Pancreatic Cystic Lesions on MRI: What Is The Likelihood of a Present or Future Diagnosis of Pancreatic Carcinoma?

BACKGROUND: Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship. PURPOSE: To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma. STUDY TYPE: Single-center retrospective cohort. POPULATION: A total of 192 patients (111 female, 58%) with median age 66 years (range 26-87 years) with PCLs on abdominal MRI from 2011 to 2016. FIELD STRENGTH/SEQUENCES: 1.5 T and 3 T, including T2 WI, T1 WI, diffusion weighted imaging and contrast-enhanced T1 WI. ASSESSMENT: Each PCL was reviewed independently by 2 of 10 fellowship-trained abdominal radiologists. Fukuoka guideline worrisome features and high-risk stigmata were evaluated. Follow-up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow-up of 67 months (interquartile range: 43-88 months). STATISTICAL TESTS: Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank-sum test were used to assess PCL morphologic features with the Kolmogorov-Smirnov test used to assess for normality. P < 0.05 defined statistical significance. RESULTS: The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high-grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person-years, respectively. DATA CONCLUSION: A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67 months of follow-up. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: 5.

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen.

BACKGROUND: Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS: This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS: The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION: We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

Radiologist Productivity Analytics: Factors Impacting Abdominal Pelvic CT Exam Reporting Times.

The purpose is to determine factors impacting radiologist abdominal pelvic CT exam reporting time. This study was Research Ethics Board approved. Between January 2019 and March 2020, consecutive abdominal pelvic CT exams were documented as structured or unstructured based on application of templates with separate sections for different organs or organ systems. Radiologist reporting location, patient class (inpatient, Emergency Department (ED) patient, outpatient), radiologist fellowship-training, report word count, and radiologist years of experience were documented. Median reporting times were compared using the Wilcoxon Rank-sum test, Kruskal-Wallis test, and regression analysis. Spearman's rank correlation was used to determine correlation between word count and radiologist experience with reporting time. P < 0.05 is defined statistical significance. A total of 3602 abdominal pelvic CT exam reports completed by 33 radiologists were reviewed, including 1150 outpatient and 2452 inpatient and Emergency Department (ED) cases. 1398 of all reports were structured. Median reporting time for structured and unstructured reports did not differ (P = 0.870). Reports dictated in-house were completed faster than reports dictated remotely (P < 0.001), and reports for inpatients/ED patients were completed faster than for outpatients (P < 0.001). Reporting time differences existed between radiologists (P < 0.001) that were not explained by fellowship training (P = 0.762). Median reporting time had a weak correlation with word count (ρ = 0.355) and almost no correlation with radiologist years of experience (ρ = 0.167), P < 0.001. Abdominal pelvic CT reporting is most efficient when dictations are completed in-house and for high-priority cases; the use of structured templates, radiologist fellowship training, and years of experience have no impact on reporting times.

Which Aspects of the CanMEDS Competencies are Most Valued in Radiologists? Perspectives of Trainees From Other Specialties.

PURPOSE: Radiologists work primarily in collaboration with other healthcare professionals. As such, these stakeholder perspectives are of value to the development and assessment of educational outcomes during the transition to competency-based medical education. Our aim in this study was to determine which aspects of the Royal College CanMEDS competencies for diagnostic radiology are considered most important by future referring physicians. METHODS: Institutional ethics approval was obtained. After pilot testing, an anonymous online survey was sent to all residents and clinical fellows at our university. Open-ended questions asked respondents to describe the aspects of radiologist service they felt were most important. Thematic analysis of the free-text responses was performed using a grounded theory approach. The resulting themes were mapped to the 2015 CanMEDS Key Competencies. RESULTS: 115 completed surveys were received from residents and fellows from essentially all specialties and years of training (out of 928 invited). Major themes were 1) timeliness and accessibility of service, 2) quality of reporting, and 3) acting as a valued team member. The competencies identified as important by resident physicians were largely consistent with the CanMEDS framework, although not all key competencies were covered in the responses. CONCLUSIONS: This study illustrates how CanMEDS roles and competencies may be exemplified in a concrete and specialty-specific manner from the perspective of key stakeholders. Our survey results provide further insight into specific objectives for teaching and assessing these competencies in radiology residency training, with the ultimate goal of improving patient care through strengthened communication and working relationships.

CAR Peer Learning Guide.

Peer learning is a quality initiative used to identify potential areas of practice improvement, both on a patient level and on a systemic level. Opportunities for peer learning include review of prior imaging studies, evaluation of cases from multidisciplinary case conferences, and review of radiology trainees' call cases. Peer learning is non-punitive and focuses on promoting life-long learning. It seeks to identify and disseminate learning opportunities and areas for systems improvement compared to traditional peer review. Learning opportunities arise from peer learning through both individual communication of cases reviewed for routine work, as well as through anonymous presentation of aggregate cases in an educational format. In conjunction with other tools such as root cause analysis, peer learning can be used to guide future practice improvement opportunities. This guide provides definitions of terms and a synthetic evidence review regarding peer review and peer learning, as well as medicolegal and jurisdictional considerations. Important aspects of what makes an effective peer learning program and best practices for implementing such a program are presented. The guide is intended to be a living document that will be updated regularly as new data emerges and peer learning continues to evolve in radiology practices.

MRI vs. CT for the Detection of Liver Metastases in Patients With Pancreatic Carcinoma: A Comparative Diagnostic Test Accuracy Systematic Review and Meta-Analysis.

BACKGROUND: The detection of liver metastases is important for pancreatic cancer curative treatment eligibility. The data suggest that magnetic resonance imaging (MRI) is more sensitive than computed tomography (CT) for the diagnosis of pancreatic cancer liver metastases. However, MRI is not currently recommended in multiple published guidelines. PURPOSE: To perform a comparative diagnostic test accuracy systematic review and meta-analysis comparing CT and MRI for pancreatic cancer liver metastases detection. STUDY TYPE: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and multiple radiology society meeting archives were searched until November 2018. Comparative design studies reporting on liver CT and MRI accuracy for detection of pancreatic cancer liver metastases in the same cohort were included. FIELD STRENGTH: 1.5T or 3.0T. ASSESSMENT: Demographic, methodologic, and diagnostic test accuracy data were extracted. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. STATISTICAL TESTS: Accuracy metrics were obtained using bivariate random-effects meta-analysis. The impact of different covariates on accuracy estimates was assessed using a meta-regression model. Covariates included modality, study design, tumor characteristics, risk of bias, and imaging protocols. RESULTS: Fourteen studies including 987 patients with pancreatic cancer (205 with liver metastases) were included. Sensitivity for CT and MRI was 45% (confidence intervals [95% CI] 21-71%) and 83% (95% CI 74-88%), respectively. Specificity for CT and MRI was 94% (95% CI 84-98%) and 96% (95% CI 93-97%), respectively. The greater observed sensitivity of MRI was preserved in the meta-regression model (P = 0.01), while no difference in specificity was detected (P = 0.16). CT sensitivity was highest for triphasic and quadriphasic examinations compared to single phase or biphasic protocols (P = 0.03). Most studies were at high risk of bias. DATA CONCLUSION: MRI is more sensitive than CT for pancreatic cancer liver metastases detection, accounting for confounding variables. Consideration of this finding in clinical practice guidelines is recommended. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 3.

MRI LI-RADS Version 2018: Impact of and Reduction in Ancillary Features.

OBJECTIVE. The purpose of this study is to determine the impact of LI-RADS ancillary features on MRI and to ascertain whether the number of ancillary features can be reduced without compromising LI-RADS accuracy. MATERIALS AND METHODS. A total of 222 liver observations in 81 consecutive patients were identified on MRI between August 2013 and December 2018. The presence or absence of major and ancillary features was used to determine the LI-RADS category for LR-1 to LR-5 observations. Final diagnosis was established on the basis of pathologic findings or one of several composite clinical reference standards. Diagnostic accuracy was compared with and without ancillary features by use of the z test of proportions. Decision tree analysis and machine learning-based feature pruning were used to identify noncontributory ancillary features for LI-RADS categorization. Interobserver agreement with and without ancillary features was measured using the Krippendorff alpha coefficient, and comparisons were made using bootstrapping. A p < .05 was considered statistically significant. RESULTS. Application of ancillary features resulted in a change in the LI-RADS category of seven hepatocellular carcinomas (HCCs), with the category of six of seven (86%) HCCs upgraded; 51 benign observations also had a change in LI-RADS category, with the category of 33 (65%) of these observations downgraded. When ancillary features were applied, the percentage of HCCs in each LI-RADS category did not differ significantly compared with major features alone (p = .06-.49). Decision tree analysis and the machine learning model identified five ancillary features as noncontributory: corona enhancement, nodule-in-nodule, mosaic architecture, blood products in mass, and fat in a mass, more than in adjacent liver. Interobserver agreement was high with and without application of ancillary features; however, it was significantly higher without ancillary features (p < .001). CONCLUSION. Although ancillary features are an important component of LI-RADS, their impact may be small. Several ancillary features likely can be removed from LI-RADS without compromising diagnostic performance.

Improving and Maintaining Radiologic Technologist Skill Using a Medical Director Partnership and Technologist Coaching Model.

OBJECTIVE: Consistent excellence in radiologic technologist performance, including ensuring high technical image quality, patient safety and comfort, and efficient workflow, largely depends on individual technologist skill. However, sustained growth in the size and complexity of health care organizations has increased the difficulty in developing and maintaining technologist expertise. In this article, we explore underlying organizational structures that contribute to this problem and propose organizational models to promote continued excellence in technologist skill. CONCLUSION: We have found that a relatively modest investment in medical directorship combined with a coaching model can bring about a significant level of improvement in skilled clinical performance. We believe that widespread implementation of similar programs could contribute to substantial improvements in quality in radiology and other health care settings.

Temporal Trends in Spinal Imaging in Ontario (2002-2019) and Manitoba (2001-2011), Canada.

Background Several studies have reported the overuse of spinal imaging, which, in Canada, led to several provincial pathways aimed at optimizing the use of imaging. We assessed temporal trends in spine imaging in two Canadian provinces. Methods We explored the use of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) examinations of the cervical, thoracic, and lumbar spine regions among adults in Ontario (April 1, 2002, to March 31, 2019) and in Manitoba, Canada (April 1, 2001, to March 31, 2011) using linked Ontario Health Insurance Plan administrative databases and data from Manitoba Health. We calculated the age- and sex-adjusted rates of spinal X-ray, CT, and MRI examinations by dividing the number of imaging studies by the population of each province for each year and estimated the use of each imaging modality per 100,000 persons. Results The total cost of spine imaging in Ontario increased from $45.8 million in 2002/03 to $70.3 million in 2018/19 (a 54% increase), and in Manitoba from $2.2 million in 2001/02 to $5 million in 2010/11 (a 127% increase). In Ontario, rates of spine X-rays decreased by 12% and spine CT scans decreased by 28% over this time period, while in Manitoba, rates of spine X-rays and CT scans remained constant. Age- and sex-adjusted utilization of spinal MRI scans per 100,000 persons markedly increased over time in both Ontario (277%) and Manitoba (350%). Conclusion Despite efforts to reduce the use of inappropriate spinal imaging, both Ontario and Manitoba have greatly increased utilization of spine MRI in the past two decades.

Emergency physician gender and head computed tomography orders for older adults who have fallen.

OBJECTIVE: Physicians vary in their computed tomography (CT) scan usage. It remains unclear how physician gender relates to clinical practice or patient outcomes. The aim of this study was to assess the association between physician gender and decision to order head CT scans for older emergency patients who had fallen. METHODS: This was a secondary analysis of a prospective observational cohort study conducted in 11 hospital emergency departments (EDs) in Canada and the United States. The primary study enrolled patients who were 65 years and older who presented to the ED after a fall. The analysis evaluated treating physician gender adjusted for multiple clinical variables. Primary analysis used a hierarchical logistic regression model to evaluate the association between treating physician gender and the patient receiving a head CT scan. Secondary analysis reported the adjusted odds ratio (OR) for diagnosing intracranial bleeding by physician gender. RESULTS: There were 3663 patients and 256 physicians included in the primary analysis. In the adjusted analysis, women physicians were no more likely to order a head CT than men (OR 1.26, 95% confidence interval 0.98-1.61). In the secondary analysis of 2294 patients who received a head CT, physician gender was not associated with finding a clinically important intracranial bleed. CONCLUSIONS: There was no significant association between physician gender and ordering head CT scans for older emergency patients who had fallen. For patients where CT scans were ordered, there was no significant relationship between physician gender and the diagnosis of clinically important intracranial bleeding.

Which adults aged 65 and older are at low-risk for cervical spine injuries after low-level falls?

OBJECTIVES: The population is aging and falls are a common reason for emergency department visits. Appropriate imaging in this population is important. The objectives of this study were to estimate the prevalence of cervical spine injury and identify factors associated with cervical spine injuries in adults ≥ 65 years after low-level falls. METHODS: This was a pre-specified sub-study of a prospective observational cohort study of intracranial bleeding in emergency patients ≥ 65 years presenting after low-level falls. The primary outcome was cervical spine injury. The risk factors of interest were Glasgow coma scale (GCS) < 15, head injury, neck pain, age, and frailty defined as Clinical Frailty Scale ≥ 5. Multivariable logistic regression was used to measure the strength of association between risk factors and cervical spine injury. A descriptive analysis of absence of significant risk factors was performed to determine patients who may not require imaging. RESULTS: There were 4308 adults ≥ 65 who sustained low-level falls with mean age of 82.0 (standard deviation ± 8.8) years and 1538 (35.7%) were male; 23 [0.5% (95% confidence interval (CI) 0.3-0.8%)] were diagnosed with cervical spine injuries. The adjusted odds ratios and 95% CIs were 1.3 (0.5-3.2) for GCS < 15, 5.3 (1.7-26.7) for head injury, 13.0 (5.7-31.2) for new neck pain, 1.4 (1.0-1.8) for 5-year increase in age, and 1.1 (0.4-2.9) for frailty. Head injury or neck pain identified all 23 cervical spine injuries. Management was a rigid collar in 19/23 (82.6%) patients and none had surgery. CONCLUSIONS: In emergency patients ≥ 65 years presenting after a low-level fall, head injury, neck pain, and older age were associated with the diagnosis of cervical spine injury. There were no cervical spine injuries in those without head injury or neck pain. Patients with no head injury or neck pain may not require cervical spine imaging.

RéSUMé: OBJECTIFS: La population vieillit et les chutes sont une raison courante pour les visites à l'urgence. Il est important d'avoir une imagerie appropriée dans cette population. Les objectifs de cette étude étaient d'estimer la prévalence des lésions de la colonne cervicale et d'identifier les facteurs associés aux lésions de la colonne cervicale chez les adultes de plus de 65 ans après des chutes de faible niveau. MéTHODES: Il s'agissait d'une sous-étude pré-spécifiée d'une étude prospective de cohorte observationnelle de saignements intracrâniens chez des patients d'urgence de plus de 65 ans se présentant après des chutes de faible niveau. Le résultat principal était une lésion de la colonne cervicale. Les facteurs de risque d'intérêt étaient l'échelle de coma de Glasgow (GCS)<15, les blessures à la tête, les douleurs au cou, l'âge et la fragilité définis comme l'échelle de fragilité clinique >5. La régression logistique multivariée a été utilisée pour mesurer la force de l'association entre les facteurs de risque et les lésions de la colonne cervicale. Une analyse descriptive de l'absence de facteurs de risque significatifs a été réalisée pour déterminer les patients qui ne nécessitent pas d'imagerie. RéSULTATS: Il y avait 4308 adultes de plus de 65 ans qui ont subi des chutes de faible intensité avec un âge moyen de 82.0 ans (écart-type 8.8) et 1538 ans (35.7 %) étaient des hommes; 23 (0.5 % (intervalle de confiance à 95 % 0.3­0.8 %) ont reçu un diagnostic de lésions du rachis cervical. Les rapports de cotes ajustés et les IC à 95 % étaient de 1.3 (0.5­3.2) pour les SCM<15, 5.3 (1.7­26.7) pour les blessures à la tête, 13.0 (5.7­31.2) pour les nouvelles douleurs au cou, 1.4 (1.0 ­ 1.8) pour l'augmentation de l'âge de cinq ans et 1.1 (0.4­2.9) pour la fragilité. Des blessures à la tête ou des douleurs au cou ont permis de déceler les 23 blessures à la colonne cervicale. La prise en charge était un collier rigide chez 19 patients sur 23 (82.6 %) et aucun n'a subi de chirurgie. CONCLUSIONS: Chez les patients d'urgence de plus de 65 ans se présentant après une chute de faible intensité, des blessures à la tête, des douleurs au cou et un âge plus avancé ont été associés au diagnostic de lésion de la colonne cervicale. Il n'y avait pas de blessures à la colonne cervicale chez les personnes sans blessure à la tête ou douleur au cou. Les patients sans blessure à la tête ou douleur au cou peuvent ne pas avoir besoin d'imagerie de la colonne cervicale.

Surgical waste audit of 5 total knee arthroplasties.

BACKGROUND: Operating rooms (ORs) are estimated to generate up to one-third of hospital waste. At the London Health Sciences Centre, prosthetics and implants represent 17% of the institution's ecological footprint. To investigate waste production associated with total knee arthroplasties (TKAs), we performed a surgical waste audit to gauge the environmental impact of this procedure and generate strategies to improve waste management. METHODS: We conducted a waste audit of 5 primary TKAs performed by a single surgeon in February 2010. Waste was categorized into 6 streams: regular solid waste, recyclable plastics, biohazard waste, laundered linens, sharps and blue sterile wrap. Volume and weight of each stream was quantified. We used Canadian Joint Replacement Registry data (2008-2009) to estimate annual weight and volume totals of waste from all TKAs performed in Canada. RESULTS: The average surgical waste (excluding laundered linens) per TKA was 13.3 kg, of which 8.6 kg (64.5%) was normal solid waste, 2.5 kg (19.2%) was biohazard waste, 1.6 kg (12.1%) was blue sterile wrap, 0.3 kg (2.2%) was recyclables and 0.3 kg (2.2%) was sharps. Plastic wrappers, disposable surgical linens and personal protective equipment contributed considerably to total waste. We estimated that landfill waste from all 47 429 TKAs performed in Canada in 2008-2009 was 407 889 kg by weight and 15 272 m3 by volume. CONCLUSION: Total knee arthroplasties produce substantial amounts of surgical waste. Environmentally friendly surgical products and waste management strategies may allow ORs to reduce the negative impacts of waste production without compromising patient care. LEVEL OF EVIDENCE: Level IV, case series.

Reporting of the estimated glomerular filtration rate decreased creatinine clearance testing.

The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines suggest that clinicians use the estimated glomerular filtration rate (eGFR) measurements and minimize the use of timed urine creatinine clearance collection. The intent of this change was to improve recognition of chronic kidney disease. Here we used time-series modeling and intervention analyses to determine the effect of publication of the K/DOQI guidelines and the introduction of widespread eGFR reporting with prompts on physician ordering of 24-h urine collection for creatinine clearance. In this setting, clinical practice guidelines did not influence creatinine clearance testing; however, the direct introduction of eGFR reporting with prompts into physician workflow resulted in a sudden and significant 23.5% decrease in creatinine clearance collection over the 43 months analyzed. Thus, eGFR reporting with prompts may have produced a clinical practice change because it is integrated directly into physician workflow. Changing physician practice patterns may require more than publishing guidelines; rather it is more likely to occur through educational and structural changes to practice.

Desmoplastic small round cell tumor involving the uterine cervix: The first reported case in the literature, and brief review of gynecologic presentations.

Background: Desmoplastic small round cell tumors are exceedingly rare, usually involve abdominal organs and predominantly affect male patients. We describe the first reported case arising from the uterine cervix and provide a summary of 20 previously reported cases involving gynecologic organs. Case: A 54 year-old was diagnosed with a rapidly growing 13 cm desmoplastic small round cell tumor of the cervix. She was treated through a multimodal approach involving neoadjuvant chemotherapy and surgery. She subsequently recurred, and this was successfully treated with radiation therapy. She is well and without evidence of disease 22 months after initial diagnosis. Conclusion: We report successful treatment through multidisciplinary and multimodal management. This can guide management of future patients as no gold-standard treatment has yet been described.

Impact of estimated GFR reporting on patients, clinicians, and health-care systems: a systematic review.

BACKGROUND: Many laboratories now report estimated glomerular filtration rate (eGFR) when a serum creatinine measurement is ordered. A summary of the impact of eGFR reporting in health care systems around the world for which it has been adopted is lacking. STUDY DESIGN: Systematic review of MEDLINE, EMBASE, other major databases, and conference proceedings of major nephrology meetings. SETTING & POPULATION: Any health care system in which eGFR reporting was introduced. SELECTION CRITERIA FOR STUDIES: Published studies or abstracts reporting patient, clinician, or health system outcomes of eGFR reporting. INTERVENTION: eGFR reporting. OUTCOMES: Volume of referrals or consults seen by nephrologists, changes in characteristics of patients who were seen, and prescription rates of kidney-related medications. RESULTS: 22 studies (10 full text and 12 conference abstracts) were identified in 2004-2010 from 5 countries. Nephrologist referrals and consultations increased after eGFR reporting, ranging from 13%-270%. The greatest increases in referrals were seen for the elderly, females, and those with stage 3 or higher chronic kidney disease (eGFR <60 mL/min/1.73 m(2)). Change in renin-angiotensin-aldosterone system-blocking drug use ranged from increases of 0%-6%. LIMITATIONS: Studies were highly variable in definition of outcomes. Reports were not available for many health care systems in which eGFR reporting was implemented. CONCLUSIONS: eGFR reporting has been associated with greater identification of patients with decreased kidney function in most health care systems that have reported its impact.

Lessons learned from radiology mentors.

As in any field, radiologists may face a number of challenges as they navigate their early careers. Because with experience comes wisdom, early-career radiologists may find helpful the advice and perspectives of mid- and late-career radiologists. The Society of Abdominal Radiology recognizes the value of this pool of knowledge and experience, prompting the establishment of the Early Career Committee. This group is designed to support early-career radiologists by sharing the experiences and insights of leaders in the field. In this series, the authors interview trailblazers Matthew S. Davenport, MD; Jonathan B. Kruskal, MD, PhD; Katherine E. Maturen, MD, MS; David B. Larson, MD, MBA; and Desiree E. Morgan, MD. This perspective explores a wide range of subjects, including personal values in medicine, the role of teleradiology, diversity of backgrounds in radiology, how to navigate workplace conflict, and lifelong learning in medicine. Beyond conveying these pearls of wisdom, the aim of this perspective is to highlight for early-career radiologists the value that mid- and late-career mentors can provide in navigating careers in medicine.

Using Online Survey Software to Enhance Radiology Learning.

RATIONALE AND OBJECTIVES: Online educational modules can augment radiology learning by creating opportunities to interact with images in more dynamic ways than with static presentation of images in lectures or journal articles. Building these modules on an online survey platform allows for quantitative assessment and learner feedback, without requiring programming knowledge or need for new website creation. MATERIALS AND METHODS: Interactive online tutorials were built on a web-based survey platform (Qualtrics, Provo, Utah) accessible by computer or mobile device to teach radiology imaging findings of selected high-morbidity diagnoses. Topics included congenital-type internal hernias (module 1), acute appendicitis in the pregnant patient (module 2), and unintentionally retained surgical instruments (RSI; module 3). Modules consisted of pretest, educational module, and post-test components. For modules 1 and 2, graphics interchange formats were utilized to show CT and MRI image stacks for the diagnosis of congenital-type internal hernias and acute appendicitis in pregnant patients, respectively. For module 3, the "Heat Map" format was chosen to showcase intraoperative radiograph cases, which allowed participants to click on the potential RSI in the image. Pre- and post-test scores were evaluated. To determine statistical significance, an alpha level of 0.05 was utilized. RESULTS: Module 1 (Internal Hernia): Twenty-one radiology trainees completed the module. The mean pretest score was 3.66 (±1.13) points out of a total 6 possible points (61%), compared to 4.52 (±1.03) points on the post-test (75%). This was a statistically significant increase on the post-test of 0.87 points (95% CI [confidence interval] 0.36, 1.38), t(20) = 3.53, p= 0.002. Module 2 (MR Appendicitis): Seventeen radiology trainees completed the module. The mean pretest score was 3.18 (±1.42) points out of a total 6 possible points (53%), compared to 5.12 (±0.86) points on the post-test (85%). This was a statistically significant increase on the post-test of 1.94 points (95% CI 1.12, 2.76), t(16) = 5.00, p< 0.001. Module 3 (RSI): One hundred seven participants completed the module. The mean pretest score was 3.60 (±1.53) points out of a total 6 possible points (60%), compared to 4.54 (±1.36) points on the post-test (76%). This was a statistically significant increase on the post-test of 0.94 points (95% CI 0.67, 1.21), t(106) = 6.84, p< 0.001. CONCLUSION: An online survey platform can be used to build interactive education modules. Post-test scores significantly improved from pretest scores with these educational modules.

Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: A systematic review.

INTRODUCTION: Seniors who fall are an increasing proportion of the patients who are treated in emergency departments (ED). Falling on level-ground is the most common cause of traumatic intracranial bleeding. We aimed to determine the incidence of intracranial bleeding among all senior patients who present to ED after a fall. METHOD: We performed a systematic review. Medline, EMBASE, Cochrane, and Database of Abstracts of Reviews of Effects databases, Google Scholar, bibliographies and conference abstracts were searched for articles relevant to senior ED patients who presented after a ground-level fall. Studies were included if they reported on patients aged 65 or older who had fallen. At least 80% of the population had to have suffered a ground-level fall. There were no language restrictions. We performed a meta-analysis (using the random effects model) to report the pooled incidence of intracranial bleeding within 6 weeks of the fall. RESULTS: We identified eleven studies (including 11,102 patients) addressing this clinical question. Only three studies were prospective in design. The studies varied in their inclusion criteria, with two requiring evidence of head injury and four requiring the emergency physician to have ordered a head computed tomography (CT). One study excluded patients on therapeutic anticoagulation. Overall, there was a high risk of bias for eight out of eleven studies. The pooled incidence of intracranial bleeding was 5.2% (95% CI 3.2-8.2%). A sensitivity analysis excluding studies with a high risk of bias gave a pooled estimate of 5.1% (95% CI 3.6-7.2%). CONCLUSION: We found a lack of high-quality evidence on senior ED patients who have fallen. The available literature suggests there is around a 5% incidence of intracranial bleeding in seniors who present to the ED after a fall.

Use of antifibrinolytic therapy to reduce transfusion in patients undergoing orthopedic surgery: a systematic review of randomized trials.

BACKGROUND: Minimizing bleeding and transfusion is desirable given its cost, complexity and potential for adverse events. Concerns have been heightened by recent data demonstrating that bleeding events may predict worse outcomes and by warnings about the safety of erythropoietic stimulating agents. Prior small studies suggest that antifibrinolytic agents may reduce bleeding and transfusion need in patients undergoing total hip replacement (THR) or total knee arthroplasty (TKA). However, no single study has been large enough to definitively determine if these agents are safe and effective. To address this issue we performed a systematic review of randomized trials describing the use of tranexamic acid, epsilon aminocaproic acid, or aprotinin administration in the perioperative setting. METHODS: MEDLINE, EMBASE, CINAHL and the Cochrane databases were searched for relevant trials. Two independent reviewers abstracted total blood loss, transfusion requirements, and venous thromboembolism (VTE) rates. Data were combined using the Mantel-Haenszel method and dichotomous data expressed as relative risk (RR) with 95% confidence intervals (CI). RESULTS: Patients receiving antifibrinolytic agents had reduced transfusion need (RR 0.52; 95% CI, 0.42 to 0.64; P<0.00001), reduced blood loss and no increase in the risk of VTE (RR 0.95% CI, 0.80 to 1.10, I(2)=0%, P=0.531). CONCLUSIONS: We conclude that antifibrinolytic agents may reduce bleeding and transfusion in patients undergoing THR or TKA who receive appropriate antithrombotic prophylaxis. There is a need for a large, adequately powered prospective study to carefully examine the safety and efficacy of these agents.