Development and External Validation of an Artificial Intelligence Model for Identifying Radiology Reports Containing Recommendations for Additional Imaging.

BACKGROUND. Reported rates of recommendations for additional imaging (RAIs) in radiology reports are low. Bidirectional encoder representations from transformers (BERT), a deep learning model pretrained to understand language context and ambiguity, has potential for identifying RAIs and thereby assisting large-scale quality improvement efforts. OBJECTIVE. The purpose of this study was to develop and externally validate an artificial intelligence (AI)-based model for identifying radiology reports containing RAIs. METHODS. This retrospective study was performed at a multisite health center. A total of 6300 radiology reports generated at one site from January 1, 2015, to June 30, 2021, were randomly selected and split by 4:1 ratio to create training (n = 5040) and test (n = 1260) sets. A total of 1260 reports generated at the center's other sites (including academic and community hospitals) from April 1 to April 30, 2022, were randomly selected as an external validation group. Referring practitioners and radiologists of varying sub-specialties manually reviewed report impressions for presence of RAIs. A BERT-based technique for identifying RAIs was developed by use of the training set. Performance of the BERT-based model and a previously developed traditional machine learning (TML) model was assessed in the test set. Finally, performance was assessed in the external validation set. The code for the BERT-based RAI model is publicly available. RESULTS. Among a total of 7419 unique patients (4133 women, 3286 men; mean age, 58.8 years), 10.0% of 7560 reports contained RAI. In the test set, the BERT-based model had 94.4% precision, 98.5% recall, and an F1 score of 96.4%. In the test set, the TML model had 69.0% precision, 65.4% recall, and an F1 score of 67.2%. In the test set, accuracy was greater for the BERT-based than for the TML model (99.2% vs 93.1%, p < .001). In the external validation set, the BERT-based model had 99.2% precision, 91.6% recall, an F1 score of 95.2%, and 99.0% accuracy. CONCLUSION. The BERT-based AI model accurately identified reports with RAIs, outperforming the TML model. High performance in the external validation set suggests the potential for other health systems to adapt the model without requiring institution-specific training. CLINICAL IMPACT. The model could potentially be used for real-time EHR monitoring for RAIs and other improvement initiatives to help ensure timely performance of clinically necessary recommended follow-up.

Electronic Health Record Order Entry-Based Interventions in Response to a Global Iodinated Contrast Media Shortage: Impact on Contrast-Enhanced CT Utilization.

BACKGROUND. Radiology informatics systems and clinical decision support tools in the electronic health record (EHR) can be leveraged to help impact ordering patterns in response to the ongoing global iodinated contrast media shortage. OBJECTIVE. The purpose of our study was to assess the impact of EHR order entry-based interventions, implemented as part of a health system's response to the global contrast media shortage, on contrast-enhanced CT utilization. METHODS. This retrospective study included 79,259 patients who underwent CT at a large multisite health system between April 1, 2022, and July 3, 2022. Two EHR-based interventions were implemented as part of the health system's response to the global contrast media shortage. A first EHR-based intervention on May 10, 2022, entailed creating an alert that appeared in a sidebar after any contrast-enhanced body CT orders, indicating the present shortage and recommending alternate imaging modalities. A second EHR-based intervention on May 16, 2022, required referrers to enter detailed clinical information for all contrast-enhanced body CT orders, which radiologists used when protocoling examinations. Data regarding CT orders and examinations performed were extracted from the electronic data warehouse. RESULTS. During the preintervention, first postintervention, and second postintervention periods, the mean number of patients who underwent contrast-enhanced CT per weekday was 726, 689, and 639, respectively (p for preintervention vs second postintervention periods, < .001). During the three periods, the mean number of patients who underwent CT per weekday was 1350, 1323, and 1314 (p < .001). During the three periods, the mean number of patients who underwent contrast-enhanced body CT per weekday was 561, 532, and 492 (p < .001). During the three periods, the mean number of orders for CT with IV contrast media per weekday was 154, 143, and 131 (p < .001). During the three periods, the mean number of orders for CT without IV contrast media per weekday was 196, 202, and 221 (p < .001). CONCLUSION. EHR order entry-based interventions implemented in response to the global contrast media shortage significantly reduced contrast-enhanced CT utilization in a large health system. CLINICAL IMPACT. The findings indicate the ability to rapidly achieve changes in ordering clinician behavior and subsequent clinical practice using systemwide EHR changes.

Utility of Patient-Reported Risk Factors for Identifying Advanced Chronic Kidney Disease Before Outpatient CT: Comparison With Recent ACR/NKF Consensus Criteria.

BACKGROUND. Practices vary for screening patients for risk of renal dysfunction before administration of iodinated contrast medium. A 2020 American College of Radiology/National Kidney Foundation (ACR/NKF) consensus statement provided streamlined screening criteria. OBJECTIVE. The purpose of this study was to assess the yield of patient-reported risk factors for identifying estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73 m2 before outpatient CT. METHODS. This retrospective study was performed at a health system that implemented an electronic screening form for patients to complete before outpatient CT encounters to report undergoing dialysis, taking cancer-treating medications, having kidney disease, undergoing prior kidney surgery, having diabetes mellitus treated with medication, having hypertension treated with medication, or having multiple myeloma. Patients with any risk factor were required to undergo eGFR testing before CT. Of 44,708 patients completing the form from June 1, 2020, through February 28, 2021, 10,256 patients (5315 men, 4941 women; mean age, 66.8 ± 11.9 [SD] years; range, 21-98 years) underwent eGFR testing on the day of CT. Multivariable regression analysis for predicting reduced eGFR was performed. Findings were compared with those from theoretic use of the ACR/NKF criteria. RESULTS. Same-day testing yielded eGFR less than 30 mL/min/1.73 m2 in 1.4% (144/10,256) of patients. The only significant independent predictors of low eGFR were dialysis (odds ratio [OR], 203.30], kidney disease (OR, 12.55), and diabetes mellitus treated with medication (OR, 2.44). If the ACR/NKF criteria (only kidney disease, defined as dialysis, kidney disease, or prior kidney surgery) had been followed as a trigger for eGFR testing, the number of patients needing testing would have decreased 89.7%, from 10,256 to 1059; yield would have increased to 7.2% (76/1059); and 47.2% (68/144) of patients with low eGFR would have been missed. If the ACR/NKF criteria had been followed but diabetes mellitus been considered a required rather than an optional criterion, the number of patients needing testing would have decreased 77.1%, to 2353; yield would have increased to 4.0% (95/2353); and 34.0% (49/144) of patients with low eGFR would have been missed. CONCLUSION. Using patient-reported risk factors resulted in frequent eGFR testing but low yield of low eGFR. Commonly applied risk factors were not independently associated with low eGFR. CLINICAL IMPACT. Application of ACR/NKF criteria would substantially reduce eGFR testing, but patients with renal dysfunction would be missed. The statement should consider omitting kidney surgery as a trigger for eGFR testing and including diabetes mellitus as a required trigger.

Abdominal Imaging Findings in COVID-19: Preliminary Observations.

Background Angiotensin-converting enzyme 2, a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), demonstrates its highest surface expression in the lung, small bowel, and vasculature, suggesting abdominal viscera may be susceptible to injury. Purpose To report abdominal imaging findings in patients with coronavirus disease 2019. Materials and Methods In this retrospective cross-sectional study, patients consecutively admitted to a single quaternary care center from March 27 to April 10, 2020, who tested positive for SARS-CoV-2 were included. Abdominal imaging studies performed in these patients were reviewed, and salient findings were recorded. Medical records were reviewed for clinical data. Univariable analysis and logistic regression were performed. Results A total of 412 patients (average age, 57 years; range, 18 to >90 years; 241 men, 171 women) were evaluated. A total of 224 abdominal imaging studies were performed (radiography, n = 137; US, n = 44; CT, n = 42; MRI, n = 1) in 134 patients (33%). Abdominal imaging was associated with age (odds ratio [OR], 1.03 per year of increase; P = .001) and intensive care unit (ICU) admission (OR, 17.3; P < .001). Bowel-wall abnormalities were seen on 31% of CT images (13 of 42) and were associated with ICU admission (OR, 15.5; P = .01). Bowel findings included pneumatosis or portal venous gas, seen on 20% of CT images obtained in patients in the ICU (four of 20). Surgical correlation (n = 4) revealed unusual yellow discoloration of the bowel (n = 3) and bowel infarction (n = 2). Pathologic findings revealed ischemic enteritis with patchy necrosis and fibrin thrombi in arterioles (n = 2). Right upper quadrant US examinations were mostly performed because of liver laboratory findings (87%, 32 of 37), and 54% (20 of 37) revealed a dilated sludge-filled gallbladder, suggestive of bile stasis. Patients with a cholecystostomy tube placed (n = 4) had negative bacterial cultures. Conclusion Bowel abnormalities and gallbladder bile stasis were common findings on abdominal images of patients with coronavirus disease 2019. Patients who underwent laparotomy often had ischemia, possibly due to small-vessel thrombosis. © RSNA, 2020.

Semiautomatic Segmentation and Radiomics for Dual-Energy CT: A Pilot Study to Differentiate Benign and Malignant Hepatic Lesions.

OBJECTIVE. This study assessed a machine learning-based dual-energy CT (DECT) tumor analysis prototype for semiautomatic segmentation and radiomic analysis of benign and malignant liver lesions seen on contrast-enhanced DECT. MATERIALS AND METHODS. This institutional review board-approved study included 103 adult patients (mean age, 65 ± 15 [SD] years; 53 men, 50 women) with benign (60/103) or malignant (43/103) hepatic lesions on contrast-enhanced dual-source DECT. Most malignant lesions were histologically proven; benign lesions were either stable on follow-up CT or had characteristic benign features on MRI. Low- and high-kilovoltage datasets were deidentified, exported offline, and processed with the DECT tumor analysis for semiautomatic segmentation of the volume and rim of each liver lesion. For each segmentation, contrast enhancement and iodine concentrations as well as radiomic features were derived for different DECT image series. Statistical analyses were performed to determine if DECT tumor analysis and radiomics can differentiate benign from malignant liver lesions. RESULTS. Normalized iodine concentration and mean iodine concentration in the benign and malignant lesions were significantly different (p < 0.0001-0.0084; AUC, 0.695-0.856). Iodine quantification and radiomic features from lesion rims (AUC, ≤ 0.877) had higher accuracy for differentiating liver lesions compared with the values from lesion volumes (AUC, ≤ 0.856). There was no difference in the accuracies of DECT iodine quantification (AUC, 0.91) and radiomics (AUC, 0.90) for characterizing liver lesions. CONCLUSION. DECT radiomics were more accurate than iodine quantification for differentiating solid benign and malignant hepatic lesions.

Can Dual-Energy Computed Tomography Quantitative Analysis and Radiomics Differentiate Normal Liver From Hepatic Steatosis and Cirrhosis?

OBJECTIVES: This study aimed to assess if dual-energy computed tomography (DECT) quantitative analysis and radiomics can differentiate normal liver, hepatic steatosis, and cirrhosis. MATERIALS AND METHODS: Our retrospective study included 75 adult patients (mean age, 54 ± 16 years) who underwent contrast-enhanced, dual-source DECT of the abdomen. We used Dual-Energy Tumor Analysis prototype for semiautomatic liver segmentation and DECT and radiomic features. The data were analyzed with multiple logistic regression and random forest classifier to determine area under the curve (AUC). RESULTS: Iodine quantification (AUC, 0.95) and radiomic features (AUC, 0.97) differentiate between healthy and abnormal liver. Combined fat ratio percent and mean mixed CT values (AUC, 0.99) were the strongest differentiators of healthy and steatotic liver. The most accurate differentiating parameters of normal liver and cirrhosis were a combination of first-order statistics (90th percentile), gray-level run length matrix (short-run low gray-level emphasis), and gray-level size zone matrix (gray-level nonuniformity normalized; AUC, 0.99). CONCLUSION: Dual-energy computed tomography iodine quantification and radiomics accurately differentiate normal liver from steatosis and cirrhosis from single-section analyses.

Development of a Drosophila melanogaster based model for the assessment of cadmium and mercury mediated renal tubular toxicity.

Xenobiotic mediated renal toxicity is one of the major health concerns to the organisms, including humans. New chemicals with nephrotoxic potential are continuously being added to the list of existing nephrotoxicants. To predict the nephrotoxicity of these new chemicals, reliable and cost-effective alternative animal models are required. It is a prerequisite for the identification and assessment of these compounds as potential nephrotoxicants to prevent renal toxicity in the exposed population. Drosophila melanogaster, a genetically tractable invertebrate animal model, has a renal system functionally analogous to humans. The Malpighian tubules (MTs) of D. melanogaster are similar to the tubular part of nephron of the human kidney. Besides, it recapitulates the renal toxicity hallmark with mammals when exposed to known nephrotoxicants. In this study, first instar larvae of D. melanogaster (Oregon R) were exposed to different concentrations of two well-known nephrotoxicants, cadmium (Cd) and mercury (Hg). Akin to higher organisms, Cd and Hg exposure to D. melanogaster produce similar phenotypes. MTs of exposed D. melanogaster larvae exhibited increased oxidative stress, activated cellular antioxidant defense mechanism, GSH depletion, increased cleaved caspase-3 expression, increased DEVDase activity and increased cell death. The functional status of MTs was assessed by fluid secretion rate (FSR), efflux activity of transporter protein, mitochondrial membrane potential (MMP), ATP level and expression of junctional protein (Dlg). All the phenotypes observed in MTs of D. melanogaster larvae recapitulate the phenotypes observed in higher organisms. Increased uric acid level, the hallmark of renal dysfunction, was also observed in exposed larvae. Taken together, the study suggests that MTs of D. melanogaster may be used as a functional model to evaluate xenobiotic mediated nephrotoxicity.

Abbreviated MRI Protocols for the Abdomen.

Technical advances in MRI have improved image quality and have led to expanding clinical indications for its use. However, long examination and interpretation times, as well as higher costs, still represent barriers to use of MRI. Abbreviated MRI protocols have emerged as an alternative to standard MRI protocols. These abbreviated MRI protocols seek to reduce longer MRI protocols by eliminating unnecessary or redundant sequences that negatively affect cost, MRI table time, patient comfort, image quality, and image interpretation time. However, the diagnostic information is generally not compromised. Abbreviated MRI protocols have already been used successfully for hepatocellular carcinoma screening, for prostate cancer detection, and for screening for nonalcoholic fatty liver disease as well as monitoring patients with this disease. It has been reported that image acquisition time and costs can be considerably reduced with abbreviated MRI protocols, compared with standard MRI protocols, while maintaining a similar sensitivity and accuracy. Nevertheless, multiple applications still need to be explored in the abdomen and pelvis (eg, surveillance of metastases to the liver; follow-up of cystic pancreatic lesions, adrenal incidentalomas, and small renal masses; evaluation of ovarian cysts in postmenopausal women; staging of cervical and uterine corpus neoplasms; evaluation of müllerian duct anomalies). This article describes some successful applications of abbreviated MRI protocols, demonstrates how they can help in improving the MRI workflow, and explores potential future directions. ©RSNA, 2019.

The S-layer biogenesis system of Synechocystis 6803: Role of Sll1180 and Sll1181 (E. coli HlyB and HlyD analogs) as type-I secretion components for Sll1951 export.

Multiple secretion pathways are known for export of protein(s) forming the S-layer in bacteria. The unicellular model cyanobacterium Synechocystis sp. strain PCC 6803 (hereafter S. 6803) also possesses a well-defined S-layer composed of Sll1951 protein. However, the mechanism of its secretion is not completely understood. In the present study, the putative T1SS (Type I secretion system) components, Sll1180 and Sll1181 [inner membrane ABC transporter and membrane fusion protein (MFP), respectively] were characterized for their role in Sll1951 secretion. The corresponding ORFs i.e. sll1180 and sll1181 were inactivated by insertion of a spectinomycin resistance gene. The viability of the homozygous mutants of both the genes indicated dispensability of the corresponding proteins under the experimental conditions. Interestingly, the culture supernatants of the mutants i.e. Δsll1180 and Δsll1181, lacked Sll1951 as observed on SDS-PAGE and confirmed by mass spectrometry. Immunofluorescence delineated a distinct outer ring of Sll1951 in S. 6803 cells only that was further iterated by transmission and scanning electron microscopy. The loss of S-layer imparted an aggregative phenotype to both the mutants. Surprisingly, Δsll1181 cells showed increased sensitivity to different antibiotics indicating a role in multidrug efflux. This is the first report establishing Sl1180 and Sll1181 proteins as partners of the previously characterized Slr1270, for Sll1951 secretion and thus S-layer biogenesis in S. 6803. Sll1181 (in conjunction with Slr1270) also acts as MFP in multidrug efflux along with a yet uncharacterized inner membrane protein.

Critical access hospital ED to quaternary medical center: successful implementation of an integrated Picture Archiving and Communications System for patient transfers by air and sea.

PURPOSE: The purpose of this study was to investigate the role of imaging in transfers between an island Critical Access Hospital (CAH) emergency department (ED) and a quaternary care hospital. METHODS: Electronic medical records were reviewed to identify all patients who were transferred from an island CAH to our quaternary care hospital in 2012 and 2013. Medical history, transfer diagnosis, and the type of imaging performed at the CAH prior to transfer were reviewed. RESULTS: During the study period, a total of 22075 ED visits were made to the CAH and 696 (3.2%) of these patients were transferred for higher level of care, with 424 (60.9%) of the patients transferred to our quaternary care hospital. The most common reasons for transfer were cardiac (121; 28.5%), trauma (82; 19.3%), gastrointestinal (63; 14.9%), and neurologic conditions (54; 12.7%). 349 patients (82.3%) had imaging prior to transfer (56.4% radiograph, 33.5% computed tomography, 4.7% magnetic resonance imaging, 8.0% ultrasound). Of patients that had imaging, 53.6% had positive imaging findings related to the transfer diagnosis, and patients transferred for noncardiac etiologies were significantly more likely to have imaging findings related to their transfer diagnosis compared with patients transferred for cardiac etiologies (72.9% vs 6.9%, respectively; P< .0001). CONCLUSION: Approximately 3 of every 100 ED visits to the rural CAH required transfer for higher level of care, with nearly three-quarters of noncardiac transferred patients having a positive imaging finding related to the reason for transfer.

Management of Hepatocellular Adenoma: Recent Advances.

Hepatocellular adenoma (HCA) is a rare benign liver cell neoplasm that occurs more frequently in young women with a history of prolonged use of oral contraceptives. Surgical resection is considered because of the risk of hemorrhage in 25% and of malignant transformation in 5% of patients with HCA. HCA is a heterogeneous disease comprising 3 subtypes with distinct molecular and complication profiles. The inflammatory or telangiectatic subtype is at increased risk for hemorrhage, the ß-catenin-activated subtype is at increased risk for malignant transformation, and the hepatocyte nuclear factor-1α-inactivated or steatotic subtype is at the least risk for complications. One-third of the patients with HCA have multiple tumors on imaging with no increased risk of complications. Magnetic resonance imaging is the modality of choice for the diagnosis and subtype characterization of HCA. Systematic resection of HCA is recommended in male patients owing to the higher incidence of malignant transformation, and surgical excision in women should be reserved for tumors 5 cm or larger associated with an increased risk of complications. Cessation of hormonal therapy and radiologic surveillance in women with HCA tumors smaller than 5 cm shows that the vast majority of HCA remain stable or undergo spontaneous regression. Percutaneous core needle biopsy is of limited value because the therapeutic strategy is based primarily on patient sex and tumor size. Transarterial embolization is the initial treatment for HCA complicated by hemorrhage. Pregnancy should not be discouraged in the presence of HCA, however, frequent sonographic surveillance is recommended.

Assessment of Filtered Back Projection, Adaptive Statistical, and Model-Based Iterative Reconstruction for Reduced Dose Abdominal Computed Tomography.

PURPOSE: To compare standard of care and reduced dose (RD) abdominal computed tomography (CT) images reconstructed with filtered back projection (FBP), adaptive statistical iterative reconstruction (ASIR), model-based iterative reconstruction (MBIR) techniques. MATERIALS AND METHODS: In an Institutional Review Board-approved, prospective clinical study, 28 patients (mean age 59 ± 13 years ), undergoing clinically indicated routine abdominal CT on a 64-channel multi-detector CT scanner, gave written informed consent for acquisition of an additional RD (<1 milli-Sievert) abdomen CT series. Sinogram data of RD series were reconstructed with FBP, ASIR, and MBIR and compared with FBP images of standard dose abdomen CT. Two radiologists performed randomized, independent, and blinded comparison for lesion detection, lesion margin, visibility of normal structures, and diagnostic confidence. RESULTS: Mean CT dose index volume was 10 ± 3.4 mGy and 1.3 ± 0.3 mGy for standard and RD CT, respectively. There were 73 "true positive" lesions detected on standard of care CT. Nine lesions (<8 mm in size) were missed on RD abdominal CT images which included liver lesions, liver cysts, kidney cysts, and paracolonic abscess. These lesions were missed regardless of patient size and types of iterative reconstruction techniques used for reconstruction of RD data sets. The visibility of lesion margin was suboptimal in (23/28) patients with RD FBP, (15/28) patients with RD ASIR, and (14/28) patients with RD MBIR compared to standard of care FBP images (P < 0.001). Diagnostic confidence for the assessment of lesions on RD images was suboptimal in most patients regardless of iterative reconstruction techniques. CONCLUSIONS: Clinically significant lesions (< 8 mm) can be missed on abdominal CT examinations acquired at a CT dose index volume of 1.3 mGy regardless of patients' size and reconstruction techniques (FBP, ASIR, and MBIR).

Imaging of hepatobiliary involvement in sarcoidosis.

Sarcoidosis is mainly a disease of the respiratory system; however, several other organ systems may be affected in the course of the disease. Liver is one of the most frequently affected organs in the setting of sarcoidosis after lungs and lymph nodes. Microscopic hepatic involvement is common in these patients but is mostly clinically silent. However, in a significant portion of these patients, macroscopic findings can be detected in the course of the disease, and these findings may easily be confused with other benign and malignant conditions of the liver. The purposes of this article are to briefly summarize the clinical findings and the underlying pathophysiology of sarcoidosis and detailed presentation of the radiologic findings of hepatic involvement in this disease. We subgrouped the imaging findings based on the location and the radiologic appearance of the hepatic involvement. We tried to provide images that would enable the readers to link the imaging findings with the underlying pathology and clinical symptoms.

Imaging utilization from the ED: no difference between observation and admitted patients.

OBJECTIVES: This study aims to determine the use of diagnostic imaging in emergency department (ED) observation units, particularly relative to inpatients admitted from the ED. STUDY DESIGN: Retrospective, descriptive analysis. METHODS: Our database of ED patients was retrospectively reviewed to identify patients managed in the observation unit or admitted to inpatient services. In February 2014, we randomly selected 105 ED observation patients and 108 patients admitted to inpatient services from the ED. Electronic medical records were reviewed to assess diagnosis as well as type and quantity of imaging tests obtained. RESULTS: Eighty (76%) ED observation patients underwent imaging tests (radiographs, 39%; computed tomography, 25%; magnetic resonance imaging (MRI), 24%; ultrasound, 8%; other, 4%); 85 inpatients (79%) underwent imaging tests while in the ED (radiographs, 52%; computed tomography, 30%; MRI, 8%; ultrasound, 9%; other, 1%). There was no significant difference in overall imaging use between ED observation patients and inpatients, but ED observation patients were more likely to undergo MRI (P=.0243). The most common presenting diagnoses to the ED observation unit were neurologic complaints (25%), abdominal pain (17%), and cardiac symptoms (16%). CONCLUSION: There is no difference in the overall use of imaging in patients transferred to the ED observation unit vs those directly admitted from the ED. However, because ED observation unit patients tend to be accountable for a higher proportion of their health care bill, the impact of imaging in these patients is likely substantive.

Interventional Radiology Peer Learning Platform and Adverse Event Reporting (IR-PEER): Initial Experience Implementing a Team-based Novel Peer Learning System in Interventional Radiology.

Although the transition from peer review to peer learning has had favorable outcomes in diagnostic radiology, experience with implementing a team-based peer review system in interventional radiology (IR) remains limited. Peer learning systems benefit diverse IR teams composed of multiple clinical roles and could contribute value in archiving events that have potential educational value. With multiple stakeholder input from clinical roles within the IR division at our institution (ie, radiologic technologists, nurses, advanced practice providers, residents, fellows, and attending physicians), we launched a HIPAA-compliant secure IR complication and learning opportunity reporting platform in April 2022. Case submissions were monitored over the subsequent 24 weeks, with monthly dashboard reports provided to departmental leadership. Preintervention and postintervention surveys were used to assess the impact of the peer learning platform and adverse event reporting in IR (IR-PEER) on perceptions of complication reporting in the IR division across clinical roles. Ninety-two peer learning submissions were collected for a weekly average ± standard error of 3.8 ± 0.6 submissions per week, and an additional 26 submissions were collected as part of the division's ongoing monthly complication review conference, for a total of 98 unique total case references. A total of 64.1% of submissions (59 of 92) involved a complication and/or adverse event, and 35.9% of submissions (33 of 92) identified a learning opportunity (no complication or adverse event). Nurses reported that IR-PEER made the complication-reporting process easier (P = .01), and all clinical roles reported that IR-PEER improved the overall process of complication reporting. Peer learning frameworks such as IR-PEER provide a more equitable communication platform for multidisciplinary teams to capture and archive learning opportunities that support quality and safety improvement efforts.

Reducing Intravenous Contrast Utilization for CT: A Health System-Wide Intervention With Sustained Impact.

OBJECTIVE: To determine the volume of intravenous iodinated contrast media used for CT before, during, and after the global iohexol shortage over a total of 17 months at a multisite health system. METHODS: This retrospective study included all patients who underwent CT at a large health system with 12 sites. Standardized contrast doses for 13 CT examinations were implemented May 23, 2022. Mean contrast utilization per CT encounter was compared between three periods (preintervention: January 1, 2022, to May 22, 2022; intervention: May 23, 2022, to September 11, 2022; postintervention: September 12, 2022, to June 30, 2023). Contrast doses and CT encounter data were extracted from the enterprise data warehouse. Categorical variables were compared with a χ2 test, and continuous variables were compared with a two-tailed t test. Multivariable linear regression assessed significance, with coefficients noted to determine magnitude and direction of effect. RESULTS: Preintervention, there were 152,009 examinations (87,722 with contrast [57.7%]); during the intervention, there were 120,031 examinations (63,217 with contrast [52.7%]); and during the postintervention, there were 341,862 examinations (194,231 with contrast [56.8%]). Preintervention, mean contrast dose was 89.3 mL per examination, which decreased to 78.0 mL after standardization (Δ of -12.7%) (P < .001). This decrease continued throughout the intervention and persisted in the postintervention period (80.4 mL; Δ -10.0%, P < .001). On multivariable analysis, patient weight, sex, and performing site were all associated with variations in contrast dose. Most but not all sites (9 of 12) sustained the decreased contrast media dose in the postintervention period. DISCUSSION: Implementing standardized contrast media dosing for commonly performed CT examinations led to a rapid decrease in contrast media utilization, which persisted over 1 year.

Magnetic Resonance Imaging, Clinical, and Biopsy Findings in Suspected Prostate Cancer: A Systematic Review and Meta-Analysis.

Importance: Multiple strategies integrating magnetic resonance imaging (MRI) and clinical data have been proposed to determine the need for a prostate biopsy in men with suspected clinically significant prostate cancer (csPCa) (Gleason score ≥3 + 4). However, inconsistencies across different strategies create challenges for drawing a definitive conclusion. Objective: To determine the optimal prostate biopsy decision-making strategy for avoiding unnecessary biopsies and minimizing the risk of missing csPCa by combining MRI Prostate Imaging Reporting & Data System (PI-RADS) and clinical data. Data Sources: PubMed, Ovid MEDLINE, Embase, Web of Science, and Cochrane Library from inception to July 1, 2022. Study Selection: English-language studies that evaluated men with suspected but not confirmed csPCa who underwent MRI PI-RADS followed by prostate biopsy were included. Each study had proposed a biopsy plan by combining PI-RADS and clinical data. Data Extraction and Synthesis: Studies were independently assessed for eligibility for inclusion. Quality of studies was appraised using the Quality Assessment of Diagnostic Accuracy Studies 2 tool and the Newcastle-Ottawa Scale. Mixed-effects meta-analyses and meta-regression models with multimodel inference were performed. Reporting of this study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Main Outcomes and Measures: Independent risk factors of csPCa were determined by performing meta-regression between the rate of csPCa and PI-RADS and clinical parameters. Yields of different biopsy strategies were assessed by performing diagnostic meta-analysis. Results: The analyses included 72 studies comprising 36 366 patients. Univariable meta-regression showed that PI-RADS 4 (ß-coefficient [SE], 7.82 [3.85]; P = .045) and PI-RADS 5 (ß-coefficient [SE], 23.18 [4.46]; P < .001) lesions, but not PI-RADS 3 lesions (ß-coefficient [SE], -4.08 [3.06]; P = .19), were significantly associated with a higher risk of csPCa. When considered jointly in a multivariable model, prostate-specific antigen density (PSAD) was the only clinical variable significantly associated with csPCa (ß-coefficient [SE], 15.50 [5.14]; P < .001) besides PI-RADS 5 (ß-coefficient [SE], 9.19 [3.33]; P < .001). Avoiding biopsy in patients with lesions with PI-RADS category of 3 or less and PSAD less than 0.10 (vs <0.15) ng/mL2 resulted in reducing 30% (vs 48%) of unnecessary biopsies (compared with performing biopsy in all suspected patients), with an estimated sensitivity of 97% (vs 95%) and number needed to harm of 17 (vs 15). Conclusions and Relevance: These findings suggest that in patients with suspected csPCa, patient-tailored prostate biopsy decisions based on PI-RADS and PSAD could prevent unnecessary procedures while maintaining high sensitivity.

CT Pulmonary Angiogram Clinical Pretest Probability Tool: Impact on Emergency Department Utilization.

OBJECTIVE: Currently, CT pulmonary angiogram (CTPA) for evaluating acute pulmonary embolism (PE) in emergency departments (EDs) is overused and with low yields. The goal of this study is to assess the impact of an evidence-based clinical decision support (CDS) tool, aimed at optimizing appropriate use of CTPA for evaluating PE. METHODS: The study was performed at EDs in a large health care system and included nine academic and community hospitals. The primary outcome was the percent difference in utilization (number of CTPAs performed per number of ED visits) and secondary outcome was yield (percentage of CTPAs positive for acute PE), comparing 12 months before (June 1, 2021, to May 31, 2022) versus 12 months after (June 1, 2022, to May 31, 2023) a systemwide implementation of the CDS. Univariate and multivariable analyses using logistic regression were performed to assess factors associated with diagnosis of acute PE. Statistical process control charts were used to assess monthly trends in utilization and yield. RESULTS: Among 931,677 visits to EDs, 28,101 CTPAs were performed on 24,675 patients. In all, 14,825 CTPAs were performed among 455,038 visits (3.26%) pre-intervention and 13,276 among 476,639 visits (2.79%) postintervention, a 14.51% relative decrease in CTPA utilization (χ2, P < .001). CTPA yield remained unchanged (1,371 of 14,825 = 9.25% pre- versus 1,184 of 13,276 = 8.92% postintervention; χ2, P = .34). Patients with coronavirus disease of 2019 diagnosis before CTPA had higher probability of acute PE. Statistical process control charts demonstrated seasonal variation in utilization (Friedman test, P = .047). DISCUSSION: Implementing a CDS based on validated decision rules was associated with a significant reduction in CTPA utilization. The change was immediate and sustained for 12 months postintervention.

Erratum to Correct Informed Patient Consent Statement.

[This corrects the article DOI: 10.17925/EE.2023.19.2.6.].

The spectrum of IgG4-related disease in the abdomen and pelvis.

OBJECTIVE: IgG4-related disease was not recognized as a specific clinical entity until 2003 when extrapancreatic lesions were reported in patients with autoimmune pancreatitis. IgG4-related disease is characterized by elevated serum IgG4 levels and infiltration of the target organ by IgG4-positive plasma cells. The complete gamut of visceral involvement is still being outlined. The purpose of this article is to highlight the plethora of lesions under the spectrum of IgG4-related disease of the abdomen and pelvis, describe their imaging appearances on multimodality cross-sectional imaging, and discuss the differential diagnoses. CONCLUSION: It is important for radiologists to recognize the multiorgan involvement and few classic features of IgG4-related disease that often tend to simulate malignancy.