Regional Standardization of Prostate Multiparametric MRI Performance and Reporting: Is There a Role for a Director of Prostate Imaging?

OBJECTIVE. The purpose of this study was to assess prostate multiparametric MRI (mpMRI) before and after intervention by a director of prostate imaging. MATERIALS AND METHODS. Images from prostate mpMRI examinations at four peripheral institutions (five 1.5-T systems) were studied. DICOM headers were analyzed for T2-weighted, DWI, and dynamic contrast-enhanced technical specifications. Reports were retrieved, and a blinded radiologist compared them with those from the regional academic referral center (3-T system) and Prostate Imaging and Data Reporting System version 2 (PI-RADSv2) technical specifications. Data were reevaluated after intervention by a director of prostate imaging. Comparisons were performed by chi-square analysis. RESULTS. Except for having insufficient DWI spatial resolution, the referral center fully complied with PI-RADSv2. For peripheral systems, compliance with PI-RADSv2 technical specifications improved from baseline to after intervention. For T2-weighted imaging, compliance with spatial resolution increased from 40% (two of five MRI systems) to 100% (all five systems) (p = 0.038). For DWI, spatial resolution compliance increased from 20% to 100%. For modified DWI, spatial resolution compliance to improve image quality at 1.5 T (matrix, 100 × 100; FOV, 28 × 28 cm; slice thickness, 4 mm) increased from 60% (b value ≥ 1400 s/mm2) to 100% (p = 0.114). For dynamic contrast-enhanced imaging, spatial resolution compliance increased from 60% to 100% (p = 0.114), temporal resolution compliance increased from 20% (≤ 10 seconds) to 100% (p = 0.10), and acquisition time compliance increased from 60% (≥ 2 minutes) to 100% (p = 0.114). Only one of the four peripheral centers provided PI-RADSv2 scores, but all of them did after the intervention (p = 0.028). CONCLUSION. A director of prostate imaging may drive standardization of prostate MRI performance and reporting within specified geographic regions.

Quality Initiative Program in Its Sixth Year: Has It Become Part of Our Radiology Culture?

PURPOSE: The study sought to determine if the Quality Initiative Program (QUIP) has become part of the radiology culture at our institution. METHODS: After Research Ethics approval, QUIPs from January 2009 to December 2014 were assessed. We evaluated the response rates of radiologists receiving QUIPs to ensure they reviewed them. We performed a survey of radiologists and trainees to gain feedback regarding their perception of QUIPs in February 2014 and in June 2015. RESULTS: Response rates of radiologists receiving a QUIP improved, with 76% response rate in 2014 up from 66% in the first year and 42% in the second year. Based on the 2015 survey including radiologists and trainees, 75% agreed that QUIPs were educational, compared with 67% 16 months earlier. Fifty percent of respondents had changed their overall practice of reporting based on feedback from the QUIP in 2015 compared with 32% in 2014. In both surveys, 100% of respondents indicated that QUIPs have not been used against them for any disciplinary measure (or other negatively perceived action). When asked if there was a perceived decrease in stigma felt when a QUIP was received, 71% agreed or were neutral and 28% disagreed. CONCLUSIONS: The QUIP is educational to radiologists and trainees, leading to positive changes in clinical practice. The majority accepts this program but there is still a stigma felt when a QUIP is received, particularly among residents. Nevertheless, we feel that QUIP has been integrated into our radiology culture and, hopefully, imminent transition to commercial quality software will be smooth.

Effect of Implementing Community of Practice Modified Thyroid Imaging Reporting and Data System on Reporting Adherence and Number of Thyroid Biopsies.

RATIONALE AND OBJECTIVES: Thyroid nodules are common in the population, although the rate of malignancy is relatively low (5%-15%). The purpose of this study was to determine if introducing a modified standardized reporting format and management algorithm (Thyroid Imaging Reporting and Data System [TI-RADS]) affects radiologist reporting adherence, number of thyroid biopsies, and other measurable outcomes. MATERIALS AND METHODS: All thyroid biopsies performed over two 6-month periods were evaluated at a tertiary care hospital with Research Ethics Board approval. The first period was before implementation of TI-RADS and the second was several months after implementation of TI-RADS (using a modified version made through a multidisciplinary collaboration). The number of biopsies performed was determined in each of the two periods as well as the percent of positive malignancy, wait times, and rates of non-diagnostic/unsatisfactory and inconclusive biopsies, which included atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS). RESULTS: The average number of biopsies performed prior to implementing modified Kwak's TI-RADS was 74 thyroid biopsies per month and the average number of diagnostic ultrasounds was 271. After the introduction of modified Kwak's TI-RADS, the average number of thyroid biopsies decreased to 60 per month (an 18.9% reduction, P < .05), and the number of diagnostic ultrasound increased to 287 per month (a 5.9% increase from 2016 to 2017). The average wait time for a thyroid biopsy decreased from 5 to 3 weeks (P < .05). There was a slight increase in the rate of positive malignancy results (from 15% to 18%), although it was not statistically significant. The rate of non-diagnostic/unsatisfactory and inconclusive results (including AUS and FLUS) remained unchanged (18% AUS/FLUS/15% non-diagnostic/unsatisfactory before and 17% AUS/FLUS/15% non-diagnostic/unsatisfactory after TI-RADS introduction, P > .05). CONCLUSIONS: Introduction of a multidisciplinary-approved standardized reporting system with evidence-based management recommendations led to no statistically significant change in the number of diagnostic ultrasounds but a statistically significant reduction in the number of monthly thyroid biopsies and associated reduction in wait times.

Transient mediastinal mass from fluid overload.

Mediastinal masses incidentally discovered on chest imaging often suggest underlying malignancy such as lymphoma or metastatic cancer. However, the radiographic appearance of mediastinal edema can mimic a mediastinal mass in the context of acute fluid overload. We describe the case of a 75 year old woman known for end-stage renal disease on hemodialysis who presented with acute pulmonary edema in the context of a Non ST-Elevation Myocardial Infarction. Chest CT imaging showed pulmonary edema, pleural effusions, and a middle mediastinum soft-tissue mass of 4.2 × 2.5cm. Malignancy was initially suspected, however given the clinical context of fluid overload and absence of other signs of malignancy, the possibility of the mass representing soft-tissue edema was raised. Therefore, the patient's fluid overload was treated with a progressive reduction in the dry weight used for dialysis and a repeat chest CT was obtained 8 weeks later once the patient was euvolemic. The repeat CT showed complete resolution of the mediastinal mass. Fluid overload can manifest in many different ways on chest imaging. Mediastinal masses lead to concerns about a potentially malignant process and often prompt further evaluation with invasive procedures that carry significant risks. In the appropriate clinical context, it is important to consider the possibility of mediastinal edema presenting as a mass on chest imaging. Under such circumstances, it is more prudent to correct the fluid overload and repeat chest imaging before undertaking invasive diagnostic procedures with the potential to cause harm.

Validity study for the cervical range of motion device used for lateral flexion in patients with neck pain.

STUDY DESIGN: A set of measurements was compared with an accepted gold standard using a methodologic design. OBJECTIVE: To estimate the criterion validity of the cervical range of motion device used for lateral flexion in patients with neck pain. SUMMARY OF BACKGROUND DATA: Reliability of the cervical range of motion device has been well established. At this writing, only validity for flexion and extension of the cervical spine has been investigated with this device. METHODS: The sample consisted of 24 volunteer subjects who had previously received physiotherapy for neck pain. In the radiograph department, subjects were stabilized on a chair. A first reading on the cervical range of motion device and a radiograph were taken in a neutral starting position. The subject then was asked to perform a maximal right lateral flexion, which was followed by a reading of the device and a second radiograph. The same procedures were followed for left lateral flexion. RESULTS: The cervical range of motion device demonstrated a very good linear relation with the radiograph measurements: left lateral flexion (r = 0.82,; 95% confidence interval, 0.62-0.92), right lateral flexion (r = 0.84; 95% confidence interval, 0.66-0.93). CONCLUSIONS: The cervical range of motion device showed very good validity for measurement of lateral flexion in this population of patients with neck pain. Because the reliability of the cervical range of motion device was established previously, the results of this study suggest that the device be used as an outcome measure for the cervical flexion, and for flexion and extension.