of 2.8 scans and 27 mSv per child. A quarter of the scans revealed significant findings, and two children required emergency craniotomies.

"We found that only one in four CT scans found a serious finding, but emergent operative interventions were required in less than 3% of injured children imaged," the researchers wrote. "Focused assessment with sonography for trauma [FAST] examination for the cohort was found to have a high specificity of 98%, but low sensitivity of 30%."

They determined the low sensitivity to result from the scans’ inability to identify injuries in solid organs without "detectable blood or retroperitoneal injury," though CT scans did appear valuable for identifying intra-abdominal hemorrhage. Abdominal CT scans were most likely to identify serious injuries when initial exams revealed anatomic or physiologic abnormalities, but chest scans had little to no utility.

The authors noted that current cancer risk estimates from CT scan radiation may be low because of the time it can take for cancers to manifest (up to 40 years) and the short time span (10 years) of the retrospective study that validated the 1 in 10,000 per CT scan risk. "Commentary on this article cautions that these preliminary data are similar to atomic bomb survivors, and the true incidence of cancer from CT scanning may be 10 times more after more time elapses following CT scans," they wrote.

The researchers did not use external funding. They reported no disclosures