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PurposeGuidelines call for routine reimaging of Grade 4–5 renal injuries at 48–72 h. The aim of the current study is to evaluate the clinical utility of computed tomography (CT) reimaging in high-grade renal injuries.Materials and methodsWe assembled data on 216 trauma patients with high-grade renal trauma at three level 1 trauma centers over a 19-year span between 1999 and 2017 in retrospectively collected trauma database. Demographic, radiographic, and clinical characteristics of patients were retrospectively reviewed.ResultsIn total, 151 cases were Grade 4 renal injuries, and 65 were Grade 5 renal injuries. 53.6% (81) Grade 4 and 15.4% (10) Grade 5 renal injuries were initially managed conservatively. Of the 6 asymptomatic cases where repeat imaging resulted in intervention, 100% had collecting system injuries at initial imaging. Collecting system injuries were only present in 42.9% of cases where routine repeat imaging did not trigger surgical intervention. Collecting system injury at the time of initial imaging was a statistically significant predictor of routine repeat imaging triggering surgical intervention (p = 0.022). Trauma grade and the presence of vascular injury were not significant predictors of intervention after repeat imaging in asymptomatic patients.ConclusionIn asymptomatic patients with high-grade renal trauma, the number needed to image is approximately one in eight (12.5%) to identify need for surgical intervention. There is potentially room to improve criteria for routine renal imaging in high-grade renal trauma based on the more predictive imaging finding of collecting system injury.

ObjectiveEvaluate the impact of positive oral contrast material (POCM) for non-traumatic abdominal pain on diagnostic confidence, diagnostic rate, and ED throughput.Materials and methodsED oral contrast guidelines were changed to limit use of POCM. A total of 2,690 abdominopelvic CT exams performed for non-traumatic abdominal pain were prospectively evaluated for diagnostic confidence (5-point scale at 20% increments; 5 = 80–100% confidence) during a 24-month period. Impact on ED metrics including time from CT order to exam, preliminary read, ED length of stay (LOS), and repeat CT scan within 7 days was assessed. A subset of cases (n = 729) was evaluated for diagnostic rate. Data were collected at 2 time points, 6 and 24 months following the change.ResultsA total of 38 reviewers were participated (28 trainees, 10 staff). 1238 exams (46%) were done with POCM, 1452 (54%) were performed without POCM. For examinations with POCM, 80% of exams received a diagnostic confidence score of 5 (mean, 4.78 ± 0.43; 99% ≥ 4), whereas 60% of exams without POCM received a score of 5 (mean, 4.51 ± 0.70; 92% ≥ 4; p < .001). Trainees scored 1,523 exams (57%, 722 + POCM, 801 -POCM) and showed even lower diagnostic confidence in cases without PCOM compared with faculty (mean, 4.43 ± 0.68 vs. 4.59 ± 0.71; p < 0.001). Diagnostic rate in a randomly selected subset of exams (n = 729) was 54.2% in the POCM group versus 56.1% without POCM (p < 0.655). CT order to exam time decreased by 31 min, order to preliminary read decreased by 33 min, and ED LOS decreased by 30 min (approximately 8% of total LOS) in the group without POCM compared to those with POCM (p < 0.001 for all). 205 patients had a repeat scan within 7 days, 74 (36%) had IV contrast only, 131 (64%) had both IV and oral contrast on initial exam. Findings were consistent both over a 6-month evaluation period as well as the full 24-month study period.ConclusionLimiting use of POCM in the ED for non-traumatic abdominal pain improved ED throughput but impaired diagnostic confidence, particularly in trainees; however, it did not significantly impact diagnostic rates nor proportion of repeat CT exams.

Background Current guidelines recommend repeat computed tomography (CT) imaging in high-grade blunt renal injury within 48–96 h, yet diagnostic value and clinical significance remain controversial. The aim of this work was to determine the possible gain of CT re-imaging in uncomplicated patients with blunt renal trauma at 48 h after injury, presenting one of the largest case series. Methods A retrospective database of patients admitted to our centre with isolated blunt renal trauma due to sporting injuries was analysed for a period of 20 years (2000–2020). We included only patients who underwent repeat imaging at 48 h after trauma irrespective of AAST renal injury grading (grade 1–5) and initial management. The primary outcome was intervention rates after CT imaging at 48 h in uncomplicated patients versus CT scan at the time of clinical symptoms. Results A total of 280 patients (mean age: 37.8 years; 244 (87.1%) male) with repeat CT after 48 h were included. 150 (53.6%) patients were classified as low-grade (grade 1–3) and 130 (46.4%) as high-grade (grade 4–5) trauma. Immediate intervention at trauma was necessary in 59 (21.1%) patients with high-grade injuries: minimally invasive therapy in 48 (81.4%) and open surgery in 11 (18.6%) patients, respectively. In only 16 (5.7%) cases, intervention was performed based on CT re-imaging at 48 h (low-grade vs. high-grade: 3.3% vs. 8.5%; p  = 0.075). On the contrary, intervention rate due to clinical symptoms was 12.5% (n = 35). Onset of clinical progress was on average (range) 5.3 (1–17) days post trauma. High-grade trauma (odds ratio [OR] grade 4 vs. grade 3 , 14.62;  p  < 0.001; OR grade 5 vs. grade 3 , 22.88, p  = 0.004) and intervention performed at the day of trauma (OR 3.22;  p  = 0.014) were powerful predictors of occurrence of clinical progress. Conclusion Our data suggest that routine CT imaging 48 h post trauma can be safely omitted for patients with low- and high-grade blunt renal injury as long as they remain clinically stable. Patients with high-grade renal injury have the highest risk for clinical progress; thus, close surveillance should be considered especially in this group.

The Brain Injury Guidelines (BIG) categorize patients with mild, moderate, and severe traumatic brain injuries (TBIs). We examined whether TBI transfer guidelines should be modified to incorporate BIG alongside polytrauma and patient frailty assessments to identify which patients are most likely to benefit from transfer. Patients ≥ 18 years old transferred to our Level 1 trauma center in 2019–2023 with nonpenetrating blunt cranial trauma were identified retrospectively. BIG scores were calculated using presentation, injury, in-hospital, and follow-up characteristics. Of the 999-patient cohort, 168 patients were considered BIG1, 133 BIG2, and 698 BIG3. BIG1 and BIG2 (compared with BIG3) patients had lower injury severity scores (14.6, 13.8, 19.9, respectively, p < 0.001), no > 1-point decline in Glasgow Coma Scale score during transportation (0, 0, 16.8 %, p < 0.001), shorter hospital stays (4.6 days, 3.6, 8.3, p < 0.001), fewer intensive care unit admissions (31.5 %, 37.6 %, 66.6 %, p < 0.001), rare progression on imaging (1.2 %, 4.6 %, 29.4 %, p) without clinical decline, and minimal neurosurgical interventions (0, 1.5 %, 13.9 %, p < 0.001). BIG2 polytrauma patients had greater risk of neurologic decline (OR 2.13, p = .04), whereas BIG1 patients had no meaningful predictors of neurologic decline. BIG3 classification (OR 5.92), SDH (OR 3.03), and high-velocity injury (OR 2.52) were the greatest risk factors for neurosurgical intervention. BIG1 and BIG2 patients without polytrauma may not require transfer, but BIG2 patients with polytrauma and BIG3 patients often required transfer. Frailty and patient age may not require consideration in decision-making. Assessment including BIG and polytrauma may reduce unnecessary transfers, preserve hospital resources, and optimize patient care. •168 patients were classified as BIG 1, 133 as BIG 2, and 698 as BIG 3.•BIG 3 patients showed more neurologic decline and more total complications.•BIG 3 was nearly six times more likely to undergo craniotomy than BIG 1 and 2.

PurposeTo retrospectively assess the relative diagnostic utility of radiologist-recommended ultrasound (US) following emergency department (ED) abdominal and pelvic computed tomography (CT) in patients with non-traumatic abdominal and/or pelvic pain.MethodsBlinded to clinical outcomes, two radiology residents and an attending radiologist reviewed radiology reports and relevant medical records for all adult patients from EDs at two academic medical centers from one institution over a 3-year time period, who underwent abdominal/pelvic US within 72 h of an initial IV contrast-enhanced abdominal and pelvic CT for non-traumatic abdominal and/or pelvic pain. Incremental diagnostic utility of subsequent US was deemed present when (1) US findings were discordant with those at CT, or (2) findings were concordant, but US yielded additional relevant diagnostic information. Diagnostic utility was stratified by whether examinations were radiologist-recommended or independently ordered by treating physicians.Results319 encounters satisfied the inclusion criteria, including 194 female patients (18–98 years of age, mean of 59.8 years) and 125 male patients (20–90 years of age, mean of 63.2 years). 7 (2.2%) subsequent US examinations were discordant with the initial CT, 100 (31.3%) were concordant but provided relevant additional information, and 212 (66.5%) were concordant without providing additional information, for an overall diagnostic utility of 33.5%. Of subsequent radiologist-recommended US examinations, 70.0% (63/90) yielded incremental diagnostic utility vs. 19.2% (44/229) ordered independently by treating physicians (OR 3.65; 95% CI 2.31–5.75). For those encounters in which US provided incremental diagnostic utility, the most commonly assessed anatomical areas were the biliary system and the female adnexal region.ConclusionIn ED patients with non-traumatic abdominal and/or pelvic pain undergoing abdominal and pelvic CT, follow-up US examinations recommended by radiologists are more likely to provide incremental diagnostic utility than those independently ordered by their treating physicians. In order to optimize the value of advanced imaging, radiologists should assume greater roles in team-based utilization management.

Patients referred to trauma centers often undergo an extensive diagnostic work-up before transfer. The purpose of our study was to quantify and examine the effects of repeat imaging in this population. A prospective cohort study of 410 patient transfers was performed. Repeat imaging was conducted at the discretion of the accepting surgeon for multiple reasons. Two groups were compared, those who did and those who did not require repeat imaging. Overall, 53% of referrals received repeat imaging, at an average cost of $2,985 per patient. This group was older (42 vs 37 y; P < .05), more severely injured (injury severity score, 12 vs 9; P < .05), and experienced longer delays before transfer (244 vs 192 min; P < .05). By using logistic regression analysis, injury severity score was found to be an independent predictor of the need for repeat imaging ( P = .003). Severely injured trauma patients often receive films that ultimately require duplication, resulting in transfer delay, unnecessary morbidity, and increased resource use. Targeted education and development of centralized radiology systems could alleviate some of the burden of unnecessary imaging.

Background Patients with renal colic have a 7% chance of annual recurrence. Previous studies evaluating cumulative Abbreviations: computed tomography (CT) exposure for renal colic patients were typically from single centers. Methods This was an observational cohort study. Inner-city ED patients with a final diagnosis of renal colic were prospectively identified (1/10/16–10/16/16). Authors conducted structured electronic record reviews from a 6-hospital system encompassing over 192,000 annual ED visits. Categorical data analyzed by chi-square; continuous data by t-tests. Primary outcome measure was the proportion of study group patients with prior history CT abdomen/pelvis CT. Results Two hundred thirteen patients in the study group; 59% male, age 38+/− 10 years, 67% Hispanic, 62% prior stone history, flank pain (78%), dysuria (22%), UA (+) blood (75%). 60% (95% CI = 53–66%) of patients received an EDCV CT; hydronephrosis seen in 55% (95% CI = 46–63%), stone in 90%(95% CI = 83–94%). No significant differences observed in the proportion of EDCV patients who received CT with respect to: female vs. male (62% vs. 56%; p  = 0.4), mean age (37+/− 9 years vs. 39+/− 11 years; p  = 0.2), and Hispanic vs. non-Hispanic white (63% vs.63%; p  = 0.96). Patients with a prior stone history were more likely than those with no history to receive an EDCV CT (88% vs. 16%; p  < 0.001). 118 (55%; 95% CI = 49–62%) of patients had at least one prior CT, 46 (22%; 95% CI = 16–28%) had ≥3 prior CTs; 29 (14%; 95% CI = 10–19%), ≥ 10 prior CTs. Patients who did not receive an EDCV CT had a significantly higher mean prior number of CTs than those who had EDCV CT (5.1+/− 7.7 vs 2.2+/− 4.9; p < 0.001). Patients with prior stone were more likely to receive only U/S during EDCV (33% vs. 15%; p  = 0.003). Conclusions Within our EDCV cohort of renal colic patients, 55% had at least one prior CT. The mean number of prior CTs was lower for patients receiving CT on EDCV, and Ultrasound (US) alone was used more often in patients with prior stone history vs. those with no prior history.

Background: There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups. Methods: We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center. Results: Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation. Conclusions: Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.

Spinal and bulbar muscular atrophy (SBMA) is a hereditary neuromuscular disorder caused by CAG trinucleotide expansion in the gene encoding the androgen receptor (AR). In the central nervous system, lower motor neurons are selectively affected, whereas pathology of patients and animal models also indicates involvement of skeletal muscle including loss of fast-twitch type 2 fibres and increased slow-twitch type 1 fibres, together with a glycolytic-to-oxidative metabolic switch. Evaluation of muscle and fat using MRI, in addition to biochemical indices such as serum creatinine level, are promising biomarkers to track the disease progression. The serum level of creatinine starts to decrease before the onset of muscle weakness, followed by the emergence of hand tremor, a prodromal sign of the disease. Androgen-dependent nuclear accumulation of the polyglutamine-expanded AR is an essential step in the pathogenesis, providing therapeutic opportunities via hormonal manipulation and gene silencing with antisense oligonucleotides. Animal studies also suggest that hyperactivation of Src, alteration of autophagy and a mitochondrial deficit underlie the neuromuscular degeneration in SBMA and provide alternative therapeutic targets.

Part 2 of the review “ Back to the Future ” is dedicated to the evolutionary role of the bio-medicolegal sciences, reporting the historical profiles, the state of the art, and prospects for future development of the main related techniques and methods of the ancillary disciplines that have risen to the role of “ autonomous ” sciences, namely, Genetics and Genomics, Toxicology, Radiology, and Imaging, involved in historic synergy in the “ post-mortem assessment ,” together with the mother discipline Legal Medicine, by way of its primary fundament, universally denominated as Forensic Pathology. The evolution of the scientific research and the increased accuracy of the various disciplines will be oriented towards the elaboration of an “algorithm,” able to weigh the value of “ evidence ” placed at the disposal of the “ justice system ” as real truth and proof.