Opportunity and Opportunism in Artificial-Intelligence-Powered Data Extraction: A Value-Centered Approach.

Radiologists' traditional role in the diagnostic process is to respond to specific clinical questions and reduce uncertainty enough to permit treatment decisions. This charge is rapidly evolving due to forces such as artificial intelligence [AI], big data [opportunistic imaging, imaging prognostication], and advanced diagnostic technologies. A new "modernistic" paradigm is emerging whereby radiologists, in conjunction with computer algorithms, will be tasked with extracting as much information from imaging data as possible, often without a specific clinical question being posed and independent of any stated clinical need. In addition, AI algorithms are increasingly able to predict long-term outcomes using data from seemingly normal examinations, enabling AI-assisted prognostication. As these algorithms become a standard component of radiology practice, the sheer amount of information they demand will increase the need for streamlined workflows, communication, and data management techniques. In addition, the provision of such information raises reimbursement, liability, and access issues. Guidelines will be needed to ensure all patients have access to the benefits of this new technology and guarantee mined data do not inadvertently create harm. In this article, we discuss challenges and opportunities relevant to radiologists in this changing landscape, with an emphasis on ensuring that radiologists provide high-value care.

Optimizing Triage: Assessing Shock Index, Pediatric Age-Adjusted as an Adjunct to Improve Emergency Severity Index Mistriage.

OBJECTIVE: We investigated the diagnostic value of shock index, pediatric age-adjusted (SIPA) in predicting Emergency Severity Index level 3 patients' outcomes. Secondary objectives included exploring the impact of fever and participant variables on SIPA's predictive ability. METHODS: A retrospective chart review identified children aged 1 to 15 years triaged as a level 3 in the emergency department between January 2018 and December 2021. Shock index, pediatric age-adjusted thresholds based on age, 1 to 6 years (>1.2), 7 to 12 years (>1.0), and 13 to 17 years (>0.9), were used. We assessed elevated SIPA and SIPA corrected for fever to evaluate associations with outcomes and interventions. RESULTS: Our findings, involving 192 patients, revealed that elevated SIPA demonstrated enhanced discrimination relative to nonelevated SIPA. Patients with elevated SIPA had more average interventions: 1.14 versus 0.74, P < 0.016; average interventions using SIPA corrected for fever: 1.14 versus 0.77, P < 0.006; average interventions controlling for race and sex: 1.15 versus 0.71, P < 0.001; hospital admission: 64.4% versus 42.9%, P = 0.004; hospital length of stay (LOS): 3.06 days (SE, 0.42) versus 1.46 days (SE, 0.23); hospital LOS using SIPA corrected for fever: 2.75 days (SE, 0.44) versus 1.72 days (SE, 0.24); ventilatory support: 16.44% versus 3.36%, P < 0.002; fluid bolus: 28.77% versus 14.29%, P < 0.015; intravenous medications (antibiotics, antiepileptics, immune globulin, albumin): 45.21% versus 30.25%, P < 0.036. There was no difference between other interventions, pediatric intensive care admission, and LOS between the 2 groups. Importantly, SIPA was unaffected by fever, race, or sex. CONCLUSIONS: Shock index, pediatric age-adjusted identifies level 3 Emergency Severity Index pediatric patients more likely to require hospital admission, longer LOS, and a lifesaving intervention especially ventilatory support, intravenous fluids, or specific intravenous medications. Shock index, pediatric age-adjusted's predictive ability remained unaffected by fever, race, or sex, making it a valuable tool in preventing mistriage and justifying inclusion in the Emergency Severity Index danger zone vitals criteria for up-triage.

In Situ Pulmonary Arterial Thrombosis: Literature Review and Clinical Significance of a Distinct Entity.

Filling defects identified in the pulmonary arterial tree are commonly presumed to represent an embolic phenomenon originating from thrombi formed in remote veins, particularly lower-extremity deep venous thrombosis (DVT). However, accumulating evidence supports an underappreciated cause for pulmonary arterial thrombosis (PAT), namely, de novo thrombogenesis-whereby thrombosis arises within the pulmonary arteries in the absence of DVT. Although historically underrecognized, in situ PAT has become of heightened importance with the emergence of SARS-CoV-2 infection. In situ PAT is attributed to endothelial dysfunction, systemic inflammation, and acute lung injury and has been described in a range of conditions including COVID-19, trauma, acute chest syndrome in sickle cell disease, pulmonary infections, and severe pulmonary arterial hypertension. The distinction between pulmonary embolism and in situ PAT may have important implications regarding management decisions and clinical outcomes. In this review, we summarize the pathophysiology, imaging appearances, and management of in situ PAT in various clinical situations. This understanding will promote optimal tailored treatment strategies for this increasingly recognized entity.

Value of CTA/MRA in the setting of intraparenchymal hemorrhage in the emergency department.

PURPOSE: To assess the diagnostic yield of computed tomography angiography (CTA)/magnetic resonance angiography (MRA) brain and neck ordered in the emergency department (ED) for patients who have intraparenchymal hemorrhage (IPH) on their initial noncontrast CT (NCCT) of the head. METHODS: In this retrospective study, we reviewed 156 patients presenting to the ED with nontraumatic IPH, documented on NCCT. We assessed if the subsequent CTA/MRA was positive, and collected data regarding the location of the bleed, patients' age group, and presence/absence of associated SAH/IVH. Two neuroradiologists were asked to predict, based on age and NCCT appearance, whether the CTA/MRA would be positive or negative for demonstrating a vascular etiology of the hemorrhage. RESULTS: The yield of CTA/MRA head for patients above 75 years old was 2% (1/49), as the etiology for IPH in such age group was more commonly related to hypertensive bleed or amyloid angiopathy. The concomitant presence of subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH), particularly in patients younger than 75 years, correlated with a higher likelihood of a positive CTA. Statistically, the neuroradiologists were able to exclude a vascular source of the IPH based on CT appearance, bleed location, and patient's age in over 92% of cases. CONCLUSION: CTA/MRA for IPH has a lower yield in patients at older age and with deep gray matter distribution without SAH. Neuroradiologists were accurate at excluding a vascular source of the IPH in most cases. This study suggests that CTA/MRA can be omitted in certain scenarios, thereby preventing overutilization, and leading to optimal use of health care resources.

Radiologist age and diagnostic errors.

PURPOSE: Previous investigations into the causes of error by radiologists have addressed work schedule, volume, shift length, and sub-specialization. Studies regarding possible associations between radiologist errors and radiologist age and timing of residency training are lacking in the literature, to our knowledge. The aim of our study was to determine if radiologist age and residency graduation date is associated with diagnostic errors. METHODS: Our retrospective analysis included 1.9 million preliminary interpretations (out of a total of 5.2 million preliminary and final interpretations) of imaging examinations by 361 radiologists in a US-based national teleradiology practice between 1/1/2019 and 1/1/2020. Quality assurance data regarding the number of radiologist errors was generated through client facility feedback to the teleradiology practice. With input from both the client radiologist and the teleradiologist, the final determination of the presence, absence, and severity of a teleradiologist error was determined by the quality assurance committee of radiologists within the teleradiology company using standardized criteria. Excluded were 3.2 million final examination interpretations and 93,963 (1.8%) of total examinations from facilities reporting less than one discrepancy in examination interpretation in 2019. Logistic regression with covariates radiologist age and residency graduation date was performed for calculation of relative risk of overall error rates and by major imaging modality. Major errors were separated from minor errors as those with a greater likelihood of affecting patient care. Logistic regression with covariates radiologist age, residency graduation date, and log total examinations interpreted was used to calculate odds of making a major error to that of making a minor error. RESULTS: Mean age of the 361 radiologists was 51.1 years, with a mean residency graduation date of 2001. Mean error rate for all examinations was 0.5%. Radiologist age at any residency graduation date was positively associated with major errors (p < 0.05), with a relative risk 1.021 for each 1-year increase in age and relative risk 1.235 for each decade as well as for minor errors (p < 0.05, relative risk 1.007 for each year, relative risk 1.082 for each decade). By major imaging modality, radiologist age at any residency graduation date was positively associated with computed tomography (CT) and X-ray (XR) major and minor error, magnetic resonance imaging (MRI) major error, and ultrasound (US) minor error (p < 0.05). Radiologist age was positively associated with odds of making a major vs. minor error (p < 0.05). CONCLUSIONS: The mean error rate for all radiologists was low. We observed that increasing age at any residency graduation date was associated with increasing relative risk of major and minor errors as well as increasing odds of a major vs. minor error among providers. Further study is needed to corroborate these results, determine clinical relevance, and highlight strategies to address these findings.

Mandating Limits on Workload, Duty, and Speed in Radiology.

Research has not yet quantified the effects of workload or duty hours on the accuracy of radiologists. With the exception of a brief reduction in imaging studies during the 2020 peak of the COVID-19 pandemic, the workload of radiologists in the United States has seen relentless growth in recent years. One concern is that this increased demand could lead to reduced accuracy. Behavioral studies in species ranging from insects to humans have shown that decision speed is inversely correlated to decision accuracy. A potential solution is to institute workload and duty limits to optimize radiologist performance and patient safety. The concern, however, is that any prescribed mandated limits would be arbitrary and thus no more advantageous than allowing radiologists to self-regulate. Specific studies have been proposed to determine whether limits reduce error, and if so, to provide a principled basis for such limits. This could determine the precise susceptibility of individual radiologists to medical error as a function of speed during image viewing, the maximum number of studies that could be read during a work shift, and the appropriate shift duration as a function of time of day. Before principled recommendations for restrictions are made, however, it is important to understand how radiologists function both optimally and at the margins of adequate performance. This study examines the relationship between interpretation speed and error rates in radiology, the potential influence of artificial intelligence on reading speed and error rates, and the possible outcomes of imposed limits on both caseload and duty hours. This review concludes that the scientific evidence needed to make meaningful rules is lacking and notes that regulating workloads without scientific principles can be more harmful than not regulating at all.

Distribution and frequency of tyrosine kinase inhibitor-associated long-term complications in children with chronic myeloid leukemia.

BACKGROUND: Tyrosine kinase inhibitors (TKIs) improve outcomes for pediatric malignancies characterized by specific gene rearrangements and mutations; however, little is known about the long-term impact of TKI exposure. Our objective was to assess the incidence and type of late-onset TKI-related toxicities in children with chronic myeloid leukemia (CML). METHODS: We reviewed medical records from patients diagnosed with CML between 2006 and 2019 at <21 years of age and prescribed one or more TKIs. Patients treated with stem cell transplant were excluded. Outcomes were captured beginning at 1 year after CML diagnosis. Outcome incidence was described overall and stratified by TKI exposure during the data-capture period. RESULTS: Twenty-two eligible TKI-exposed patients with CML were identified. The median follow-up was 6.0 years (range: 2.2-14.3). All pericardial (n = 3) or pleural (n = 3) effusion outcomes occurred in patients treated with TKIs during the data-capture period. Other outcomes included hypertension (n = 2), ectopy on electrocardiogram (n = 2), and gastrointestinal bleed (n = 1). All outcomes were graded as mild to moderate: some resulted in a temporary discontinuation of TKI, but none led to a change in TKI. No differences were noted in outcome incidence by type of TKI exposure. CONCLUSIONS: TKIs have substantially improved prognosis for subsets of childhood leukemia, but there are limited long-term data to inform exposure-based risk for late-onset complications and screening. Our results suggest that TKI-exposed survivors may be at risk for long-term outcomes that extend well into survivorship.

How are our residents doing on trauma tonight? The frequency of overnight resident-faculty report discrepancies in trauma patients.

PURPOSE: To determine if preliminary radiology reports issued overnight (10 pm to 7 am) on adult trauma patients cause major changes of high clinical significance or patient harm. METHODS: Following extraction of preliminary and final radiology reports from the report server, presence of changes was determined by an automated text differential checker. If text changes were present, reports were then subsequently manually graded by an attending radiologist and placed in category by degree of severity. 81 weeks of trauma report data were analyzed by two faculty radiologists. RESULTS: Of the 6063 preliminary reports from 1214 separate overnight trauma patients, 65.5% had no changes in final report text. The remaining reports were graded: A 8.9% (503), B 17.2% (1005), C 7.0% (426), and D 1.3% (100). No reports demonstrated a major change of high clinical significance (E) or patient harm (F). CONCLUSION: Most preliminary report changes were minor and had no clinical significance. Furthermore, the few that were deemed to be major changes were of little clinical significance, particularly in the setting of the other traumatic injuries that the patient may have sustained. No negative patient safety events were caused by an error in a radiology resident preliminary report.

Direct observation of intermediates in the SufS cysteine desulfurase reaction reveals functional roles of conserved active-site residues.

Iron-sulfur (Fe-S) clusters are necessary for the proper functioning of numerous metalloproteins. Fe-S cluster (Isc) and sulfur utilization factor (Suf) pathways are the key biosynthetic routes responsible for generating these Fe-S cluster prosthetic groups in Escherichia coli Although Isc dominates under normal conditions, Suf takes over during periods of iron depletion and oxidative stress. Sulfur acquisition via these systems relies on the ability to remove sulfur from free cysteine using a cysteine desulfurase mechanism. In the Suf pathway, the dimeric SufS protein uses the cofactor pyridoxal 5'-phosphate (PLP) to abstract sulfur from free cysteine, resulting in the production of alanine and persulfide. Despite much progress, the stepwise mechanism by which this PLP-dependent enzyme operates remains unclear. Here, using rapid-mixing kinetics in conjunction with X-ray crystallography, we analyzed the pre-steady-state kinetics of this process while assigning early intermediates of the mechanism. We employed H123A and C364A SufS variants to trap Cys-aldimine and Cys-ketimine intermediates of the cysteine desulfurase reaction, enabling direct observations of these intermediates and associated conformational changes of the SufS active site. Of note, we propose that Cys-364 is essential for positioning the Cys-aldimine for Cα deprotonation, His-123 acts to protonate the Ala-enamine intermediate, and Arg-56 facilitates catalysis by hydrogen bonding with the sulfhydryl of Cys-aldimine. Our results, along with previous SufS structural findings, suggest a detailed model of the SufS-catalyzed reaction from Cys binding to C-S bond cleavage and indicate that Arg-56, His-123, and Cys-364 are critical SufS residues in this C-S bond cleavage pathway.

Structural Evidence for Dimer-Interface-Driven Regulation of the Type II Cysteine Desulfurase, SufS.

SufS is a type II cysteine desulfurase and acts as the initial step in the Suf Fe-S cluster assembly pathway. In Escherichia coli, this pathway is utilized under conditions of oxidative stress and is resistant to reactive oxygen species. Mechanistically, this means SufS must shift between protecting a covalent persulfide intermediate and making it available for transfer to the next protein partner in the pathway, SufE. Here, we report five X-ray crystal structures of SufS including a new structure of SufS containing an inward-facing persulfide intermediate on C364. Additional structures of SufS variants with substitutions at the dimer interface show changes in dimer geometry and suggest a conserved ß-hairpin structure plays a role in mediating interactions with SufE. These new structures, along with previous HDX-MS and biochemical data, identify an interaction network capable of communication between active-sites of the SufS dimer coordinating the shift between desulfurase and transpersulfurase activities.

Playing Well With Others: The Challenge of Academic and Community Radiology Practice Integration.

OBJECTIVE. In this article, we review models for clinical integration across the full spectrum of radiologic services in merged health systems that include both academic and community practice components. We also discuss the issues involved in the integration of disparate practice models and reward systems for both the community radiology group and the academic faculty practice group. CONCLUSION. Although we see advantages to the current trends in mergers and acquisitions within academic radiology, it remains to be seen whether academic and community practice radiology groups can truly work and play well together.

Difficult Intubation and Ventilation in an Infant With Retropharyngeal Abscess With Mediastinal Extension.

A previously healthy 7-month-old male infant presented for evaluation of fever, deceased oral intake, and intermittent noisy breathing. Physical examination revealed neck tenderness. Soft tissue neck radiographs and computed tomography (CT) scan supported a diagnosis of retropharyngeal swelling with extension to the superior mediastinum. Surgical exploration was planned, and endotracheal intubation was performed in the operating room. Significant cardiorespiratory derangements developed immediately after the tracheal tube was inserted, including hypotension, hypoxia, and bradycardia with signs of cardiac ischemia. The patient was resuscitated with intravenous fluids, vasopressors, and bronchodilators; his condition improved after resuscitation and surgical evacuation of purulent material. A combination of mediastinal mass effect, aspiration, and bronchospasm likely contributed to the patient's deterioration. The subsequent clinical course was uneventful. The patient was extubated in a delayed fashion and discharged on the fourth postoperative day. This case highlights the importance of preparing for a difficult airway in cases of retropharyngeal abscesses that necessitate tracheal intubation. A multidisciplinary approach is best suited to manage the airway, preferably in the operating room.

Overnight Resident versus 24-hour Attending Radiologist Coverage in Academic Medical Centers.

Academic medical centers have long relied on radiology residents to provide after-hours coverage, which means that they essentially function with autonomy. In this approach, attending radiologist review of resident interpretations occurs the following morning, often by subspecialist faculty. In recent years, however, this traditional coverage model in academic radiology departments has been challenged by an alternative model, the 24-hour attending radiologist coverage. Proponents of this new model seek to improve patient care after hours by increasing report accuracy and the speed with which the report is finalized. In this article, we review the traditional and the 24-hour attending radiologist coverage models. We summarize previous studies that indicate that resident overnight error rates are sufficiently low so that changing to an overnight attending model may not necessarily provide a meaningful increase in report accuracy. Whereas some centers completely replaced overnight residents, we note that most centers use a hybrid model, and overnight residents work alongside supervising attending radiologists, much as they do during the day. Even in this hybrid model, universal double reading and subspecialist final review, typical features of the traditional autonomous resident coverage model, are generally sacrificed. Because of this, changing from resident coverage to coverage by an attending radiologist that is 24 hours/day, 7 days/week may actually have detrimental effects to patient safety and quality of care provided. Changing to an overnight attending radiologist model may also have negative effects on the quality of radiology resident training, and it significantly increases cost.

Key Principles in Quality and Safety in Radiology.

OBJECTIVE: The purpose of this article is to introduce the reader to basic concepts of quality and safety in radiology. CONCLUSION: Concepts are introduced that are keys to identifying, understanding, and utilizing certain quality tools with the aim of making process improvements. Challenges, opportunities, and change drivers can be mapped from the radiology quality perspective. Best practices, informatics, and benchmarks can profoundly affect the outcome of the quality improvement initiative we all aim to achieve.

Communicating Uncertainty in the Radiology Report.

OBJECTIVE: The purposes of this article are to explore the issue of diagnostic uncertainty in radiology and how the radiology report has often fallen short in this regard and to suggest approaches that can be helpful in addressing this challenge. CONCLUSION: The practice of medicine involves a great deal of uncertainty, which is an uncomfortable reality for most physicians. Radiologists are more often than not faced with considerable diagnostic uncertainty and in their written reports are challenged to effectively communicate that uncertainty to referring physicians and others.

Online Portals: Gateway to Patient-Centered Radiology.

OBJECTIVE: Online portals typically allow access to radiology reports, causing a shift in the communication. This article evaluates the studies available in the literature about patient portals and the use of patient portals in radiology. Patient and physician preferences and the impact on radiology reporting are presented. CONCLUSION: Patient portals provide an opportunity for radiologists to engage with their patients via a new method of communication. Radiologist collaboration with referring physicians is important in providing care in accordance with patient preferences.

Application of fast-scan cyclic voltammetry for the in vivo characterization of optically evoked dopamine in the olfactory tubercle of the rat brain.

The olfactory tubercle (OT), as a component of the ventral striatum, serves as an important multisensory integration center for reward-related processes in the brain. Recent studies show that dense dopaminergic innervation from the ventral tegmental area (VTA) into the OT may play an outsized role in disorders such as psychostimulant addiction and disorders of motivation, increasing recent scientific interest in this brain region. However, due to its anatomical inaccessibility, relative small size, and proximity to other dopamine-rich structures, neurochemical assessments using conventional methods cannot be readily employed. Here, we investigated dopamine (DA) regulation in the OT of urethane-anesthetized rats using in vivo fast-scan voltammetry (FSCV) coupled with carbon-fiber microelectrodes, following optogenetic stimulation of the VTA. The results were compared with DA regulation in the nucleus accumbens (NAc), a structure located adjacent to the OT and which also receives dense DA innervation from the VTA. FSCV coupled with optically evoked release allowed us to investigate the spatial distribution of DA in the OT and characterize OT DA dynamics (release and clearance) with subsecond temporal and micrometer spatial resolution for the first time. In this study, we demonstrated that DA transporters play an important role in regulating DA in the OT. However, the control of extracellular DA by uptake in the OT was less than in the NAc. The difference in DA transmission in the terminal fields of the OT and NAc may be involved in region-specific responses to drugs of abuse and contrasting roles in mediating reward-related behavior.

A Patient-Centered Radiology Quality Process Map: Opportunities and Solutions.

OBJECTIVE: The purpose of this article is to review the tools and opportunities available for patient-centered care in radiology and to create a quality patient-centered care process map to organize them for radiology practices. CONCLUSION: This article provides a review of the many opportunities to increase and improve patient-centered care in radiology. A process map that organizes and highlights key elements of patient-centered care throughout the radiology care process is provided that can be implemented to enhance the patient experience of our services and improve the quality of care provided.