Canadian Association of Radiologists Journal

The purpose of this study is to critically appraise the Canadian Association of Radiologists (CAR) guidelines on the prevention of contrast-induced nephropathy (CIN).

The Appraisal of Guidelines Research and Evaluation (AGREE) tool is a questionnaire that consists of 23 key items organized in 6 domains (scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, editorial independence). Four radiologists read the guidelines and completed the questionnaire independently. To assess the quality of the evidence, the articles listed in the bibliography were reviewed, and the following data were collected and tabulated: the type of contrast, the administration route, and the level of evidence (Centre for Evidence Based Medicine, University of Oxford).

The highest score was for scope and purpose (92%), whereas the lowest scores were for rigor of development (50%) and applicability (40%). The score for the remaining domains were the following: stakeholder involvement (59%), clarity and presentation (69%), and editorial independence (63%). Although the bibliography of the CAR guidelines list 46 articles, only 33 were deemed pertinent to support the recommendations related to risk stratification or risk reduction of CIN. Only 3 articles dealt specifically with intravenous injection of iodinated contrast. Four articles dealt with ionic contrast, and, in 17 references, the contrast type was not specified. The best evidence (level 1) was in support of risk-reduction recommendations, but, in 8 of the 9 articles cited, the route of administration studied was exclusively intra-arterial.

It would be appropriate to revisit the topic of CIN and formulate new guidelines. A formal systematic review of the literature should be undertaken and the data extraction should specifically address contrast type and route of administration, as well as the applicability of any recommendations.

This study was designed to evaluate whether a bowel preparation used for computed tomography (CT) colonography could also be suitable for same-day colonoscopy regardless of which test was done first.

Six different endoscopists working at 3 separate hospitals evaluated 75 patients who underwent colonoscopy after receiving a bowel preparation that contained contrast material used to tag fecal and fluid material to facilitate CT colonography. This bowel preparation has been used in more than 1500 CT colonography studies. Evaluation included assessment of whether the colon was clean and dry, and whether the contrast material caused any impairment of visualization or clogging of the endoscopes. Some of the patients had first undergone CT colonography followed by same-day colonoscopy, whereas other patients had colonoscopy as their initial test.

Although the contrast material was sometimes perceptible, the volumes were very small, and caused no impairment of mucosal visualization and no clogging of the endoscopes. The bowel preparation was well tolerated. Same-day CT colonography and colonoscopy with fecal tagging was technically possible.

A simple, fairly low cost 1-day bowel preparation with fluid and fecal tagging is suitable for CT colonography and colonoscopy done the same day in either order. However, the preferences of individual endoscopists and difficulties with making oral contrast agents readily available are challenges to widespread adoption of a common bowel preparation regimen.

Benign breast masses, such as fibroadenomas, are common, and their management is variable, depending on symptoms and patient concerns. We undertook this study to determine the safety, efficacy, and patient acceptance of percutaneous excision of benign breast masses by using a hand-held vacuum-assisted device.

By using sonographic guidance, percutaneous removal was performed in 40 patients with 42 lesions by using a 9-gauge (n = 13) or 12-gauge (n = 29) probe (ATEC; Suros Surgical). Technical success, procedural complications, and patient experience were recorded at the time of excision and at 48 hours. Clinical, imaging, and/or surgical follow-up was obtained for 39 of 42 lesions (93%). Three of 42 lesions (7%) were lost to follow-up.

Of 42 lesions, maximal diameters ranged from 0.6–4.0 cm (mean 1.6 cm), with lesion volumes between 0.05 and 11.2 mL (mean [SD] 1.4 ± 2.1 mL, median 7 mL). The procedure was well tolerated by all patients, and no residual mass was visible in any case at the conclusion of the procedure. All the patients preferred this approach to open surgical biopsy. After percutaneous excision, surgery was performed on 3 of 42 lesions (7%) for atypia (n = 2) or malignancy (n = 1), with a residual mass found only for the malignant case. Of the 26 of 42 lesions (62%) with imaging follow-up, 24 (92%) had no lesion recurrence. Overall, the procedure either completely removed the mass and/or relieved the patient's symptoms of a mass in 36 of 39 lesions (92%) for which clinical, imaging, and/or surgical follow-up was available. Three lesions were lost to follow-up.

Ultrasound-guided percutaneous excision of benign breast masses is a safe, effective, and well-tolerated minimally invasive procedure for the diagnosis and removal of benign breast masses. It may serve as an alternative to surgical excision for women with a known benign or probably benign breast mass who desire excision but prefer to avoid surgery or who are poor surgical candidates.

To provide a quantative analysis of postlobectomy chest radiographic changes and to evaluate whether the scarring from prior sternotomy affects the size of the hemithorax and the duration of air leak in patients with subsequent lobectomy.

In this retrospective case-controlled series, 10 consecutive patients who had a lobectomy after a prior sternotomy and 30 controls, 3 for each case, matched for lobectomy site were identified. Pre- and postoperative chest radiographs were quantitatively analysed for diaphragmic elevation, size of each hemithorax, mediastinal shift, and the presence of pneumothorax. Charts were reviewed for air-leak duration, surgical complications, and duration of hospitalization.

There was no difference between patients with lobectomy and with and without prior sternotomy for the following variables expressed as mean (SD): hemidiaphragm elevation (1.5 ± 2.5 vs 0.5 ± 2.0 cm; P = .2), change of hemithorax size (mean transverse, 0.99 ± 0.05 vs 0.97 ± 0.07; P = .5; craniocaudal, 0.93 ± 0.08 vs 0.91 ± 0.08; P = .4) and mediastinal shift (upper, 1.2 ± 0.4 vs 1.3 ± 0.6; P = .5; lower, 1.2 ± 0.4 vs 1.2 ± 0.3; P = .8), the latter 2 were expressed as the ratio of post- to preoperative measurements. These postlobectomy radiographic findings varied, depending on the resected lobe, and became progressively more pronounced during the first 12 months after surgery. There was no difference in pneumothorax duration (mean [SD]) (9.5 ± 21 days vs 6.4 ± 7.5 days; P = .5), air leak duration (mean [SD]) (0.7 ± 0.8 days vs 1.3 ± 3.9 days; P = .6), complication rate (20% vs 30%; P = .5), or hospital stay (mean [SD]) (6.0 ± 1.7 days vs 6.9 ± 4.7 days; P = .6).

There are specific patterns of volume loss, mediastinal shift, and hemidiaphragm displacement that can be quantified on postlobectomy chest radiographs. Prior sternotomy did not affect postlobectomy radiographic changes or patient outcome.

To evaluate the utility of chest radiography in demonstrating clinically significant pacemaker complications that required reoperation.

In this retrospective case-controlled series, we identified 14 consecutive adults who required pacemaker reoperation and who had chest radiographs available for review (6 men, 8 women; mean age, 71 years [range, 43–95 years]). Ten patients had pacemakers implanted at our institution, and 4 were referred for reoperation. Forty-two controls, 3 for each patient, had postoperative chest radiographs and normal device function (25 men, 17 women; mean age 76 years [range, 37–96 years]). All postoperative chest radiographs, including 1-year follow-ups, were blindly reviewed by at least 2 of 4 radiologists for lead perforation and position of right atrial and right ventricular leads. Follow-up radiographs were assessed for lead perforation, lead displacement, and lead fracture. Data were analysed by using the Fisher exact test.

Of the patients, 1.7% (10/581) required reoperation for pacemaker dysfunction (noncapture, oversensing, abnormal atrial and ventricular thresholds, failing impedance), extracardiac stimulation, and lead perforation and/or displacement. There were no lead fractures. Chest radiographs demonstrated pacemaker complications in 57% of patients (8/14) at a median of 2 days (<1–32 days) after implantation and in 5% of the controls (2/42) (P < .0001). None of the abnormalities were noted on the official reports. Among subgroups, chest radiographs were abnormal for the following indications: pacemaker dysfunction in 4 of 7 patients versus 0 of 21 controls (P = .0017), extracardiac stimulation in 1 of 3 patients vs 0 of 9 controls (P = .25), and lead perforation and/or displacement in 3 of 4 patients vs 2 of 12 controls (P = .06).

Chest radiographs are useful after pacemaker placement and demonstrate the majority of complications that require reoperation. Familiarity with the expected normal position of the leads, appearances of pacemaker complications, and comparison with prior radiographs is crucial in rendering a correct diagnosis that guides patient management.