Direct MRI-guided In-Bore Targeted Biopsy of the Prostate: A Step-by-Step How To and Lessons Learned.

Multiparametric MRI-the most accurate imaging technique for detection of prostate cancer-has transformed the landscape of prostate cancer diagnosis by enabling targeted biopsies. In a targeted biopsy, tissue samples are obtained from suspicious regions identified at prebiopsy diagnostic MRI. The authors briefly compare the different strategies available for targeting an MRI-visible suspicious lesion, followed by a step-by-step description of the direct MRI-guided in-bore approach and an illustrated review of its application in challenging clinical scenarios. In this technique, direct visualization of the needle, needle guide, and needle trajectory during the procedure provides a precise and versatile strategy to accurately sample suspicious lesions, improving detection of clinically significant cancers. Published under a CC BY 4.0 license Test Your Knowledge questions for this article are available in the supplemental material.

Online Interactive Case-Based Instruction in Prostate Magnetic Resonance Imaging Interpretation Using Prostate Imaging and Reporting Data System Version 2: Effect for Novice Readers.

PURPOSE: To assess the effect on reader performance of an interactive case-based online tutorial for prostate magnetic resonance imaging (MRI) interpretation using Prostate Imaging and Reporting Data System (PI-RADS). METHODS: An educational website was developed incorporating scrollable multiparametric prostate MRI examinations with annotated solutions based on PI-RADS version 2. Three second-year radiology residents evaluated a separate set of 60 prostate MRI examinations both before and after review of the online case material, identifying and scoring dominant lesions. These 60 examinations included 30 benign cases and 30 cases with a dominant lesion demonstrating Gleason score ≥3 + 4 tumor on fusion-targeted biopsy. The readers' pooled performance was compared between the 2 sessions using logistic regression and Wilcoxon signed rank tests. RESULTS: All readers completed the online material within four-hours. Review of the online material significantly improved sensitivity (from 57.8%-73.3%, P = 0.003) and negative predictive value (from 69.2%-78.2%, P = 0.049), but not specificity (from 70.0%-67.8%, P = 0.692) or positive predictive value (from 59.6%-64.7%, P = 0.389). Reader confidence (1-10 scale; 10 = maximal confidence) also improved significantly (from 5.6 ± 2.7 to 6.3 ± 2.6, P = 0.026). However, accuracy of assigned PI-RADS scores did not improve significantly (from 45.5%-53.3%, P = 0.149). CONCLUSION: An online interactive case-based website in prostate MRI interpretation improved novice readers' sensitivity and negative predictive value for tumor detection, as well as readers' confidence. This online material may serve as a resource complementing existing traditional methods of instruction by providing a more flexible educational experience among a larger volume of learners. However, further more targeted educational initiatives regarding the proper application of PI-RADS remain warranted.

Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors.

OBJECTIVE: To conduct a bedside study to determine the factors driving insulin noncompliance in inner-city patients with recurrent diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS: We analyzed socioeconomic and psychological factors in 164 adult patients with DKA who were admitted to Grady Hospital between July 2007 and August 2010, including demographics, diabetes treatment, education, and mental illness. The Patient Health Questionnaire-9 and the Short Form-36 surveys were used to screen for depression and assess quality of life. RESULTS: The average number of admissions was 4.5 ± 7 per patient. A total of 73 patients presented with first-time DKA, and 91 presented with recurrent DKA; 96% of patients were African American. Insulin discontinuation was the leading precipitating cause in 68% of patients; other causes were new-onset diabetes (10%), infection (15%), medical illness (4%), and undetermined causes (3%). Among those who stopped insulin, 32% gave no reasons for stopping, 27% reported lack of money to buy insulin, 19% felt sick, 15% were away from their supply, and 5% were stretching insulin. Compared with first-time DKA, those with recurrent episodes had longer duration of diabetes (P < 0.001), were a younger age at the onset of diabetes (P = 0.04), and had higher rates of depression (P = 0.04), alcohol (P = 0.047) and drug (P < 0.001) abuse, and homelessness (P = 0.005). There were no differences in quality-of-life scores, major psychiatric illnesses, or employment between groups. CONCLUSIONS: Poor adherence to insulin therapy is the leading cause of recurrent DKA in inner-city patients. Several behavioral, socioeconomic, psychosocial, and educational factors contribute to poor compliance. The recognition of such factors and the institution of culturally appropriate interventions and education programs might reduce DKA recurrence in minority populations.