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Take a look at a selection of our recent media coverage:
4th July 2022
The introduction of an alert system to provide clinical decision support in emergency departments on whether to perform a computed tomography (CT) scan on children with head trauma, has resulted in more appropriate use of such scans. This was the main conclusion of a study by a team from Utah, US.
Traumatic brain injury (TBI) is an important public health problem and data produced by the CDC in the US reveal how there are approximately half a million emergency department visits for TBI every year by children aged 0 to 14 years. An important concern for clinicians is to identify whether a child has a clinically important TBI and a CT scan represents an excellent imaging modality for the identification of an intracranial injury. However, not all children with a head injury require a CT scan and clinical decision rules can help standardise and improve the use of CT for children with minor head injury.
For the present study, the US wanted to explore whether the introduction of an alert system at the point when clinicians were considering the use of a CT scan, could provide enhanced support and therefore make more appropriate use of these scans. The alert system made use of the Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules, which provided risk stratification to help reduce diagnostic uncertainty and the need for unnecessary CT scans. Prior to the decision-making for the need to perform a CT scan, clinicians were presented with a pop-up’ alert, which provided a risk assessment. In trying to assess the value of introducing the alert system, the researchers considered guideline adherence, which they considered to be not performing a CT scan when the alert system identified the patient as being at low risk. For the study, all sites provided data on the level of CT scans before and after introduction of the intervention for comparative purposes.
Alert system and change in CT scanning
A total of 12, 670 paediatric minor head trauma encounters were included in the analysis. The proportion of guideline-adherent encounters increased from 94.8% in the control period to 99.4% during the time when the intervention was implemented. Furthermore, the proportion of CT scans performed reduced from 38.6% in the control period to 29.8% after implementation of the intervention.
The authors calculated that the odds of an encounter being guideline-adherent was 1.12 (95% CI 1.03 – 1.22) or approximately 10% higher during the intervention compared to the control time period. Moreover, when using a pre-post comparison, guideline adherence remained significantly higher than the control period (odds ratio = 5.33, 95% CI 3.75 – 7.59).
The authors concluded that the implementation of the alert system led to sustained improvements in adherence to guidelines on the need for a CT scan and a modest reduction in scans among low risk patients.
Knighton AJ et al. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study Ann Emerg Med 2022
27th June 2022
The presence of incidental findings (IF) occurs in roughly a third of all computed tomography (CT) scans undertaken with emergency departments according to the findings of a systematic review by a group of US researchers.
The term ‘incidentaloma’ refer to an incidentally discovered mass or lesion, detected using imaging and which was performed for an unrelated reason. Such incidental findings are not uncommon, especially among scans for trauma patients with one study revealing how the findings were present in 15% of trauma CT scans. Whilst the presence of IF do not affect or alter the emergency department clinician’s current diagnostic work-up, it is important that these observations are communicated to patients so as to ensure that where necessary, appropriate further tests and follow-up are instigated. However, in non-trauma patients, little is known about the level of incidental findings among CT scans undertaken within emergency departments. For the present study, the US team sought to estimate the prevalence of radiologic IF among patients visiting an emergency department and who underwent a CT scan. A secondary aim was look at how hospitals managed and stratified the risks associated with abnormal findings.
Undertaking a comprehensive literature search, the authors looked for studies including terms such as ‘incidentaloma’ without a restriction on the type of study design and which included those that were retrospective, cross-sectional or prospective in nature. The primary outcome of the systematic review was the prevalence of IF on a CT scan.
Prevalence of incidental findings on CT scans
A total of 69 studies representing 147,763 emergency department encounters or radiology reports, with a median patient sample size of 882, were included in the analysis. The majority of studies were cross-sectional in design (82.6%) with the remainder comprising cohort (7.2%) and those with a pre- and post-interventional design. Just over half of the studies (50.7%) were in trauma patients and 63.8% of studies included some form a risk stratification of IF.
The pooled prevalence of any incidental finding on CT scan was 31.3% (95% CI 24.4% – 39.1%) although there was marked evidence of heterogeneity in the studies. The highest prevalence of IF occurred in patients having a CT scan because of chest pain (36.6%), followed by trauma (34.7%).
In a total of five studies, all based in trauma centres, there were structural interventions designed to improve the recognition and notification or follow-up of patients identified with an IF on a CT scan. In one such study, for example, following implementation of the strategy to manage IF, patient notification increased from 17.7% to 32.4%.
The researchers also discovered that documentation of IF in the patient’s discharge notes was present in only 20.1% to 47.2% of cases.
In their conclusion, the authors identified the need to establish a comprehensive classification system and standard-based approach to help clinicians when faced with an IF. They also called for more flexible care co-ordination programs to ensure timely follow-up, clear documentation in medical records and which could easily be implemented within a busy emergency department.
Evans CS et al. Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis Ann Emerg Med 2022
20th September 2021
According to Cancer Research UK, there are around 47,800 new lung cancer cases each year and approximately 35,100 deaths, which equates to 96 deaths every day. Furthermore, Cancer Research UK estimates that 79% of lung cancer cases in the UK are preventable with 72% caused by smoking. With such a high incidence of not only cases, but more importantly, preventable cases, there is an urgent need for effective screening methods, especially among individuals who are deemed at high risk such as smokers. In a 1999 study, a low computed-tomography (CT scan) was shown to greatly improve the likelihood of detecting small, non-calcified nodules and hence lung cancer, at an earlier and hence more curable stage. Moreover, subsequent studies have also demonstrated a reduction in lung cancer mortality among those undergoing a low dose CT scan.
With the value of CT screening already firmly established, a UK-based team have published their own findings of a trial comparing the effect of a low dose CT scan compared to usual care, in high-risk patients. The UK lung cancer screening (UKLS) trial, randomised patients to low dose CT screening or usual care, i.e., with no CT scan and was undertaken at two thoracic hospitals in the UK. Eligible patients, aged 50 to 75 years, were those deemed to be at a high risk of developing lung cancer over the next 5 years defined by a risk score of at least 4.5% based on the Liverpool Lung Project risk model (LLPv2). This model includes several possible risk factors such as gender, age, smoking status, smoking duration, family history of lung cancer. Included patients were then randomised to the intervention group (CT scan) or usual care although given the nature of the intervention, blinding was not possible. The primary outcome was mortality due to lung cancer, defined as a death during the follow-up period where lung cancer was listed as an underlying cause. In an effort to provide further evidence, the researchers also undertook a meta-analysis of other recent trials and included their own data, to get a more robust estimate of the benefits of CT scanning.
A total of 1987 and 1981 individuals were randomised to the CT scan and control arm respectively and followed for a median of 7.3 years. The median age at consent was 68 years (25% female) and among the CT scan group, 38% were current smokers, of whom, 93% had smoked for more than 20 years. During the follow-up period, 76 lung cancers were detected, 30 in the CT scan arm and 46 in the control arm although this difference was not significant (relative risk, RR = 0.65, 96% CI 0.41 – 1.02, p = 0.062). Furthermore, there were no significant differences between the sexes. In addition, there were 512 deaths from any cause and again there was no significant difference between the groups (p = 0.315).
When these results were added to a meta-analysis of 9 randomised, controlled trials, low dose CT scan screening was associated with a 16% relative reduction in lung cancer mortality compared with no screening (RR = 0.84, 95% CI 0.76 – 0.92).
The authors concluded that while their trial had not demonstrated a statistically significant reduction in lung cancer mortality, when their data was combined with other studies, the pooled estimate was significant and provided further support for lung cancer screening via a low dose CT scan.
Field JK et al. Lung cancer mortality reduction by LDCT screening: UKLS randomised trial results and international meta-analysis. Lancet Regional health Europe 2021