Referring Physicians Assess the Quality of Outpatient Diagnostic Imaging Services: Development and Psychometric Evaluation of a Questionnaire.

GOAL: In order to ensure high-quality cooperation between referring physicians and imaging services, it is important to assess the quality of imaging services as perceived by referring physicians. The present study aimed to develop and validate a questionnaire for referring physicians to assess the quality of outpatient diagnostic imaging services. MATERIALS & METHODS: The questionnaire was developed by discussing and modifying an existing instrument by the German Association of Surgeons. After qualitative pretesting, the instrument was tested with physicians referring to four outpatient diagnostic imaging services in Switzerland. The results were first assessed using descriptive statistics. The final instrument was tested for validity using the concept of known-groups validity. The hypothesis underlying this procedure was that physicians referring frequently to services estimated the quality of these services to be higher than physicians who referred less often to services. The differences in ratings were assessed using a one-sided two-sample Wilcoxon test. The final questionnaire was tested for internal consistency and reliability using Cronbach's Alpha. RESULTS: Results show a high level of satisfaction of referring physicians with the relevant services but also potential for quality improvement initiatives. The psychometric evaluation of the final questionnaire shows that it is a valid instrument, showing significant differences between the ratings of physicians referring with high and low frequency. Furthermore, the instrument proves to be consistent and reliable. CONCLUSION: The final instrument presents a valid, consistent and reliable option for assess the quality of outpatient diagnostic imaging services as perceived by referring physicians. Results can be used as a basis for quality improvement. KEY POINTS: · A newly developed questionnaire assesses the quality of outpatient diagnostic imaging services as perceived by referring physicians. The questionnaire was developed and tested in Switzerland.. · Psychometric evaluation showed the questionnaire to be a valid, consistent and reliable instrument.. · Results are of interest for imaging services as well as for initiatives encompassing several services.. CITATION FORMAT: · Jossen M, Valeri F, Heilmaier C et al. Referring Physicians Assess the Quality of Outpatient Diagnostic Imaging Services: Development and Psychometric Evaluation of a Questionnaire. Fortschr Röntgenstr 2019; 191: 725 - 731.

Establishing Local Diagnostic Reference Levels in IR Procedures with Dose Management Software.

PURPOSE: To obtain local diagnostic reference levels (DRLs) in diagnostic and therapeutic IR procedures with dose management software to improve radiation protection. MATERIALS AND METHODS: Dose data of various vascular and nonvascular IR procedures performed within 18 months were collected and analyzed with dose management software. To account for different levels of complexity, procedures were subdivided into simple, standard, and difficult procedures as graded by interventional radiologists. Based on these analyses, local DRLs (given as kerma-area product [KAP]) were proposed. Comparison with dose data of others was conducted, and Spearman correlation coefficients were calculated to evaluate relationships between dose metrics. RESULTS: Analysis included 1,403 IR procedures (simple/standard/difficult, n = 346/702/355). Within the same procedure, KAP tended to increase with level of complexity. Overall, very strong correlation between KAP (Gy ∙ cm2) and cumulative air kerma (KA,R; Gy) was observed, and moderate to strong correlation between KAP and time and KA,R and time was observed. For simple procedures, strong correlation was seen between KAP and time and KA,R and time; for standard and difficult procedures, only moderate correlation was seen. Correlation between KAP and time and KA,R and time was strong in nonvascular procedures but only moderate in vascular procedures. CONCLUSIONS: Dose management software can be used to derive local DRLs for various IR procedures, taking into consideration different levels of complexity. Proposed local DRLs can contribute to obtaining detailed national DRLs as part of efforts to improve patients' radiation protection further.

Does Real-Time Monitoring of Patient Dose With Dose Management Software Increase CT Technologists' Radiation Awareness?

OBJECTIVE: Dose management software can be used to increase patient safety. The purpose of the current study was to evaluate whether real-time monitoring of patient dose in CT examinations increases CT technologists' dose awareness. MATERIALS AND METHODS: Dose data of two scanners (clinical routine CT scanner, mainly outpatients; emergency CT scanner, predominantly emergency department and ICU patients) were analyzed before (period 1) and after (period 2) dose management software was implemented in clinical routine and technologists were advised to check for dose notifications (dose values above reference levels) after each examination (i.e., real-time monitoring). To assess statistically significant differences between both the scanners and the study periods, we used chi-square tests. RESULTS: A total of 6413 examinations were performed (period 1 = 3214 examinations, period 2 = 3199 examinations). Dose notifications were mainly because of patient miscentering (period 1 = 45% of examinations, period 2 = 23%), overweight patients (period 1 = 35%, period 2 = 49%), and scanning repetition (period 1 = 10%, period 2 = 15%). Overall, the number of dose notifications significantly declined in period 2 (period 1, n = 210; period 2, n = 120; p < 0.001). Miscentering was more often seen on the clinical routine CT examinations (period 1 = 46%, period 2 = 23%) than on the emergency CT examinations (period 1 = 44%, period 2 = 22%) and occurred significantly less frequently on both scanners in period 2 (period 1: n = 94; period 2: n = 27; p < 0.001). The relative values of dose notifications due to overweight patients or scanning repetition were higher in period 2, but these differences did not reach statistical significance (p > 0.05). CONCLUSION: Real-time monitoring of patient dose with dose management software increases CT technologists' dose awareness and leads to a reduced number of dose notifications due to human error.

Combined Use of a Patient Dose Monitoring System and a Real-Time Occupational Dose Monitoring System for Fluoroscopically Guided Interventions.

PURPOSE: To determine the effect on patient radiation exposure of the combined use of a patient dose monitoring system and real-time occupational dose monitoring during fluoroscopically guided interventions (FGIs). MATERIALS AND METHODS: Patient radiation exposure, in terms of the kerma area product (KAP; Gy ∙ cm(2)), was measured in period 1 with a patient dose monitoring system, and a real-time occupational dose monitoring system was additionally applied in period 2. Mean/median KAP in 19 different types of FGIs was analyzed in both periods for two experienced interventional radiologists combined as well as individually. Patient dose and occupational dose were correlated, applying Pearson and Spearman correlation coefficients. RESULTS: Although FGIs were similar in numbers and types over both periods, a substantial decrease was found for period 2 in total mean ± SD/median KAP for both operators together (period 1, 47 Gy ∙ cm(2) ± 67/41 Gy ∙ cm(2); period 2, 37 Gy ∙ cm(2) ± 69/34 Gy ∙ cm(2)) as well as for each individual operator (for all, P < .05). Overall, KAP declined considerably in 15 of 19 types of FGIs in period 2. Mean accumulated dose per intervention was 4.6 µSv, and mean dose rate was 0.24 mSv/h. There was a strong positive correlation between patient and occupational dose (r = 0.88). CONCLUSIONS: Combined use of a patient dose monitoring system and a real-time occupational dose monitoring system in FGIs significantly lessens patient and operator doses.

Improving Patient Safety: Implementing Dose Monitoring Software in Fluoroscopically Guided Interventions.

PURPOSE: To assess whether dose monitoring software can be successfully implemented in fluoroscopically guided interventions and to provide dose data based on levels of complexity. MATERIALS AND METHODS: After launching the software (DoseWatch; GE Healthcare Systems, Buc, France), data were collected for 6 months and analyzed by means of kerma-area product (KAP; Gy/cm(2)), cumulative air kerma (KA,R; Gy), and fluoroscopic time (minutes). Data analysis was executed by level of complexity as graded by the operators. Complexity grading was based on factors such as tortuosity and calcification of vessel, variant anatomy, and patient cooperation. RESULTS: The software successfully transferred dose data of 357 fluoroscopically guided procedures. KAP was 0.238-400 Gy/cm(2) with mean, median, and 75th percentile values of 46.0 Gy/cm(2), 163.2 Gy/cm(2), and 541.1 Gy/cm(2) (KA,R, 0.013-4.1 Gy; mean, median, 75th percentile, 0.48 Gy, 0.97 Gy, 3.98 Gy). Highest dose values were seen in transarterial chemoembolization (KAP mean, median, 75th percentile, 229.5 Gy/cm(2), 216.4 Gy/cm(2), 299.9 Gy/cm(2); KA,R mean, median, 75th percentile, 1.9 Gy, 1.2 Gy, 1.7 Gy). Analysis revealed that the level of complexity strongly correlated with KAP (r = 0.88; P < .001) whereas there was no direct correlation of KAP and fluoroscopy time. During the same intervention, KA,R and fluoroscopy time increased with level of complexity, but the correlation was not statistically significant. CONCLUSIONS: Implementation of dose monitoring software in fluoroscopically guided interventions can be successfully accomplished, and it facilitates data comparison.

Single breath-hold magnetic resonance cine imaging for fast assessment of global and regional left ventricular function in clinical routine.

OBJECTIVE: To evaluate a TGRAPPA (temporal parallel acquisition technique)-accelerated, single breath-hold multi-slice cine imaging approach for the assessment of left ventricular (LV) function. METHODS: One hundred eleven patients were examined at 1.5 T. Cine imaging was performed with single-slice breath-hold acquisitions in short-axis orientation using a SSFP (TR 2.63 ms, TE 1.12 ms, FA 72°) sequence and a TGRAPPA SSFP (TR 2.66 ms, TE 1.11 ms, FA 72°, AF 3) sequence, which covered the entire LV in multiple short-axis slices during a single breath-hold. End-diastolic (EDV), end-systolic (ESV), stroke volumes (SV), ejection fraction (EF), muscle mass (MM) and regional wall motion were assessed for both data sets. RESULTS: Single breath-hold imaging was feasible in 108 patients. Excellent correlations were observed for all volumetric parameters derived from both data sets (all r > 0.97). While EDV and ESV showed marginally lower values for single breath-hold imaging (EDV: -1.6 ± 7.9 ml; ESV: -1.8 ± 6.0 ml, p < 0.05), no differences were observed for SV, EF, MM and regional wall motion assessment. Single breath-hold imaging required significant shorter acquisition times (28 ± 6 s vs. 335 ± 87 s). CONCLUSION: TGRAPPA-accelerated multi-slice SSPF imaging allows for fast and accurate assessment of regional and global LV function within a single breath-hold.

Focal liver lesions: detection and characterization at double-contrast liver MR Imaging with ferucarbotran and gadobutrol versus single-contrast liver MR imaging.

PURPOSE: To retrospectively compare, in a multiobserver study, double-contrast-material (sequential administration of ferucarbotran and gadobutrol) magnetic resonance (MR) imaging with single-contrast-material ferucarbotran-enhanced and dynamic postferucarbotran gadobutrol-enhanced MR imaging for the detection and characterization of benign and malignant focal liver lesions. MATERIALS AND METHODS: This study was institutional review board approved, and the requirement for informed patient consent was waived. Eighty-nine patients with a total of 128 focal liver lesions underwent double-contrast liver MR imaging (nonenhanced, ferucarbotran-enhanced, and dynamic postferucarbotran gadobutrol-enhanced MR imaging performed during one session). Four readers independently reviewed the data sets during three reading sessions focused on focal liver lesion detection and characterization: In session 1, the nonenhanced and dynamic postferucarbotran gadobutrol-enhanced images obtained at double-contrast MR imaging were analyzed. In session 2, the nonenhanced and ferucarbotran-enhanced images were analyzed. In session 3, all MR images were analyzed together. The diagnostic performance of each MR technique and each reader was evaluated by using receiver operating characteristic (ROC) analysis; differences between postferucarbotran gadobutrol-enhanced, ferucarbotran-enhanced, and double-contrast MR imaging were assessed at Wilcoxon signed rank testing; and interreader agreement was assessed at Cohen kappa analysis. Histopathologic confirmation or an unchanged clinical course or MR finding was the reference standard. RESULTS: The four readers' detection of the benign and malignant lesions was not significantly different (P > or = .11) between the three MR techniques. The benign and malignant focal liver lesions were differentiated with significantly higher confidence (P < or = .01) on the double-contrast (area under ROC curve [A(z)] = 0.988) and ferucarbotran-enhanced (A(z) = 0.985) MR images than on the dynamic gadobutrol-enhanced images (A(z) = 0.963). Accuracy in the diagnosis of hepatocellular carcinoma (HCC) was highest (P = .02) and confidence in the final diagnosis of HCC (P = .001) or metastasis (P = .049) was significantly higher with double-contrast imaging. CONCLUSION: In select cases, double-contrast MR imaging can improve diagnostic accuracy and increase confidence in characterizing focal liver lesions as HCC or metastasis.

The proinflammatory cytokine interleukin 1beta and hypoxia cooperatively induce the expression of adrenomedullin in ovarian carcinoma cells through hypoxia inducible factor 1 activation.

Adrenomedullin (ADM) is a potent hypotensive peptide produced by macrophages and endothelial cells during ischemia and sepsis. The molecular mechanisms that control ADM gene expression in tumor cells are still poorly defined. It is known, however, that hypoxia potently increases ADM expression by activation of the transcription factor complex hypoxia inducible factor 1 (HIF-1). Proinflammatory cytokines produced by tumor invading macrophages likewise activate expression of ADM. Herein, we show that apart from hypoxia, the proinflammatory cytokine interleukin 1beta (IL-1beta) induced the expression of ADM mRNA through activation of HIF-1 under normoxic conditions and enhanced the hypoxia-induced expression in the human ovarian carcinoma cell line OVCAR-3. IL-1beta significantly increased accumulation and nuclear translocation of HIF-1alpha under normoxic conditions and amplified hypoxic HIF-1 activation. IL-1beta treatment affected neither HIF-1alpha mRNA levels nor the hydroxylation status of HIF-1alpha and, thus, stability of the protein. Instead cycloheximide effectively prevented the increase in HIF-1alpha protein, indicating a stimulatory effect of IL-1beta on HIF-1alpha translation. Finally, treatment of HIF-1alpha with short interfering RNA revealed a significant role for HIF-1 in the IL-1beta-dependent stimulation of ADM expression.