Israel Medical Association Journal

Background: Coronary computed tomography angiography (CCTA) is an established modality for ruling out coronary artery disease. However, it has been suggested that CCTA may be a source of non-negligible radiation exposure.

Objectives: To evaluate the potential degradation in coronary image quality when using prospective gated (PG) CCTA as compared with retrospective gated (RG) CCTA in chest pain evaluation.

Methods: The study cohort comprised 216 patients: 108 consecutive patients in the PG CCTA arm and 108 patients matched for age, gender and heart rate in the RG CCTA arm. Scans were performed using a 64-slice multidetector CT scanner. All 15 coronary segments were evaluated subjectively for image quality using a 5-point visual scale. Dose-length product was recorded for each patient and the effective radiation dose was calculated

Results: The PG CCTA technique demonstrated a significantly higher incidence of step artifacts in the middle and distal right coronary artery, the distal left anterior descending artery, the second diagonal, the distal left circumflex artery, and the second marginal branches. Nevertheless, the diagnostic performance of these scans was not adversely affected. The mean effective radiation doses were 3.8 ± 0.9 mSv vs.17.2 ± 3 mSv for PG CCTA and RG CCTA, respectively (P < 0.0001).

Conclusions: Artifacts caused by the PG CCTA technique (64 MDCT) scanners tended to appear in specific coronary segments but did not impair the overall diagnostic quality of CCTA and there was a marked reduction in radiation exposure. We conclude that 64-slice PG CCTA is suitable for clinical use, especially for acute chest pain "fast track" evaluation targeted at relatively young subjects in a chest pain unit.
 

Background: Assessment of small intestinal disease remains a challenge for both clinicians and radiologists. Modern magnetic resonance enterography (MRE) is a non-radiation modality that can demonstrate both intestinal wall pathologies and extraluminal lesions.

Objectives: To analyze the results of 213 MRE scans performed since 2005.

Methods: Consecutive MRE[1] scans performed in our academic medical center between December 2005 and November 2009 were reviewed for patients' demographic data, indications for the examination, and main imaging findings. The imaging findings recorded were mural changes and intraluminal filling defects; there were also mesenteric findings and extraintestinal inflammatory findings.

Results: During the study period 213 MRE scans were performed; 70% of them for proven or suspected Crohn's disease (CD) of the small bowel. Another indication was small bowel neoplasm (6% of the scans). Bowel wall thickening and enhancement were seen in 60% and 53% of MRE scans, respectively. Mesenteric involvement was found in 52% of the patients. Incidental extraintestinal findings were detected in 17% of the scans. In 22% of the scans there was no pathological finding.

Conclusions: Our 4-year clinical experience with MRE shows that this non-invasive and non-radiating modality is a powerful technique for evaluation and long-term follow-up of small bowel pathologies. The most common clinical indication was the evaluation of Crohn’s disease. With physicians’ increased awareness, the future use of MRE in the evaluation of other small bowel pathologies such as neoplasm and celiac disease will increase.

Background: Many patients present to the emergency department with chest pain. While in most of them chest pain represents a benign complaint, in some patients it underlies a life-threatening illness.

Objectives: To assess the routine evaluation of patients presenting to the ED[1] with acute chest pain via the utilization of a cardiologist-based chest pain unit using different non-invasive imaging modalities.

Methods: We evaluated the records of 1055 consecutive patients who presented to the ED with complaints of chest pain and were admitted to the CPU[2]. After an observation period and according to the decision of the attending cardiologist, patients underwent myocardial perfusion scintigraphy, multidetector computed tomography, or stress echocardiography.

Results: The CPU attending cardiologist did not prescribe non-invasive evaluation for 108 of the 1055 patients, who were either admitted (58 patients) or discharged (50 patients) after an observation period. Of those remaining, 445 patients underwent MDCT[3], 444 MPS[4], and 58 stress echocardiography. Altogether, 907 patients (86%) were discharged from the CPU. During an average period of 236 ± 223 days, 25 patients (3.1%) were readmitted due to chest pain of suspected cardiac origin, and only 8 patients (0.9%) suffered a major adverse cardiovascular event.

Conclusions: Utilization of the CPU enabled a rapid and thorough evaluation of the patients’ primary complaint, thereby reducing hospitalization costs and occupancy on the one hand and avoiding misdiagnosis in discharged patients on the other.
 

[1] ED = emergency department

[2] CPU = chest pain unit

[3] MDCT = multidetector computed tomography

[4] MPS = myocardial perfusion scintigraphy

Background: Cardiac computed tomography scans influde several extra-cardiac structures such as mediastinum, lung parenchyma and upper abdominal organs. A variety of abnormalities in those structures might be clinically important and in some cases might explain the patient's complaints.

Objectives: To analyze consecutive cardiac computed tomography examinations for the prevalence and clinical significance of extra-cardiac findings.

Methods: Cardiac CT scans of 134 sequential patients (104 males, 30 females) aged 20–77 years (mean 54 years) with suspected coronary artery disease were prospectively and independently reviewed by a consensus of two radiologists for the presence of lung, mediastinal, pleural, upper abdominal and skeletal abnormalities. CT scans with extra-cardiac abnormalities were divided into two groups: group A – defined as "clinically significant" or "potentially significant findings" – consisted of patients requiring further evaluation or follow-up, and group B – "clinically non-significant findings."

Results: Extra-cardiac abnormalities were found in 103 of the 134 patients (76.8%). Group A abnormalities were found in 52/134 patients (39%), while group B abnormalities were seen in 85/134 (63%). The most common abnormalities in group A were non-calcified lung nodules (> 4 mm) noted in 17/134 patients (13%), followed by enlarged mediastinal lymph nodes (> 10 mm) in 14/134 (10%), diaphragmatic hernia (2 cm) in 12/134 (9%), moderate or severe degenerative spine disease in 12/134 (9%), and emphysema and aortic aneurysm in 6 patients each (4.5%). A malignant lung tumor was noted in one patient.

Conclusions: There is a high prevalence of non-cardiac abnormalities in patients undergoing CCT[1]. Clinically significant or potentially significant findings can be expected in 40% of patients who undergo CCT, and these will require further evaluation and follow-up. The reporting radiologist should be experienced in chest imaging and aware of the large variety of non-cardiac findings in CCT that might explain the patient's complaints. 

Background: Earlier studies comparing minilaparotomy cholecystectomy with laparoscopic cholecystectomy did not find significant differences between the MC[1] and the LC[2] groups in operating times and patients' recovery.

Objectives: To compare the postoperative quality of life between the MC and LC groups.

Methods: The 157 patients with uncomplicated symptomatic gallstones, confirmed by ultrasound, were randomized to two groups: 85 for MC and 72 for LC. The study was prospective and randomized but not blinded or consecutive. The study groups were similar in patients' age, gender, body mass index, American Association of Anesthesiology physical fitness classification, and the operating surgeon. Patients were reevaluated 4 weeks after operation using the RAND-36 quality of life questionnaire.

Results: The RAND-36 questionnaire did not identify statistically significant differences between the study groups in general health perceptions, physical functioning, emotional well-being, social functioning, energy, bodily pain, and role functioning/emotional. Only the role functioning/physical score was slightly higher in the LC group (P = 0.038).
Conclusions: The results of this study showed that the MC procedure is a good alternative to the LC procedure, when postoperative quality of life ia measured

Objectives: To present a variety of radiologic findings on high resolution computerized tomography in eight sequential patients with COP[1], together with clinical and pathologic correlation.

Methods: Sequential HRCT[2] examinations of eight patients (four males) aged 53–80 years (mean 65.5 years) with pathologically proven COP were retrospectively analyzed by a consensus of two experienced chest radiologists for the existence and distribution of airspace consolidation, ground-glass opacities, nodular thickening along bronchovascular bundles, small (<1 cm) and large (>1 cm) nodules. The distribution of radiologic findings was classified as unilateral or bilateral, located in the upper, lower or middle lobe, and central or peripheral. Also recorded was the presence or absence of mediastinal lymphadenopathy and pleural effusion. Correlation with clinical symptoms was analyzed.

Results: All eight patients had bilateral airspace consolidations: in two cases consolidations were limited to central fields, in four they were peripheral, and in the remaining two cases they were both central and peripheral. Small nodules were noted in six cases and large nodules in three. Ground-glass opacities were found in four cases. All patients had enlarged lymph nodes (1–1.5 cm) in the mediastinum. Radiologic abnormalities resolved or improved after steroid treatment in all patients.

Conclusions: HRCT findings of bilateral multiple heterogenic lung infiltrates and nodules associated with mild mediastinal lymphadenopathy in a patient with non-specific clinical symptoms are suggestive of COP; in such cases, lung biopsy is indicated. Radiologic resolution of abnormalities correlates well with clinical improvement under adequate steroid treatment.

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[1] COP = cryptogenic organizing pneumonia

[2] HRCT = high resolution computerized tomography

Objectives: To compare the subjective visibility of normal anatomic landmarks in the chest on storage phosphor-based digital radiographs versus conventional screen-film radiographs.

Methods: Digital phosphor-based and screen-film posteroanterior chest radiographs were obtained during 1 year in 140 asymptomatic patients without any known pulmonary disease (119 men, 21 women; mean age 52.1 years, range 23–86). Both sets of films were independently compared by two experienced radiologists in different sessions. The visibility of each of the following anatomic landmarks was graded from 1 to 3: pulmonary fissures, carina, bronchi to left upper lobe, right upper lobe and left lower lobe, bronchus intermedius, anterior and posterior junctional lines, and vessels behind the heart and diaphragm. Additionally, subjective general quality impression of each radiograph was graded similarly. Statistical analyses were performed using the chi-square test. A P value less than 0.05 was considered significant.

Results: Visibility with the digital images was statistically significantly higher for the carina, left lower lobe bronchus, bronchus intermedius, and vessels behind the heart and diaphragm. Subjective general quality impression of digital radiographs was also higher (P < 0.001). No significant visibility differences were found for pulmonary fissures or junctional lines.

Conclusion: Subjective visibility of anatomic structures behind the heart and diaphragm and at the hilae is significantly improved with phosphor-based digital radiography compared with conventional screen-film radiography. This suggests that pathologic processes such as pulmonary nodules, masses or consolidations projected over those structures may be more easily and reliably depicted on digital than conventional chest X-rays.