Facets of facet joint interventions.

Facet joint (FJ) disease is a common cause of axial low back pain with many minimally invasive image-guided treatment options. This article discusses fluoroscopic and CT-guided intraarticular FJ injections, medial branch (MB) radiofrequency ablation (RFA), and lumbar facet synovial cyst (LFSC) aspiration, rupture, or fenestration. Additionally, the article will highlight medial branch blocks (MBBs) utilized to diagnose facet-mediated pain and to predict outcomes to RFA.

Percutaneous image-guided bone biopsy of osteomyelitis in the foot and pelvis has a low impact on guiding antibiotics management: a retrospective analysis of 60 bone biopsies.

OBJECTIVE: Image-guided percutaneous bone biopsy may be requested by clinicians to guide antibiotics management decisions in patients with extremity osteomyelitis. Much of the clinical literature describes a high rate of bone biopsy culture positivity in patients with osteomyelitis, but anecdotally biopsy is felt to be fairly low yield in many musculoskeletal radiology practices. The objective of the study is to determine the culture positivity rate and clinical utility of bone biopsy in guiding the management of patients with osteomyelitis. MATERIALS AND METHODS: All image-guided bone biopsy procedures of the pelvis or foot performed at a single institution were identified by a retrospective report search, and only those with a clinical suspicion for infection were included. Cases were included based on convincing imaging findings of osteomyelitis on retrospective review. Microbiology results were reviewed in the clinical chart, as were antibiotics management decisions and response to antibiotics therapy. RESULTS: A total of 60 bone biopsies met the inclusion criteria, 25 within the foot and 35 biopsies of the pelvis. Overall, 11 out of 60 core biopsies (18%) yielded positive cultures. Antibiotics management was altered in only 27% patients with a positive culture; thus, only 5% of patients with MRI findings of osteomyelitis undergoing biopsy had an impact on management. CONCLUSION: Percutaneous bone biopsies may have a low rate of culture positivity, and even when positive, frequently do not have an impact on antibiotics choice. These data differ from much of the clinical literature, which describes a very high rate of culture positivity.

Incidence of gadolinium or fluid signal within surgically proven glenoid labral tears at MR arthrography.

OBJECTIVE: To determine how often patients with surgically proven labral tears have labral signal on shoulder MR arthrography (MRA) that is not equal to gadolinium or fluid on T1- and T2-weighted images, respectively. MATERIALS AND METHODS: Consecutive patients with surgical repair of a SLAP or Bankart labral tear within 95 days of an MRA were included. Using cartilage signal as an internal reference, two musculoskeletal (MSK) radiologists retrospectively categorized labral signal as T1-hyperintense, T1-gadolinium, T2-hyperintense, or T2-fluid. In patients without T1-gadolinium or T2-fluid labral signal, secondary findings such as the orientation, extent, shape, and width of the abnormal signal was recorded. Statistical analyses were performed using Fisher's test and ANOVA. RESULTS: Sixty-one labral tears (36 SLAP and 25 Bankart) in 54 patients (mean age, 30.7; F:M 8:46) met the inclusion criteria. In 67% and 76% of SLAP and Bankart labral tears, T1-gadolinium signal was present (p = 0.43). T2-fluid signal was present in 50% and 92% of these same labral tears (p = 0.001). The absence of T1-gadolinium or T2-fluid signal was more common in SLAP tears (33%) compared to Bankart tears (8%) (p = 0.02). In the SLAP cases, at least two secondary findings of a SLAP tear were present in 92% (11/12). CONCLUSIONS: Lack of surfacing T1-gadolinium or T2-fluid labral signal is unusual in Bankart tears but relatively common in SLAP tears. However, a SLAP tear was diagnosed in 92% of these 12 cases when two secondary findings were present.

Quick Guide: Programming a Gaming Keyboard for PACS to Optimize Radiology Workflow.

The surging demand for diagnostic imaging has highlighted inefficiencies with traditional input devices. Radiologists, using conventional mice and keyboards, grapple with cumbersome shortcuts leading to fatigue, errors, and possible injuries. Gaming keyboards, designed for gamers' precision and adaptability, feature customizable keys that simplify complex tasks into single-touch actions, offering radiologists a more efficient workflow with less physical and mental strain. Incorporating these keyboards could revolutionize radiologists' engagement with PACS. The customizable feature significantly trims time spent searching, ushering in swifter, ergonomic interactions. This manuscript delineates a guide for adapting a Logitech gaming keyboard to radiology needs, from profile creations and shortcut mapping to intricate macro setups. Although the guide uses a Logitech gaming keyboard for demonstration, it is designed to be intuitive, helping users adapt to their unique needs across different modalities, subspecialties, and various radiology viewer software. Furthermore, its fundamental concepts are transferrable to other mouse brands or models with similar customization software. As radiology pivots toward utmost efficiency, gaming keyboards emerge as invaluable assets, promising significant workflow enhancements.

ACR Appropriateness Criteria® Chronic Hand and Wrist Pain: 2023 Update.

Chronic hand and wrist pain is a common presenting complaint. The intricate anatomy results in a variety of pain generators-multiple bones, articular cartilage, intrinsic ligaments, triangular fibrocartilage complex, joint capsules and synovium, tendons and tendon sheaths, muscles, and nerves-in a compact space. The need for imaging and the choice of the appropriate imaging modality are best determined by the patient's presentation, physical examination, and the clinician's working differential diagnosis. Radiography is usually appropriate as the initial imaging study in the evaluation of chronic hand or wrist pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Stress (Fatigue-Insufficiency) Fracture Including Sacrum Excluding Other Vertebrae: 2024 Update.

Stress fractures, including both fatigue and insufficiency types, are frequently encountered in clinical practice as a source of pain in a variety of patients (athletes, older patients, and patients with predisposing conditions). Radiography is the imaging modality of choice for baseline diagnosis. MRI has greatly improved our ability to diagnose radiographically occult stress fractures. Nuclear medicine scintigraphy and CT may also be useful as diagnostic tools. Although fatigue and insufficiency fractures can be self-limited and go on to healing even without diagnosis, there is usually value in initiating prompt therapeutic measures as incomplete stress fractures have the potential to progress to completion, necessitating surgery. This is particularly important in the setting of stress fractures of the femoral neck. Accuracy in the identification of these injuries is also relevant because the differential diagnosis includes entities that would otherwise be treated differently (ie, metastatic disease). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Quick Guide: Programming a Gaming Mouse for PACS to Optimize Radiology Workflow.

The increasing demand for diagnostic imaging has added to the radiologists' workload, highlighting the shortcomings of conventional computer mice. Radiologists grapple with inefficiencies from frequent mouse clicks and keyboard shortcuts required for various PACS functions. These inefficiencies contribute to cognitive strain, errors, and repetitive strain injuries. High-performance gaming mice, known for their precision in the gaming world, offer multiple custom buttons and superior tracking. These features can streamline radiology tasks. Utilizing a gaming mouse tailored for radiology tasks can substantially enhance efficiency. Our guide offers a step-by-step approach to harnessing the gaming mouse's capabilities for radiology tasks, ensuring radiologists can enhance their workflow and minimize injury risks. Although the guide uses a Logitech gaming mouse for demonstration, it is designed to be intuitive, helping users adapt to their unique needs across different modalities, subspecialties, and various radiology viewer software. Importantly, its fundamental concepts are transferrable to other mouse brands or models with similar customization software.

ACR Appropriateness Criteria® Imaging After Total Knee Arthroplasty: 2023 Update.

Total knee arthroplasty is the most commonly performed joint replacement procedure in the United States. This manuscript will discuss the recommended imaging modalities for six clinical variants; 1. follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging, 2. Suspected infection after total knee arthroplasty. Additional imaging following radiographs, 3. Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs, 4. Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs, 5. Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs, and 6. Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy. Additional imaging following radiographs. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update.

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Chronic Hip Pain: 2022 Update.

Chronic hip pain is a frequent chief complaint for adult patients who present for evaluation in a variety of clinical practice settings. Following a targeted history and physical examination, imaging plays a vital role in elucidating the etiologies of a patient's symptoms, as a wide spectrum of pathological entities may cause chronic hip pain. Radiography is usually the appropriate initial imaging test following a clinical examination. Depending on the clinical picture, advanced cross-sectional imaging may be subsequently performed for further evaluation. This documents provides best practice for the imaging workup of chronic hip pain in patients presenting with a variety of clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update.

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty.

This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Optimizing radiologist productivity and efficiency: Work smarter, not harder.

Radiologists' personal productivity and efficiency are critically important for both improving patient outcomes and protecting clinician well-being. There are several solutions that individuals can implement to improve personal productivity and efficiency in the radiology workroom. Strategies include understanding the psychology behind productivity, using personal productivity methodologies to accomplish daily tasks, and learning to modulate stress to optimize performance. Institutional infrastructure requirements include a robust departmental commitment to information technology and informatics, including universal log-in systems, internal websites, and dashboards. The workstation itself can be optimized by utilizing hanging protocols, customized keyboard shortcuts, hotkeys, advanced scripts, gaming mice, and other input devices. Personal devices like smartphones can be harnessed to maximize productivity by using online storage applications and radiology-specific applications to augment knowledge. Reading room layouts must be designed to minimize interruptions and workstations must consider ergonomics to prevent fatigue and strain. High-efficiency teams also need to be created to allow radiologists to delegate non-clinical tasks to reduce administrative burdens. Lastly, continued advances in artificial intelligence including the use of smart report templates will lead to substantial gains in radiologists' productivity and efficiency.

Prospective Multireader Evaluation of Photon-counting CT for Multiple Myeloma Screening.

Purpose To determine whether photon-counting CT (PCCT) acquisition of whole-body CT images provides similar quantitative image quality and reader satisfaction for multiple myeloma screening at lower radiation doses than does standard energy-integrating detector (EID) CT. Materials and Methods Patients with monoclonal gammopathy of undetermined significance prospectively underwent clinical noncontrast whole-body CT with EID and same-day PCCT (August-December 2021). Five axial scan locations were evaluated by seven radiologists, with 11% (eight of 70) of images including osteolytic lesions. Images were shown in randomized order, and each reader rated the following: discernibility of the osseous cortex and osseous trabeculae, perceived image noise level, and diagnostic confidence. Presence of lytic osseous lesions was indicated. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were calculated. Comparisons were made using paired t tests and mixed linear effects models. Results Seven participants (four women) were included (mean age, 66 years ± 9 [SD]; body mass index, 30.1 kg/m2 ± 5.2). Mean cortical definition, trabecular definition, image noise, and image quality scores were 83, 67, 75, and 78 versus 84, 66, 74, and 76 for EID and PCCT, respectively (P = .65, .11, .26, and .11, respectively). PCCT helped identify more lesions (79% [22 of 28]) than did EID (64% [18 of 28]). CNRs and SNRs were similar between modalities. PCCT had lower radiation doses than EID (volume CT dose index: EID, 11.37 ± 2.8 vs PCCT, 1.8 ± 0.6 [P = .06]; dose-length product: EID, 1654.1 ± 409.6 vs PCCT, 253.4 ± 89.6 [P = .05]). Conclusion This pilot investigation suggests that PCCT affords similar quantitative and qualitative scores as EID at significantly lower radiation doses. Keywords: CT, CT-Spectral, Skeletal-Axial, Spine, Hematologic Diseases, Whole-Body Imaging, Comparative Studies Supplemental material is available for this article. © RSNA, 2022.

A Reliability Study of Multiplanar Radiographs for the Evaluation of SNAC Wrist Arthritis.

Background: Scaphoid nonunion advanced collapse (SNAC) is a common form of wrist arthritis, the treatment of which depends on the arthritic stage. The Vender classification serves to describe SNAC arthritis based on a single posteroanterior (PA) radiograph. The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Vender classification, comparing multi versus single radiographic views. Methods: A retrospective review of patients with SNAC arthritis who underwent a proximal row carpectomy or a 4-corner fusion was performed. The included patients had 3 radiographic views of the pathologic wrist. Fifteen patients were analyzed by 5 blinded reviewers. Wrists were graded using the Vender classification first on the PA view and then using multiview radiographs. The intraobserver and interobserver agreement was determined using weighted kappa analysis. χ2 tests were calculated comparing the evaluation between single- versus multiview radiographs and determining a higher Vender stage. Results: Multiview radiographs demonstrated a higher intraobserver κw compared with single-view radiographs (0.72 vs 0.66), both representing substantial agreement. The average interobserver agreement was moderate (κw of 0.48) for single view and slight (κw of 0.30) for multiview evaluation. Evaluating multiview radiographs was 6.37 times more likely to demonstrate Vender stage 3 arthritis compared with single view (odds ratio = 6.37 [confidence interval, 3.81-10.64], P < .0001). Conclusion: Reviewing multiview radiographs more commonly yielded Vender stage 3 osteoarthritis classification. The decreased interrater reliability in the multiview analysis is likely related to the increased number of articular surfaces evaluated. Using a single PA view may underestimate the severity of arthritis present.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update.

Osteoporosis constitutes a significant public health risk. An estimated 10.2 million adults in the United States >50 years of age have osteoporosis, a systemic condition that weakens the bones increasing the susceptibility for fractures. Approximately one-half of women and nearly one-third of men >50 years of age will sustain an osteoporotic fracture. These fractures are associated with a decrease in quality of life, diminished physical function, and reduced independence. Dual-energy X-ray absorptiometry (DXA) is the primary imaging modality used to screen for osteoporosis in women >65 years of age and men >70 years of age. DXA may be used in patients <65 years of age to evaluate bone mass density if there are additional risk factors. In certain situations, vertebral fracture assessment and trabecular bone score may further predict fracture risk, particularly in patients who are not yet osteoporotic but are in the range of osteopenia. Quantitative CT is useful in patients with advanced degenerative changes in the spine. Given the proven efficacy of pharmacologic therapy, the role of imaging to appropriately identify and monitor high-risk individuals is critical in substantially reducing osteoporosis-associated morbidity and mortality, and reducing the considerable cost to the health care system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update.

Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Deep learning-based algorithm for assessment of knee osteoarthritis severity in radiographs matches performance of radiologists.

A fully-automated deep learning algorithm matched performance of radiologists in assessment of knee osteoarthritis severity in radiographs using the Kellgren-Lawrence grading system. PURPOSE: To develop an automated deep learning-based algorithm that jointly uses Posterior-Anterior (PA) and Lateral (LAT) views of knee radiographs to assess knee osteoarthritis severity according to the Kellgren-Lawrence grading system. MATERIALS AND METHODS: We used a dataset of 9739 exams from 2802 patients from Multicenter Osteoarthritis Study (MOST). The dataset was divided into a training set of 2040 patients, a validation set of 259 patients and a test set of 503 patients. A novel deep learning-based method was utilized for assessment of knee OA in two steps: (1) localization of knee joints in the images, (2) classification according to the KL grading system. Our method used both PA and LAT views as the input to the model. The scores generated by the algorithm were compared to the grades provided in the MOST dataset for the entire test set as well as grades provided by 5 radiologists at our institution for a subset of the test set. RESULTS: The model obtained a multi-class accuracy of 71.90% on the entire test set when compared to the ratings provided in the MOST dataset. The quadratic weighted Kappa coefficient for this set was 0.9066. The average quadratic weighted Kappa between all pairs of radiologists from our institution who took part in the study was 0.748. The average quadratic-weighted Kappa between the algorithm and the radiologists at our institution was 0.769. CONCLUSION: The proposed model performed demonstrated equivalency of KL classification to MSK radiologists, but clearly superior reproducibility. Our model also agreed with radiologists at our institution to the same extent as the radiologists with each other. The algorithm could be used to provide reproducible assessment of knee osteoarthritis severity.

Moving Radiology Workflow to the Electronic Health Record: Quantitative and Qualitative Experience From a Large Academic Medical Center.

RATIONALE AND OBJECTIVES: To objectively and subjectively evaluate a large, academic radiology department's transition to electronic health record (EHR) centered workflow. MATERIALS AND METHODS: Multiple metrics were compared from before and after the move to EHR-driven workflow. Examination ordering and reading priority data were obtained for 30 days both before and after the transition. Sixteen radiologists were observed opening a computed tomography (CT) examination, and time to open, mouse clicks, and keystrokes were recorded. Information available to the radiologist during interpretation was also compared. Additionally, a 12 question survey was sent out to the residents and faculty both before and after the transition. RESULTS: Implementation of an eight-level reading priority system increased worklist granularity and improved identification of more urgent studies to read. Radiologists opened CT studies in picture archiving and communications system-driven workflow in 52.4 ± 16.9 seconds using 9.5 ± 3.9 clicks and 6.3 ± 2.9 keystrokes, compared to 17.3 ± 9.5 seconds, 4.8 ± 1.5 clicks, and 0.1 ± 0.3 keystrokes in EHR-driven workflow (p < 0.001 for each measure). More information was available to the radiologist during examination interpretation, and 54.7% of radiologists rated the ease of use of the new system as good or very good (compared to 4.2% for the old system, p < 0.001). CONCLUSION: Transitioning to an EHR-driven workflow at a large academic medical center improved efficiency, was favorable to radiologists, and enhanced examination prioritization.

Magnetic resonance imaging features of pubic symphysis urinary fistula with pubic bone osteomyelitis in the treated prostate cancer patient.

INTRODUCTION: Pubic bone osteomyelitis with pubic symphysis urinary fistula represents a debilitating complication of radiation and ablative treatments for prostate cancer. The definitive radiographic diagnosis of this clinical entity is not described. In this study, we characterize the plain film and magnetic resonance imaging findings of pubic osteomyelitis. MATERIALS AND METHODS: We reviewed a database of prostate cancer survivors with diagnosed pubic osteomyelitis from 2011 to 2015. These patients underwent pelvic plain radiographs and magnetic resonance imaging with T1-weighted and fat-suppressed T2-weighted fast spin echo sequences. Intravenous gadolinium was utilized. The diagnosis was verified with extirpative surgery. 16 patients with diagnosed pubic osteomyelitis from 2011 to 2015 underwent imaging at our institution. RESULTS: All patients demonstrated increased signal on T2- weighted sequences and decreased signal on T1-weighted sequences along the pubic symphysis and the marrow of the involved pubic rami. Inflammatory myositis with diastasis of the pubic symphysis and cortical bone erosion were identified in the majority of patients. Fluid collections were identified in 75% of patients. 63% of conventional radiographs demonstrated no radiographic evidence of pubic osteomyelitis. CONCLUSION: Magnetic resonance imaging of pubic symphysis osteomyelitis in the prostate cancer survivor is characterized by high signal on T2-weighted images and low signal on T1-weighted images of the involved pubic rami, with the majority of patients demonstrating regional myositis. Imaging data combined with clinical assessment should prompt diagnosis and management of pubic osteomyelitis. Conventional radiography is generally insensitive to these findings. We consider magnetic resonance imaging to be the definitive diagnostic modality for this clinical entity.