scholarly journals LO008: Assessment of the need for diagnostic imaging in extremity injuries by advanced care paramedics

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S32-S33
Author(s):  
P. Froese ◽  
M.B. Butler ◽  
S.G. Campbell ◽  
K. Magee ◽  
R.P. Mackinley
Keyword(s):  
Diagnostic Imaging ◽  
Patient Flow ◽  
Body Part ◽  
Initial Assessment ◽  
X Rays ◽  
Convenience Sample ◽  
Predictive Values ◽  
X Ray ◽  
Subsequent Test ◽  
Extremity Injuries

Introduction: Emergency department (ED) crowding is a national challenge. Initiatives to help address this at our ED include the use of a six-bed fast-track unit staffed by advanced-care paramedics (ACPs). Institutional byelaws only allow diagnostic imaging (DI) ordering by physicians (MD). An ACP requesting DI at the time of first assessment would likely improve patient flow. We investigated whether ACPs can safely and cost-effectively request DI for extremity injuries without increasing cost or exposing patients to unnecessary radiation. Methods: A prospective evaluation of a convenience sample of patients presenting with an extremity injury sustained within 48 hours of presentation. At time of initial assessment, the ACP, following specific guidelines, recorded whether or not they believed an x-ray was indicated, and if so, what DI views they felt appropriate. Their opinion was blinded from the physician subsequently assessing the patient. An ACP opinion of the need for DI was compared with the subsequent test ordered by the MD. The MD decision to order DI was considered ‘gold standard’. Opinions were considered “matched” if the MD ordered DI of the same body part that the ACP believed was indicated. Sensitivity, specificity, positive predictive and negative predictive values (PPV, NPV) were calculated. Using data from our ED information system, we estimated the time that would have been saved by allowing ACPs to order DI. Results: Of 199 patients 192 images were ordered and 89 fractures were diagnosed. ACPs and MDs agreed that DI was necessary 94.70% of the time (95% CI: {90.6%, 97.4%}). There were 8 x-rays the ACP did not order that the MD did order, of which one showed a fracture. Twice, the ACP would have ordered an x-ray that the MD did not. In terms of identifying the need for DI, ACPs were 95.8% sensitive and 71.4% specific. The PPV was 98.9% (95% CI: {95.8%, 99.8%}), and the NPV was 38.5% (95% CI: {15.1%, 67.7%}). On average, ACP opinion of DI indication was made 54.1 minutes (95% CI: {48.0, 60.2}) earlier that of the MD. Conclusion: The overall agreement between MDs and ACPs was almost 95%. ACPs are more likely to under-order x-rays than to over-order them, lowering the risk of increasing radiation exposure and cost. ACP DI ordering may decrease the time of processing of patients with extremity injuries by almost an hour.

scholarly journals SP9.1.3 Abdominal X-Rays in the Emergency Setting- A Review of Current Practice

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Lará Armstrong ◽  
Helen Monaghan ◽  
Sarah Jeffers
Keyword(s):  
Diagnostic Imaging ◽  
Radiation Exposure ◽  
Diagnostic Yield ◽  
Hospital Costs ◽  
Radiology Department ◽  
Emergency Setting ◽  
X Rays ◽  
X Ray ◽  
Imaging Results ◽  
Patient Radiation Exposure

Abstract Aim Abdominal radiographs (AXRs) are commonly used in the setting of acute abdominal pain. However, with low diagnostic yield, they can increase workload within the radiology department, increase patient radiation exposure and ultimately delay further diagnostic imaging. The average cost of an abdominal film, excluding staffing costs, is £45. This study aimed to investigate the appropriate use of AXRs in the emergency setting, as per the Royal College of Radiologists Guidelines (RCR). Methods A single centre retrospective review was conducted of all patients referred to the emergency surgical team over a 21 day period. Data was retrieved from electronic handover records. Demographics, radiology request forms and imaging results were obtained from up to date electronic care records. Results A total of 160 patients presented within the audit window, with a median age 49 (16-94) and 61.3% male. Overall, 36.9% of patients underwent an abdominal x-ray, 66.1% of which were not indicated in accordance with RCR guidelines. 71.2% of patients who underwent an abdominal x-ray required further diagnostic imaging by means of CT or USS. Only 10.2% of AXRs provided diagnostic information. Total cost expenditure for inappropriate AXRs = £1,755, excluding staffing costs. Conclusions Approximately two thirds of AXRs performed did not comply with the published RCR guidelines. Adherence to RCR guidelines can reduce needless radiation exposure, hospital costs and delay to diagnosis. We plan to conduct a teaching session on the RCR guidelines alongside the development of information posters, and re-audit our results.

scholarly journals Sensitivity of chest ultrasound for postoperative pneumothorax in comparison to chest X-ray after lung resecting surgery

2019 ◽  
Vol 57 (5) ◽  
pp. 846-853
Author(s):  
Thomas Galetin ◽  
Jérôme Defosse ◽  
Mark Schieren ◽  
Ben Marks ◽  
Alberto Lopez-Pastorini ◽  
...  
Keyword(s):  
Patient Selection ◽  
Chest Tube ◽  
X Rays ◽  
Medical Patients ◽  
Clinical Trial Registration ◽  
Predictive Values ◽  
Thoracic Ultrasound ◽  
X Ray ◽  
Therapeutic Decisions ◽  
Chest X Ray

Abstract OBJECTIVES Thoracic ultrasound is superior to chest X-ray for the detection of a pneumothorax in trauma and intensive care medicine. Data regarding its use in non-cardiac thoracic surgery are scarce and contradictory. Previous studies are heterogeneous regarding sonographic methodology and patient selection. This study aimed to evaluate the accuracy of thoracic ultrasound for pneumothorax assessment after lung resecting surgery in unselected patients. METHODS SONOR (SONOgraphy vs x-Ray) is a prospective observational trial (registry-ID DRKS00014557). A total of 123 consecutive patients with lung resecting surgery received a standardized thoracic ultrasound the same day and in addition to routine chest X-rays in erect position after removal of the chest tube. The sonographer was blinded to radiological findings and vice versa. RESULTS Sensitivity, specificity, positive and negative predictive values of ultrasound after removing the chest tube were 0.32, 0.85, 0.54, 0.69 for any pneumothorax and 1.0, 0.82, 0.19, 1.0 for pneumothorax ≥3 cm. No clinically relevant pneumothorax was missed. The agreement between sonography- and routine-based therapeutic decisions was 97%. Lung pulse was the most frequently detected sign to sonographically rule out a pneumothorax. CONCLUSIONS Postoperative thoracic ultrasound in unselected patients has a low overall sensitivity to detect a residual pneumothorax; however, its sensitivity and negative predictive values regarding clinically relevant pneumothorax are high. Test quality depends on the distinct sonographic methodology and patient selection. Anatomic differences in postsurgical and medical patients may be responsible for the contradictory results of previous trials. Studies with a larger population size are required to validate the accuracy of relevant pneumothoraces and identify appropriate selection criteria. Clinical trial registration number DRKS—German Clinical Trials Register, www.drks.de, registry-ID DRKS00014557.

scholarly journals P128: Emergency physician efficiency benchmarking and diagnostic imaging use

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S110-S110
Author(s):  
S. Weerasinghe ◽  
N. Chandratilleke ◽  
S. Campbell
Keyword(s):  
Diagnostic Imaging ◽  
Optimal Performance ◽  
Audit And Feedback ◽  
X Rays ◽  
X Ray ◽  
Use Of Resources ◽  
Quartile Range ◽  
Workload Measurement ◽  
Number Of Patients ◽  
Return Visits

Introduction: As part of our audit and feedback process, Emergency Physicians (EP) are provided feedback on flow metrics and resource utilization. We analysed the relationship between two specific metrics (adjusted workload measurement (AWM), with the number of patients seen per hour adjusted according to CTAS, and percentage of revisits within 72 hours and diagnostic imaging use. Unfortunately, we are unable to evaluate quality of care, nor appropriateness of DI indication at this stage. Methods: We used data from 86 physicians at an academic ED, from June 1, 2015 to May31, 2017. The Data Envelope Analysis (DEA) model incorporated performance quality measures as outputs and efficiency measures as inputs. DEA is a method widely used in physician performance analysis. The method provides a score (optimal performance efficiency-OPE) for each EP based on maximization of the performance (AWM) in proportion to the combination of efficient use of resources, diagnostic imaging (DI). The score was used to regress against demographic characteristics and training. Results: The median AWM was 6.8 (quartiles Q1-Q3 = 6.4-7.4) with the median diagnostic imaging use of percentages of CT (median = 10.1, 8.6-11.9), US (median = 4.7, 3.6-5.6) and x-ray (80, 74-84). The EPs who had highest AWM combined with least use of DI (OPE = 100%), provided median AWM of 9.1 (range 8.9-9.7) with percentage CT, US and x-ray medians at 5.8% (range 5.8-6.2), 2.7% (range 2.4-3.6) and 59% (range 59-72). These provided benchmarks for optimal performance indicators. We found statistically significant differences of OPE scores based on gender (men 4.1 times higher, p < 0.001) and degree (RCPS < CCFPEM, Other < CCFPEM, p < 0.001). Overall AWM diminishes at the rate of 14% (95%CI: 9-20%) for a combination of 100 DI tests ordered. In order to reach the optimal level of performance, to reach an OPE of 100%, the median CT use percentage needs to be reduced by 6% (quartile range 3.9- 7.7%), US by 2.2% (quartile range 1.5-3.4%) and x-rays by 37.2% (quartile range: 26.8-44.3%). Return visit rates were not associated with DI use, possibly due to homogeneity in the percentage of return visits. Conclusion: We found significant performance variations in terms of average workload measurement in proportion to the weighted average of diagnostic imaging use, with increased use of DI being associated with decreasing AWM. Percentage of return visits does not appear to be useful as a performance indicator.

Utilization patterns of diagnostic imaging across the late life course: A population-based study in Ontario, Canada

2008 ◽  
Vol 24 (04) ◽  
pp. 384-390 ◽  
Author(s):  
Li Wang ◽  
Jason X. Nie ◽  
C. Shawn Tracy ◽  
Rahim Moineddin ◽  
Ross E. G. Upshur
Keyword(s):  
Diagnostic Imaging ◽  
Life Course ◽  
Late Life ◽  
Population Based ◽  
Ct Scans ◽  
X Rays ◽  
Age Group ◽  
X Ray ◽  
Utilization Patterns ◽  
Ct And Mri

Objectives:Due to the aging baby boom population, utilization rates of diagnostic imaging (i.e., X-ray, CT, and MRI scanning) have risen rapidly relative to other health services. The aim of this study is to investigate the utilization patterns of outpatient diagnostic imaging services (X-ray, CT, and MRI) across the late life course (65 years and older).Methods:A population-based retrospective cohort study was conducted for the period April 1, 2005, to March 31, 2006. All Ontario residents aged 65+ and eligible for government health insurance were included in the analysis.Results:Utilization of diagnostic imaging followed an inverted U-pattern: increasing with advancing age, peaking in the 80–84 age group for CT scans and in the 70–74 age group for MRI and X-rays, and then declining in the later years. Overall, females received significantly more X-rays than males (p&lt; .01), but males received significantly more CT and MRI scans (p&lt; .01). A small proportion of high-users of radiology services accounted for a large proportion of overall utilization. Finally, our analysis revealed that a disproportionately large proportion of high-users of MRI services were in the highest SES quintile. No SES differences were observed for X-ray or CT scans.Conclusions:Population aging will lead to increased demand for healthcare services. Utilization of outpatient diagnostic imaging services is associated with age, gender, and SES. Given the increasing demand and the limited resources available, there may be a need for programs to target underserved populations to reduce remediable inequities. Whereas patient-level decisions regarding the use of diagnostic imaging are rightfully determined on the basis of clinical factors, allocation decisions should also be informed by the ethical principles of equity and fairness.

Accuracy of lung ultrasound and chest X-rays in diagnosing acute pulmonary oedema in patients presenting with acute dyspnoea in emergency department

2021 ◽  
Vol 71 (10) ◽  
pp. 2423-2425
Author(s):  
Sanniya Khan Ghauri ◽  
Khawaja Junaid Mustafa ◽  
Arslaan Javaeed ◽  
Abdus Salam Khan
Keyword(s):  
Emergency Department ◽  
Lung Ultrasound ◽  
Acute Pulmonary Oedema ◽  
X Rays ◽  
Acute Dyspnea ◽  
Inclusion Criteria ◽  
Predictive Values ◽  
X Ray ◽  
Acute Dyspnoea ◽  
Chest X Ray

To determine the diagnostic accuracy of lung ultrasound and chest X-ray in diagnosing Acute Pulmonary Edema (APE) in patients presenting with acute dyspnea in emergency department. This study was conducted at the emergency department of Shifa International Hospital, Islamabad from 31st July 2018 to 31st January 2019. A total of 225 patients presenting with dyspnoea and satisfying inclusion criteria were assessed by clinical examination, lung USG and chest X-ray. The results of chest X-ray and lung USG were compared with clinical diagnosis. The current study revealed sensitivity of chest X-ray and LUS ( 60.16% versus 91.05%), specificity (66.67% versus 91.18%), positive predictive value  (68.52% versus 92.56%) and the negative predictive values (58.12% versus 89.42%) respectively. Present study revealed that the LUS has better accuracy than chest X-ray for diagnosis of APE. Continuou...

White-Light Coronal Structures: Streamers and CMEs

1994 ◽  
Vol 144 ◽  
pp. 82
Author(s):  
E. Hildner
Keyword(s):  
Emission Line ◽  
Electron Density ◽  
White Light ◽  
Coronal Mass Ejections ◽  
X Rays ◽  
Solar Cycles ◽  
Temperature Function ◽  
X Ray ◽  
Eclipse Observations ◽  
Coronal Structures

AbstractOver the last twenty years, orbiting coronagraphs have vastly increased the amount of observational material for the whitelight corona. Spanning almost two solar cycles, and augmented by ground-based K-coronameter, emission-line, and eclipse observations, these data allow us to assess,inter alia: the typical and atypical behavior of the corona; how the corona evolves on time scales from minutes to a decade; and (in some respects) the relation between photospheric, coronal, and interplanetary features. This talk will review recent results on these three topics. A remark or two will attempt to relate the whitelight corona between 1.5 and 6 R⊙to the corona seen at lower altitudes in soft X-rays (e.g., with Yohkoh). The whitelight emission depends only on integrated electron density independent of temperature, whereas the soft X-ray emission depends upon the integral of electron density squared times a temperature function. The properties of coronal mass ejections (CMEs) will be reviewed briefly and their relationships to other solar and interplanetary phenomena will be noted.

Chemical Species Identification in an SEM by Changes in Emitted X-Ray Energies

1974 ◽  
Vol 32 ◽  
pp. 570-571
Author(s):  
R. H. Duff
Keyword(s):  
Species Identification ◽  
Valence Electron ◽  
Chemical Species ◽  
X Rays ◽  
Chemical Bonds ◽  
Small Shift ◽  
X Ray ◽  
Electron Transitions ◽  
Peak Energy ◽  
Chemical Combination

A material irradiated with electrons emits x-rays having energies characteristic of the elements present. Chemical combination between elements results in a small shift of the peak energies of these characteristic x-rays because chemical bonds between different elements have different energies. The energy differences of the characteristic x-rays resulting from valence electron transitions can be used to identify the chemical species present and to obtain information about the chemical bond itself. Although these peak-energy shifts have been well known for a number of years, their use for chemical-species identification in small volumes of material was not realized until the development of the electron microprobe.

Influence of X-Ray Induced Fluorescence on Energy Dispersive X-Ray Analysis of Thin Foils

1977 ◽  
Vol 35 ◽  
pp. 328-329
Author(s):  
E. A. Kenik ◽  
J. Bentley
Keyword(s):  
Thin Foil ◽  
Electron Excitation ◽  
Simple Approach ◽  
Foil Thickness ◽  
X Rays ◽  
X Ray ◽  
Hole Spectrum ◽  
Illumination System ◽  
Thin Foils ◽  
Intensity Ratios

Cliff and Lorimer (1) have proposed a simple approach to thin foil x-ray analy sis based on the ratio of x-ray peak intensities. However, there are several experimental pitfalls which must be recognized in obtaining the desired x-ray intensities. Undesirable x-ray induced fluorescence of the specimen can result from various mechanisms and leads to x-ray intensities not characteristic of electron excitation and further results in incorrect intensity ratios.In measuring the x-ray intensity ratio for NiAl as a function of foil thickness, Zaluzec and Fraser (2) found the ratio was not constant for thicknesses where absorption could be neglected. They demonstrated that this effect originated from x-ray induced fluorescence by blocking the beam with lead foil. The primary x-rays arise in the illumination system and result in varying intensity ratios and a finite x-ray spectrum even when the specimen is not intercepting the electron beam, an ‘in-hole’ spectrum. We have developed a second technique for detecting x-ray induced fluorescence based on the magnitude of the ‘in-hole’ spectrum with different filament emission currents and condenser apertures.

X-ray micro tomography in the scanning electron microscope

1978 ◽  
Vol 36 (1) ◽  
pp. 106-107 ◽  
Author(s):  
W. Brünger
Keyword(s):  
Electron Beam ◽  
Electron Microscope ◽  
Scanning Electron Microscope ◽  
Target Surface ◽  
The Body ◽  
X Rays ◽  
Cross Sectional ◽  
X Ray ◽  
Micro Tomography ◽  
Scanning Electron

Reconstructive tomography is a new technique in diagnostic radiology for imaging cross-sectional planes of the human body /1/. A collimated beam of X-rays is scanned through a thin slice of the body and the transmitted intensity is recorded by a detector giving a linear shadow graph or projection (see fig. 1). Many of these projections at different angles are used to reconstruct the body-layer, usually with the aid of a computer. The picture element size of present tomographic scanners is approximately 1.1 mm2.Micro tomography can be realized using the very fine X-ray source generated by the focused electron beam of a scanning electron microscope (see fig. 2). The translation of the X-ray source is done by a line scan of the electron beam on a polished target surface /2/. Projections at different angles are produced by rotating the object.During the registration of a single scan the electron beam is deflected in one direction only, while both deflections are operating in the display tube.

Digital x-ray mapping of nanometer-size supported bimetallic catalysts

1988 ◽  
Vol 46 ◽  
pp. 530-531
Author(s):  
L. T. Germinario
Keyword(s):  
Background Radiation ◽  
Metal Cluster ◽  
Single Element ◽  
Beam Diameter ◽  
X Rays ◽  
X Ray ◽  
Major Interest ◽  
Induced Changes

Understanding the role of metal cluster composition in determining catalytic selectivity and activity is of major interest in heterogeneous catalysis. The electron microscope is well established as a powerful tool for ultrastructural and compositional characterization of support and catalyst. Because the spatial resolution of x-ray microanalysis is defined by the smallest beam diameter into which the required number of electrons can be focused, the dedicated STEM with FEG is the instrument of choice. The main sources of errors in energy dispersive x-ray analysis (EDS) are: (1) beam-induced changes in specimen composition, (2) specimen drift, (3) instrumental factors which produce background radiation, and (4) basic statistical limitations which result in the detection of a finite number of x-ray photons. Digital beam techniques have been described for supported single-element metal clusters with spatial resolutions of about 10 nm. However, the detection of spurious characteristic x-rays away from catalyst particles produced images requiring several image processing steps.

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