Fournier gangrene is a rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions and constitutes a true surgical emergency with a potentially high mortality rate. Although the diagnosis of Fournier gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. CT not only helps evaluate the perineal structures that can become involved by Fournier gangrene, but also helps assess the retroperitoneum, to which the disease can spread. Findings at CT include asymmetric fascial thickening, subcutaneous emphysema, fluid collections, and abscess formation. Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases. Compared with radiography and ultrasonography, CT provides a higher specificity for the diagnosis of Fournier gangrene and superior evaluation of disease extent; however, diagnosis and evaluation can also be performed with these other modalities. The administration of broad-spectrum antibiotics and aggressive surgical débridement of the nonviable tissue are both essential for successful treatment. An awareness of the CT features of Fournier gangrene is imperative for prompt diagnosis and effective treatment planning.

AimsTo investigate the relationship between high diabetes‐related lower limb amputation incidence and foot care services in the South‐West region of England.MethodsThe introduction of 10 key elements of foot care service provision in one area of the South‐West resulted in stabilization of foot ulcer incidence and sustained reduction in amputation incidence from 2007. Services introduced included administrative support, standardized general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit. Peer reviews of the region's diabetes foot care services were undertaken to assess delivery of these service provisions and compare this with major amputation incidence in other regions with data provided by Yorkshire and Humber Public Health Observatory Hospital Episode Statistics. Recommendations were made to improve service provision. In 2015 changes in service provision and amputation incidence were reviewed.ResultsInitial reviews in 2013 showed that the 3‐year diabetes‐related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services (P=0.0024, adjusted R 2 =0.51). Repeat reviews in 2015 found that two or more foot care service improvements were reported by six diabetes foot care providers, with improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012–2015 and in the year 2015 only (P ≤0.0012, adjusted R 2 =0.56, and P= 0.0005, R 2=0.62, respectively).ConclusionsMajor diabetes‐related lower limb amputation incidence is significantly inversely correlated with foot care services provision. Introduction of more effective service provision resulted in significant reductions in major amputation incidence within 2 years. Failure to improve unsatisfactory service provision resulted in continued high amputation incidence.

Female urethral diverticulum is an uncommon pathologic entity and can manifest with a variety of symptoms involving the lower urinary tract. Selection of the appropriate imaging modality is critical in establishing the diagnosis. Urethrography has traditionally been used in the evaluation of urethral diverticulum but provides only intraluminal information. Ultrasonography is advantageous in that it does not involve ionizing radiation and has the capacity to help detect a diverticulum without contrast agent filling. Multidetector computed tomographic (CT) voiding urethrography yields urethral images during micturition. In addition, the diverticulum and diverticular orifice can be visualized on two- and three-dimensional reformatted CT images. Interactive virtual urethroscopy provides simulated visualization of the intraluminal anatomy and the diverticular orifice. New magnetic resonance imaging techniques that make use of a surface or endoluminal coil have higher diagnostic accuracy and can delineate the diverticular cavity and help detect related complications. Clinicians should consider the possibility of a urethral diverticulum in women with chronic or recurrent lower urinary tract symptoms. Moreover, because female urethral diverticulum is becoming more prevalent in clinical practice, radiologists should be familiar with its imaging features and with the imaging techniques that are optimal for its evaluation.

Subhepatic location was the most common location for dropped gallstones with associated abscess and for dropped surgical clips. Dropped cholecystectomy clips are not associated with increased risk of abscess formation and therefore do not need screening follow-up or operative removal. Abscess formation around dropped gallstone is a more common complication and requires surgical treatment in most when associated with an abscess.

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BACKGROUND Previous studies demonstrate an association between rib fractures and morbidity and mortality in trauma. This relationship in low-mechanism injuries, such as ground-level fall, is less clearly defined. Furthermore, computed tomography (CT) has increased sensitivity for rib fractures compared with chest x-ray (CXR); its utility in elderly fall patients is unknown. We sought to determine whether CT-diagnosed rib fractures in elderly fall patients with a normal CXR were associated with increased in-hospital resource utilization or mortality. METHODS Retrospective analysis of emergency department patients presenting over a 3-year period. Inclusion criteria: age, 65 years or older; chief complaint, including mechanical fall; and both CXR and CT obtained. We quantified rib fractures on CXR and CT and reported operating characteristics for both. Outcomes of interest included hospital admission/length of stay (LOS), intensive care unit (ICU) admission/LOS, endotracheal intubation, tube thoracostomy, locoregional anesthesia, pneumonia, in-hospital mortality. RESULTS We identified 330 patients, mean age was 84 years (±SD, 9.4 years); 269 (82%) of 330 were admitted. There were 96 (29%) patients with CT-diagnosed rib fracture, 56 (17%) by CT only. Compared with CT, CXR had a sensitivity of 40% (95% confidence interval, 30–50%) and specificity of 99% (95% confidence interval, 97–100%) for rib fracture. A median of two additional radiographically occult rib fractures were identified on CT. Despite an increased hospital admission rate (91% vs. 78%) p = 0.02, there was no difference between patients with and without radiographically occult (CT+ CXR−) rib fracture(s) for: median LOS (4; interquartile range (IQR) 2–7 vs 4, IQR 2–8); p = 0.92), ICU admission (28% vs. 27%) p = 0.62, median ICU LOS (2, IQR 1–8 vs 3, IQR 1–5) p = 0.54, or in-hospital mortality (10.3% vs. 7.3%) p = 0.45. CONCLUSION Among elderly fall patients, CT-identified rib fractures were associated with increased hospital admissions. However, there was no difference in procedural interventions, ICU admission, hospital/ICU LOS or mortality for patients with and without radiographically occult fractures. LEVEL OF EVIDENCE Diagnostic, level III.

This study aimed to assess the effect of eliminating routine oral contrast use for abdominopelvic (AP) computed tomography (CT) on emergency department (ED) patient throughput and diagnosis. Retrospective analysis was performed on patients undergoing AP CT during 2-month periods prior to and following oral contrast protocol change in an urban, tertiary care ED. Patients with inflammatory bowel disease, prior gastrointestinal tract-altering surgery, or lean body habitus continued to receive oral contrast. Oral contrast was otherwise eliminated from the AP CT protocol. Patients were excluded if they would not have typically received oral contrast, regardless of the intervention. Data recorded include patient demographics, ED length of stay (LOS), time from order to CT, 72-h ED return, and repeat imaging. Two thousand and one ED patients (1,014 before and 987 after protocol change) underwent AP CT during the study period. Six hundred seven pre-intervention and 611 post-intervention were eligible for oral contrast and included. Of these, 95 % received oral contrast prior to the intervention and 42 % thereafter. After the intervention, mean ED LOS among oral contrast eligible patients decreased by 97 min, P < 0.001. Mean time from order to CT decreased by 66 min, P < 0.001. No patient with CT negative for acute findings had additional subsequent AP imaging within 72 h at our institution that led to a change in diagnosis. Eliminating routine oral contrast use for AP CT in the ED may be successful in decreasing LOS and time from order to CT without demonstrated compromise in acute patient diagnosis.

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