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Stu Schroff, MD (PGY 3) Robert Lieberman, MD, MBA (PGY4) Aaron Schein, MD (PGY5, Chief Resident) Andrew Kim, MD (PGY5, Chief Resident) Sebastian Sugay,

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Presentation on theme: "Stu Schroff, MD (PGY 3) Robert Lieberman, MD, MBA (PGY4) Aaron Schein, MD (PGY5, Chief Resident) Andrew Kim, MD (PGY5, Chief Resident) Sebastian Sugay,"— Presentation transcript:

1 Stu Schroff, MD (PGY 3) Robert Lieberman, MD, MBA (PGY4) Aaron Schein, MD (PGY5, Chief Resident) Andrew Kim, MD (PGY5, Chief Resident) Sebastian Sugay, MD (PGY5, Chief Resident)

2 Topics 1. The Department of Radiology 2. Radiology as a Consult Service 3. Risks of Radiation/ALARA 4. Optimal Imaging Strategy

3 Topics 1. The Department of Radiology 2. Radiology as a Consult Service 3. Risks of Radiation/ALARA 4. Optimal Imaging Strategy

4 THE FIELD OF RADIOLOGY “Radiology is a medical specialty that employs the use of imaging to both diagnose and treat disease visualized within the human body.” - wikipedia  Radiograph of the Left hand of Anna Roentgen (wife of Wilhelm Roentgen) on November 8, 1895 in Wurzburg, Germany.

5  This is an enormously busy hospital  28 percent of trauma victims in the region  39,000 inpatient discharges/year  150,000 emergency department visits/year  1 million ambulatory care visits/year  LAC+USC Medical Center Final Budget FY : $1.189 billion

6 Statistics  60,015 CTs  12,227 MRIs  18,751 Interventional Procedures  20,281 Nuclear Medicine Studies  71,244 Ultrasounds  239,807 Radiographs

7  We are a subspecialized department  Body imaging (abdomen and pelvis)  CT, US, MRI, and Plain film/fluoroscopy (barium studies) are separate reading areas  Cardiothoracic imaging (CXR, CT chest, cardiac MRI)

8  Neuroradiology (Brain, spine, ENT, angiography)  Musculoskeletal imaging (X-ray, MRI, CT, arthrograms and biopsies)  Nuclear medicine (PET/CT, cardiac SPECT, bone scans, V/Q scans…)

9  Pediatric imaging  Women’s imaging (breast imaging, pelvic US and MRI)  Vascular and Interventional Radiology (angiography, liver/biliary interventions, neprhostomies)  CT and US guided procedures are handled by the pertinent division, not IR

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13 Hours of Operation, Mon-Fri: 8AM-4PM (Normal workday— All staff/fellows/residents in house) 4PM-10PM (On call resident and staff/fellow in house) 10PM-8AM (On call resident in house; staff/fellow at home)

14 Hours of Operation, Weekends and Holidays: 8AM-8PM (On call resident and staff/fellow in house) 8PM-8AM (On call resident on call in house; staff/fellow at home)

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16 LAC+USC Radiology Directory

17 Radread.usc.edu

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19  Protocoling studies: Protocol resident  Scheduling studies:Radiology tech  Interpretation: Reading room radread.usc.edu pw: usc rad, dofusc, usc

20  Staging CTs  “Need a prelim before morning rounds”—There must be an urgent clinical concern to justify an overnight prelim  Old studies  Didactic

21 Mon-Fri 7am-3:30 pm Tony or Kenny F102 (the “bowling alley”)

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23 Topics 1. The Department of Radiology 2. Radiology as a Consult Service 3. Risks of Radiation/ALARA 4. Optimal Imaging Strategy

24 The more useful information you provide – the more valuable information you will get out of an imaging study.

25 1. Symptom location and duration

26 The more useful information you provide – the more valuable information you will get out of an imaging study. 1. Symptom location and duration 2. Sidedness!!

27 The more useful information you provide – the more valuable information you will get out of an imaging study. 1. Symptom location and duration 2. Sidedness!! 3. Prior pertinent interventions

28 The more useful information you provide – the more valuable information you will get out of an imaging study. 1. Symptom location and duration 2. Sidedness!! 3. Prior pertinent interventions 4. Possible ddx

29 The more useful information you provide – the more valuable information you will get out of an imaging study. 1. Symptom location and duration 2. Sidedness!! 3. Prior pertinent interventions 4. Possible ddx 5. CONTACT Info

30 For example… 1. Ordering Dx: 34yo M h/o Crohn’s s/p partial SB resxn new RLQ abd pain x 1day 2. Chief Complaint: Abscess, SBO, perf. 3. Physican #: Reliable physician #, team VOIP preferred

31 Radiology Consult Without HistoryWith History: Impression Significantly abnormal CXR

32 Radiology Consult Without HistoryWith History: Impression Significantly abnormal CXR Actual history: 19yo M organ donor s/p organ harvesting with abnormal counts in the OR looking for foreign body per protocol

33 Radiology Consult Without HistoryWith History: Impression Significantly abnormal CXR No radioopaque FB s/p organ harvesting

34 Topics 1. The Department of Radiology 2. Radiology as a Consult Service 3. Risks of Radiation/ALARA 4. Optimal Imaging Strategy

35 First, a note on radiation. Computed Tomography – An Increasing Source of Radiation Exposure. The New England Journal of Medicine. 2007; 357; Radiation

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38 Schaal B. National Academy of the Sciences – What we’ve learned about the Atomic Bomb survivors. 12/8/2010. Radiation

39 What Are the Risks Associated with Radiation Exposure: Radiation

40 What Are the Risks Associated with Radiation Exposure: 1. Acute Radiation Syndrome Radiation -Sorenson 2000

41 What Are the Risks Associated with Radiation Exposure: 1. Acute Radiation Syndrome 2. Cancer Radiation

42 What is ALARA?

43 Q:What is a safe dose of radiation?

44 A: There is no such thing as a safe dose of radiation.

45 DECREASED MORBIDITY/MORTALIYINCREASED MORBIDITY/MORTALITY Diagnosis & Treatment Cancer ALARA

46 DECREASED MORBIDITY/MORTALIYINCREASED MORBIDITY/MORTALITY Diagnosis & Treatment Cancer ALARA

47 DECREASED MORBIDITY/MORTALIYINCREASED MORBIDITY/MORTALITY Diagnosis & Treatment Cancer ALARA ALARA: As Low As Reasonably Acceptable

48 Why should you care about radiation dosages?

49 1.Patient Safety – preventing unnecessary morbidity/mortality

50 Why should you care about radiation dosages? 1.Patient Safety – preventing unnecessary morbidity/mortality 2.Public Perception

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54 Why should you care about radiation dosages? 1.Patient Safety – preventing unnecessary morbidity/mortality 2.Public Perception 3.Reimbursement

55 Topics 1. The Department of Radiology 2. Radiology as a Consult Service 3. Risks of Radiation/ALARA 4. Optimal Imaging Strategy

56  Indications for Imaging:  Screening—No clinical signs of disease  e.g. Mammography, liver screening in patients with known chronic liver disease, certain high risk groups…  Diagnosis following clinical workup  Imaging should be targeted based on the clinical suspicion  There should be a working differential diagnosis before imaging  Treatment Planning  Only when the imaging findings will dictate a change in management

57 CT with Contrast When should you order IV contrast?

58 CT with Contrast When should you order IV contrast? 1. If you are looking for: 1. Infection

59 CT with Contrast When should you order IV contrast? 1. If you are looking for: 1. Infection 2. Abscess

60 CT with Contrast When should you order IV contrast? 1. If you are looking for: 1. Infection 2. Abscess 3. Neoplasm

61 CT with Contrast When should you order IV contrast? 1. If you are looking for: 1. Infection 2. Abscess 3. Neoplasm 4. You do not know what you are looking for.

62 CT without Contrast When should you avoid IV contrast?

63 CT without Contrast When should you avoid IV contrast? 1. Looking for Ca++ - (eg: Kidney stones)

64 CT without Contrast When should you avoid IV contrast? 1. Looking for Ca++ 2. Looking for acute intracranial hemorrhage

65 62yo F with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

66 62yo F with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

67 CT without Contrast When should you avoid IV contrast? 1. Looking for Ca++ 2. Looking for acute intracranial hemorrhage 3. Patient has prior history of anaphylaxis to IV contrast

68 CT without Contrast When should you avoid IV contrast? 1. Looking for Ca++ 2. Looking for acute intracranial hemorrhage 3. Patient has prior history of anaphylaxis to IV contrast 4. Patient is at risk of Contrast Induced Nephropathy

69 CreatinineGFRRisk Factors* Guidelines <1.3>60  Acceptable for most situations  Hydration None  Hydration Present  Hydration  N-acetylcysteine (Mucomyst) PO 600mg BID the day before and day of IV contrast load(*controversial) >1.9<30-  IV contrast should be avoided *Risk Factors for Renal disease: 1.Diabetes Mellitus 2.Dehydration 3.Cardiovascular disease and the use of diuretics 4.Age > 70yrs 5.Multiple Myeloma 6.Hypertension Contrast

70 CreatinineGFRRisk Factors* Guidelines <1.3>60  Acceptable for most situations  Hydration None  Hydration Present  Hydration  N-acetylcysteine (Mucomyst) PO 600mg BID the day before and day of IV contrast load(*controversial) >1.9<30-  IV contrast should be avoided *Risk Factors for Renal disease: 1.Diabetes Mellitus 2.Dehydration 3.Cardiovascular disease and the use of diuretics 4.Age > 70yrs 5.Multiple Myeloma 6.Hypertension Contrast

71 Dialysis Dependent Patients:  Contrast agents are not protein-bound and have relatively low molecular weights and readily cleared by dialysis.

72 Contrast Dialysis Dependent Patients:  Contrast agents are not protein-bound and have relatively low molecular weights and readily cleared by dialysis.  Dialysis should be scheduled within 24 hrs of intravenous contrast load

73 Contrast Prior Contrast Reactions to IV contrast 1. Anaphylaxis: 1. avoid IV contrast 2. PO contrast is OK

74 Contrast Prior Contrast Reactions to IV contrast 1. Anaphylaxis: 1. avoid IV contrast 2. PO contrast is OK 2. Mild reactions: 1. Prednisone 50mg PO x 3doses given 13hrs, 7hrs, and 1hr prior to IV contrast load. 2. Benadryl 50mg PO x 1 dose 1hr prior to IV contrast load.

75 MRI with IV Contrast (Gadolinium) When should you order IV contrast with MRI? 1. If you are looking for: 1. Infection 2. Abscess 3. Neoplasm

76 CreatinineGFRRisk Factors* Guidelines <1.3>60  Acceptable for most situations  Hydration None  Hydration >1.9<30-  IV contrast should be avoided Nephrogenic systemic fibrosis (NSF) First case 1997, first described in 2000 Resembles scleroderma/connective tissue disease Systemic disorder, no consistently effective treatment Very rare, and happens only in patients with CKD Higher stage of CKD  Higher risk of NSF Cowper SE. Nephrogenic Systemic Fibrosis [ICNSFR Website] Available at Accessed 07/12/2012. MRI IV Contrast (Gadolinium)

77 62yo immunocompromised HIV+ female with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

78 What do you do if you have NO idea what study to order? ACR Appropriateness Criteria

79 What do you do if you have NO idea what study to order? 1. ACR Appropriateness Criteria

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84 62yo immunocompromised HIV+ female with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

85 62yo immunocompromised HIV+ female with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

86 32yo pregnant female with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

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88 32yo pregnant female with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

89 32yo pregnant female with sudden onset of severe headache 1.CT head without contrast 2.CTA head with contrast 3.MRA head and neck 4.MRI head without contrast 5.MRI head with and without contrast 6.CT head with AND without contrast Radiology Consult

90 What do you do if you have NO idea what study to order? 1. ACR Appropriateness Criteria 2. Call Radiology

91 What do you do if you have NO idea what study to order? 1. ACR Appropriateness Criteria 2. Call Radiology

92 Thank you. Questions?


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