Background Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic test results remains a challenge. We hypothesized that an EMR that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. Methods We studied critical imaging alert notifications in the outpatient setting of a tertiary care VA facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (i.e. provider opened the message for viewing) within two weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted providers to determine timely follow-up actions (e.g. ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by providers analyzed predictors for two outcomes; lack of acknowledgment and lack of timely follow-up. Results Of 123,638 studies (including X-rays, CT scans, ultrasounds, MRI and mammography), 1196 (0.97%) images generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when ordering providers were trainees (OR, 5.58;95%CI, 2.86-10.89) and when dual (more than one provider alerted) as opposed to single communication was used (OR, 2.02;95%CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs. 9.7%;p=0.2). Risk for lack of timely follow-up was higher with dual communication (OR,1.99;95%CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12;95%CI: 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. Conclusions Critical imaging results may not receive timely follow-up actions even when providers receive and read results in an advanced, integrated EMR system. A multidisciplinary approach is needed to improve patient safety in this area.

Imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.

Benign nerve cell tumours have been given various names like schwannoma, neurilemmoma, neurinoma, neurofibroma, spindle cell tumours etc. Extra cranial head and neck schwannomas usually present as solitary and well-demarcated lesions. The lesion can cause secondary symptoms, such as nasal obstruction, dysphasia, and hoarseness, depending upon the location of the lesion. Fine needle aspiration cytology, CT scans, and MRI may be of limited help in the diagnosis of schwannomas. The treatment is complete surgical excision of the benign tumour and postoperative histopathological examination establishes the final diagnosis.

A 60-year-old hypertensive male with non-ST segment elevation myocardial infarction had a hyperdynamic LV with mild posterior leaflet mitral valve prolapse without significant regurgitation on transthoracic echocardiogram. Two-dimensional (2D) TEE showed severe mitral regurgitation with prolapse of P2 and P3 scallops. Posteromedial papillary muscle rupture was suspected. Three-dimensional (3D) TEE demonstrated severely prolapsing P2 and P3 valve scallops with a clear view of the partially ruptured posteromedial papillary muscle. Patient underwent emergency coronary bypass and mitral valve replacement. Surgical pathology of papillary muscle confirmed coagulative necrosis. 3D TEE was superior in identifying the partial posteromedial papillary muscle rupture.

Metered dose inhaler (MDI) with spacer is the preferred method for administration of aerosolized medications in pediatric asthma. The expense of commercial spacers limits their use and indigenous alternatives have therefore been developed. Information on the clinical efficacy of home-made spacers is limited. This study was conducted to compare the efficacy of a valve-less home-made spacer with a commercial spacer in delivering salbutamol via MDI in acute asthma. Asthmatic children aged 5-15 years who presented with an acute exacerbation to the pediatric chest clinic of a tertiary care hospital were enrolled in a single blinded randomized parallel group study. The study patients received 10 puffs of salbutamol (100 microg/puff) via MDI-home-made spacer or MDI-commercial spacer. Pre and post inhalation measurements of peak expiratory flow rate (PEFR), oxygen saturation (SaO2), respiratory rate (RR), pulse rate (PR) were made and compared. Sixty children were enrolled in the study, 31 were administered salbutamol via the home-made spacer and 29 via the commercial spacer. The median increase in PEFR was similar in both the groups (20.8% vs 22.2%, p=0.4), clinical improvement being satisfactory in all patients. The valve-less home-made spacer is equally efficacious and cheaper than the commercial spacer in administering bronchodilators in acute exacerbations of asthma. Further studies on the efficacy of home-made spacer in delivery of inhaled steroids are needed.