Predictors of Completion of Clinically Necessary Radiologist-Recommended Follow-Up Imaging: Assessment Using an Automated Closed-Loop Communication and Tracking Tool.

BACKGROUND. Patients with adverse social determinants of health may be at increased risk of not completing clinically necessary follow-up imaging. OBJECTIVE. The purpose of this study was to use an automated closed-loop communication and tracking tool to identify patient-, referrer-, and imaging-related factors associated with lack of completion of radiologist-recommended follow-up imaging. METHODS. This retrospective study was performed at a single academic health system. A tool for automated communication and tracking of radiologist-recommended follow-up imaging was embedded in the PACS and electronic health record. The tool prompted referrers to record whether they deemed recommendations to be clinically necessary and assessed whether clinically necessary follow-up imaging was pursued. If imaging was not performed within 1 month after the intended completion date, the tool prompted a safety net team to conduct further patient and referrer follow-up. The study included patients for whom a follow-up imaging recommendation deemed clinically necessary by the referrer was entered with the tool from October 21, 2019, through June 30, 2021. The electronic health record was reviewed for documentation of eventual completion of the recommended imaging at the study institution or an outside institution. Multivariable logistic regression analysis was performed to identify factors associated with completion of follow-up imaging. RESULTS. Of 5856 recommendations entered during the study period, the referrer agreed with 4881 recommendations in 4599 patients (2929 women, 1670 men; mean age, 61.3 ± 15.6 years), who formed the study sample. Follow-up was completed for 74.8% (3651/4881) of recommendations. Independent predictors of lower likelihood of completing follow-up imaging included living in a socioeconomically disadvantaged neighborhood according to the area deprivation index (odds ratio [OR], 0.67 [95% CI, 0.54-0.84]), inpatient (OR, 0.25 [95% CI, 0.20-0.32]) or emergency department (OR, 0.09 [95% CI, 0.05-0.15]) care setting, and referrer surgical specialty (OR, 0.70 [95% CI, 0.58-0.84]). Patient age, race and ethnicity, primary language, and insurance status were not independent predictors of completing follow-up (p > .05). CONCLUSION. Socioeconomically disadvantaged patients are at increased risk of not completing recommended follow-up imaging that referrers deem clinically necessary. CLINICAL IMPACT. Initiatives for ensuring completion of follow-up imaging should be aimed at the identified patient groups to reduce disparities in missed and delayed diagnoses.

Real-Time and Delayed Imaging of Tissue and Effects of Prostate Tissue Ablation.

PURPOSE OF REVIEW: Prostate ablation is increasingly being utilized for the management of localized prostate cancer. There are several energy modalities with varying mechanism of actions which are currently used for prostate ablation. Prostate ablations, whether focal or whole gland, are performed under ultrasound and/or MRI guidance for appropriate treatment plan execution and monitoring. A familiarity with different intraoperative imaging findings and expected tissue response to these ablative modalities is paramount. In this review, we discuss the intraoperative, early, and delayed imaging findings in prostate from the effects of prostate ablation. RECENT FINDINGS: The monitoring of ablation both during and after the therapy became increasingly important due to the precise targeting of the target tissue. Recent findings suggest that real-time imaging techniques such as MRI or ultrasound can provide anatomical and functional information, allowing for precise ablation of the targeted tissue and increasing the effectiveness and precision of prostate cancer treatment. While intraprocedural imaging findings are variable, the follow-up imaging demonstrates similar findings across various energy modalities. MRI and ultrasound are two of the frequently used imaging techniques for intraoperative monitoring and temperature mapping of important surrounding structures. Follow-up imaging can provide valuable information about ablated tissue, including the success of the ablation, presence of residual cancer or recurrence after the ablation. It is critical and helpful to understand the imaging findings during the procedure and at different follow-up time periods to evaluate the procedure and its outcome.

Differentiating Radiation-Induced Necrosis from Tumor Progression After Stereotactic Radiosurgery for Brain Metastases, Using Evaluation of Blood Flow with Arterial Spin Labeling (ASL): The Importance of Setting a Baseline.

OBJECTIVE: This study evaluated the usefulness of arterial spin labeling (ASL) for assessment of tumor blood flow (TBF) and cerebral blood flow (CBF) before Gamma Knife surgery (GKS) for intracranial metastases, in order to analyze the variability of perfusion characteristics at baseline and to reveal how these data may impact differentiation of radiation-induced effects from tumor progression during follow-up. METHODS: Radiological data from 87 patients with intracranial metastases of solid cancers, who underwent TBF/CBF analysis by means of ASL at the Hawaii Advanced Imaging Institute between 2015 and 2018 both before and after GKS, were reviewed retrospectively. Only cases with a largest tumor diameter of ≥10 mm were included in the study cohort (N = 53). RESULTS: In comparison with CBF in the healthy contralateral cerebral cortex, TBF before GKS was greater in 32 cases (60%), lesser in 7 cases (13%), and equivalent in 14 cases (27%). There was significant variability in TBF both within and between histologically different groups of tumors. CONCLUSION: Since, at baseline, approximately 40% of intracranial metastases have TBF that is lesser or equivalent to CBF, increased blood flow in the contrast-enhancing lesion after GKS may have insufficient sensitivity for identification of tumor progression. Availability of baseline TBF data may significantly facilitate differential diagnosis in such cases.

Natural course of acquired pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation-Is routine follow-up imaging indicated or not?

INTRODUCTION: Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). The aim of the present study was to analyze the natural course of RFA-induced PVS with regard to the grade of stenosis, clinical symptoms, and mortality during long-term follow-up. METHODS AND RESULTS: All patients with follow-up imaging for radiofrequency-induced untreated PVS were retrospectively assessed. From 2004 to 2017, the total rate of PVS following AF ablation in our center was 0.78% (87 of 11 103). Thirty-eight patients with a total of 54 untreated PVS underwent follow-up including imaging scan. The mean degree of stenosis at the time of diagnosis was 57% ± 27% vs 45% ± 35% (P = .05) after a mean follow-up of 43 ± 31 months. There was a shift in severity of the PVS: 18 of 54 (33%) vs 16 of 54 (30%) severe PVS, 19 of 54 (35%) vs 10 of 54 (18%) moderate PVS, and 17 of 54 (32%) vs 28 of 54 (52%) mild PVS (P = .0001). The mean symptom score decreased significantly during follow-up (1.8 ± 1.0 vs 0.4 ± 0.5, P = .0001). Each of the four patients with progression of PVS underwent another pulmonary vein isolation for AF recurrence following pulmonary vein reconduction during follow-up period. CONCLUSION: This study showed a spontaneous reduction in stenosis grade and symptoms of PVS over a 3.5-year follow-up. Consequently, routine follow-up imaging of PVS seems not to be necessary. However, additional RF energy delivery to stenotic pulmonary veins should be avoided if possible. In case of conduction recovery, the ablation line should be done wide-antrally and follow-up imaging of PVS is recommended.

Automated Tracking of Follow-Up Imaging Recommendations.

OBJECTIVE. Radiology reports often contain follow-up imaging recommendations. Failure to comply with these recommendations in a timely manner can lead to poor patient outcomes, complications, and legal liability. As such, the primary objective of this research was to determine adherence rates to follow-up recommendations. MATERIALS AND METHODS. Radiology-related examination data, including report text, for examinations performed between June 1, 2015, and July 31, 2017, were extracted from the radiology departments at the University of Washington (UW) and Lahey Hospital and Medical Center (LHMC). The UW dataset contained 923,885 examinations, and the LHMC dataset contained 763,059 examinations. A 1-year period was used for detection of imaging recommendations and up to 14-months for the follow-up examination to be performed. RESULTS. On the basis of an algorithm with 97.9% detection accuracy, the follow-up imaging recommendation rate was 11.4% at UW and 20.9% at LHMC. Excluding mammography examinations, the overall follow-up imaging adherence rate was 51.9% at UW (range, 44.4% for nuclear medicine to 63.0% for MRI) and 52.0% at LHMC (range, 30.1% for fluoroscopy to 63.2% for ultrasound) using a matcher algorithm with 76.5% accuracy. CONCLUSION. This study suggests that follow-up imaging adherence rates vary by modality and between sites. Adherence rates can be influenced by various legitimate factors. Having the capability to identify patients who can benefit from patient engagement initiatives is important to improve overall adherence rates. Monitoring of follow-up adherence rates over time and critical evaluation of variation in recommendation patterns across the practice can inform measures to standardize and help mitigate risk.

Incidental Renal Lesions on Lumbar Spine MRI: Who Needs Follow-Up?

OBJECTIVE: Incidentally discovered renal lesions on lumbar spine MRI are a common occurrence. Many follow-up recommendations are generated by radiologists encountering renal lesions to help characterize the finding as a benign cyst or a more complex, potentially malignant lesion. We hypothesized that analysis of T2-weighted imaging features of incidentally discovered renal lesions could reliably distinguish complex renal lesions from simple cysts. MATERIALS AND METHODS: Two independent readers retrospectively evaluated 149 renal lesions identified on lumbar spine MRI examinations. Presence or absence of a complex renal lesion was determined using T2-weighted imaging only. Using dedicated renal cross-sectional imaging examinations as the reference standard, statistical analysis was performed to determine the accuracy of lumbar spine MRI in predicting a complex and potentially neoplastic renal lesion. RESULTS: Of 149 renal lesions, 115 were simple cysts, and 34 were complex renal lesions (20 Bosniak II cysts, nine renal cell carcinomas, three Bosniak IIF cysts, and two angiomyolipomas). Lumbar spine MRI readers identified 72 lesions as simple cysts and 77 lesions as complex renal lesions. Reader sensitivity for detection of a complex renal lesion on lumbar spine MRI was 94% (95% CI, 80-99%); specificity, 63% (95% CI, 53-72%); positive predictive value, 43% (95% CI, 37-49%); and negative predictive value, 97% (95% CI, 90-99%). Readers correctly identified all neoplastic and potentially neoplastic lesions (≥ Bosniak IIF). Interreader agreement was excellent (κ = 0.84). CONCLUSION: Follow-up imaging may not be required in all cases of incidentally discovered renal lesions on lumbar spine MRI. Analysis of T2-weighted imaging alone appears to reliably rule out neoplastic and potentially neoplastic complex renal lesions.

Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas.

INTRODUCTION: Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making. METHODS: A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon. RESULTS: Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline. CONCLUSION: Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.

The RADCAT-3 system for closing the loop on important non-urgent radiology findings: a multidisciplinary system-wide approach.

The goal of this project was to create a system that was easy for radiologists to use and that could reliably identify, communicate, and track communication of important but non-urgent radiology findings to providers and patients. Prior to 2012, our workflow for communicating important non-urgent diagnostic imaging results was cumbersome, rarely used by our radiologists, and resulted in delays in report turnaround time. In 2012, we developed a new system to communicate important non-urgent findings (the RADiology CATegorization 3 (RADCAT-3) system) that was easy for radiologists to use and documented communication of results in the electronic medical record. To evaluate the performance of the new system, we reviewed our radiology reports before (June 2011-June 2012) and after (June 2012-June 2014) the implementation of the new system to compare utilization by the radiologists and success in communicating these findings. During the 12 months prior to implementation, 250 radiology reports (0.06 % of all reports) entered our workflow for communicating important non-urgent findings. One-hundred percent were successfully communicated. During the 24 months after implementation, 13,158 radiology reports (1.4 % of all reports) entered our new RADCAT-3 workflow (3995 (0.8 % of all reports) during year 1 and 9163 (1.9 % of all reports) during year 2). 99.7 % of those reports were successfully communicated. We created a reliable system to ensure communication of important but non-urgent findings with providers and/or patients and to document that communication in the electronic medical record. The rapid adoption of the new system by radiologists suggests that they found it easy to use and had confidence in its integrity. This system has the potential to improve patient care by improving the likelihood of appropriate follow-up for important non-urgent findings that could become life threatening.

Predictors of residual flow in embolized intracranial ruptured aneurysms at early follow-up.

BACKGROUND: The possibility of recanalization and the need for retreatment are the most important drawbacks of intracranial aneurysm embolization. The purpose of the study was to prospectively analyze the results of early follow-up angiography of embolized ruptured aneurysms in an attempt to determine factors predicting the presence of residual flow. MATERIAL/METHODS: Evaluation included 72 patients with 72 aneurysms, which were followed-up 3 months after the treatment. Analysis of residual flow predictors included: age and gender, clinical state in Hunt-Hess scale, aneurysm localization, aneurysm three dimensions and volume, neck width, sac-to-neck ratio, initial result of embolization, number of coils used and the use of hydrogel coils and stents. RESULTS: Mean sac diameter was 6.5±3.9 mm, and mean neck width was 2.9±1.4 mm. Follow-up angiography presented residual flow in 26 aneurysms (36.1%): class 2 in 8 aneurysms (11.1%), and class 3 in 18 cases (25.0%). Stable aneurysm filling was observed in 45 cases (62.5%), progression of residual flow in 25 cases (34.7%), and regression in 2 cases (2.8%). According to ROC analysis independent predictors of residual flow were aneurysm neck diameter (AUC 0.857, 95% CI: 0.755-0.928, p<0.0001) and sac-to-neck ratio (AUC 0.817, 95% CI: 0.708-0.898, p<0.0001). Cut-off point of the ROC curve was established at 2.8 mm for neck diameter, and 1.73 for sac-to-neck ratio. CONCLUSIONS: Aneurysm neck diameter and sac-to-neck ratio are independently related to the residual flow in embolized ruptured aneurysms at early follow-up.

Utility of structured follow-up imaging after aortic surgery.

BACKGROUND: Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging. METHODS: All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density. RESULTS: After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years. CONCLUSIONS: Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.

Follow-Up Imaging Guidelines for Patients with Stage III Unresectable NSCLC: Recommendations Based on the PACIFIC Trial.

The PACIFIC trial showed a survival benefit with durvalumab through five years in stage III unresectable non-small cell lung cancer (NSCLC). However, optimal use of imaging to detect disease progression remains unclearly defined for this population. An expert working group convened to consider available evidence and clinical experience and develop recommendations for follow-up imaging after concurrent chemotherapy and radiation therapy (CRT). Voting on agreement was conducted anonymously via online survey. Follow-up imaging was recommended for all suitable patients after CRT completion regardless of whether durvalumab is received. Imaging should occur every 3 months in Year 1, at least every 6 months in Year 2, and at least every 12 months in Years 3-5. Contrast computed tomography was preferred; routine brain imaging was not recommended for asymptomatic patients. The medical oncologist should follow-up during Year 1 of durvalumab therapy, with radiation oncologist involvement if pneumonitis is suspected; medical and radiation oncologists can subsequently alternate follow-up. Some patients can transition to the family physician/community primary care team at the end of Year 2. In Years 1-5, patients should receive information regarding smoking cessation, comorbidity management, vaccinations, and general follow-up care. These recommendations provide guidance on follow-up imaging for patients with stage III unresectable NSCLC whether or not they receive durvalumab consolidation therapy.

Usefulness of PETRA-MRA for Postoperative Follow-Up of Stent-Assisted Coil Embolization of Cerebral Aneurysms.

Objective: Image evaluation after stent-assisted coil embolization (SAC) for a cerebral aneurysm is difficult with conventional MRA or CTA because of metal artifacts. Pointwise encoding time reduction with radial acquisition (PETRA)-MRA is a noninvasive imaging examination that can reduce metal artifacts. This study aimed to examine whether PETRA-MRA can be used as a follow-up imaging after SAC. Methods: Twelve patients (eight women and four men; mean age, 66.9 ± 13.2 years) underwent SAC for unruptured aneurysms and were retrospectively evaluated using time-of-flight (TOF)- and PETRA-MRA data from the same follow-up session. Two neurosurgeons independently compared the aneurysm occlusion status and flow visualization score in the stented parent artery (4-point scale, where 4 points represented excellent visualization) between TOF- and PETRA-MRA images. If DSA was performed within 3 months before or after PETRA-MRA, the aneurysm assessment was compared between MRA and DSA. The interobserver agreement for each MRA was evaluated. Results: Nine of the 12 patients underwent DSA within 3 months before and after TOF- and PETRA-MRA. The aneurysm occlusion status on DSA was more consistent with PETRA-MRA (eight of nine cases) than with TOF-MRA (one of nine cases; P = 0.023). The median visualization score of the stented parent artery was significantly higher for PETRA-MRA (4 [interquartile range {IQR} 3-4]) than for TOF-MRA (1 [IQR 1-1], P = 0.003). The interobserver agreement for evaluation of the aneurysm occlusion status and visualization score of the parent artery for PETRA-MRA were excellent (κ = 0.98 and 0.93, respectively). In one case, PETRA-MRA was able to detect aneurysm recurrence, leading to subsequent retreatment. Conclusion: PETRA-MRA is a noninvasive examination that can be used to evaluate the occlusion status of aneurysms after SAC and visualize the stented parent artery. PETRA-MRA is useful for repeated follow-up examinations after SAC.

Impact of an Automated Closed-Loop Communication and Tracking Tool on the Rate of Recommendations for Additional Imaging in Thoracic Radiology Reports.

OBJECTIVE: Assess the effects of feedback reports and implementing a closed-loop communication system on rates of recommendations for additional imaging (RAIs) in thoracic radiology reports. METHODS: In this retrospective, institutional review board-approved study at an academic quaternary care hospital, we analyzed 176,498 thoracic radiology reports during a pre-intervention (baseline) period from April 1, 2018, to November 30, 2018; a feedback report only period from December 1, 2018, to September 30, 2019; and a closed-loop communication system plus feedback report (IT intervention) period from October 1, 2019, to December 31, 2020, promoting explicit documentation of rationale, time frame, and imaging modality for RAI, defined as complete RAI. A previously validated natural language processing tool was used to classify reports with an RAI. Primary outcome of rate of RAI was compared using a control chart. Multivariable logistic regression determined factors associated with likelihood of RAI. We also estimated the completeness of RAI in reports comparing IT intervention to baseline using χ2 statistic. RESULTS: The natural language processing tool classified 3.2% (5,682 of 176,498) reports as having an RAI; 3.5% (1,783 of 51,323) during the pre-intervention period, 3.8% (2,147 of 56,722) during the feedback report only period (odds ratio: 1.1, P = .03), and 2.6% (1,752 of 68,453) during the IT intervention period (odds ratio: 0.60, P < .001). In subanalysis, the proportion of incomplete RAI decreased from 84.0% (79 of 94) during the pre-intervention period to 48.5% (47 of 97) during the IT intervention period (P < .001). DISCUSSION: Feedback reports alone increased RAI rates, and an IT intervention promoting documentation of complete RAI in addition to feedback reports led to significant reductions in RAI rate, incomplete RAI, and improved overall completeness of the radiology recommendations.

Risk Factors Associated With the Development of Acute Peripancreatic Fluid Collections on Follow-Up Imaging After Acute Pancreatitis: What Physicians Need to Know.

OBJECTIVES: This study aims to identify various risk factors for acute peripancreatic fluid collections (APFCs) in patients presenting with acute pancreatitis (AP). METHODS: A blinded retrospective case-control study was conducted at a tertiary care hospital in Riyadh. Data from 327 patients who presented with AP between January 2008 and 2021 were analyzed. Following the application of inclusion/exclusion criteria, the final sample size consisted of 82 patients. Patients were divided into cases and controls based on the presence or absence of APFCs, respectively. APFCs were defined as fluid collections in the peripancreatic region that develop within four weeks of presentation without well-defined walls or solid internal components. Demographic, clinical, and laboratory variables were collected and subjected to multivariate binary regression analysis to assess the odds of developing APFCs. RESULTS: A total of 34 patients were categorized as cases, while 48 patients were controls. A significant association was found between age (P=0.022), total bilirubin (P=0.012), lipase level (P<0.001), albumin level (P=0.038), and lactate dehydrogenase (LDH) (P=0.037) on admission and the odds of developing APFCs. CONCLUSION: Older age, higher levels of bilirubin and lipase, and low levels of albumin and LDH were found to be risk factors for developing APFCs. No other variables were found to be significant. The findings of this study may provide insight into how often clinicians can expect APFCs in patients presenting with AP.

Computer-assisted Reporting and Decision Support Increases Compliance with Follow-up Imaging and Hormonal Screening of Adrenal Incidentalomas.

OBJECTIVE: To assess the impact of using a computer-assisted reporting and decision support (CAR/DS) tool at the radiologist point-of-care on ordering provider compliance with recommendations for adrenal incidentaloma workup. METHOD: Abdominal CT reports describing adrenal incidentalomas (2014 - 2016) were retrospectively extracted from the radiology database. Exclusion criteria were history of cancer, suspected functioning adrenal tumor, dominant nodule size < 1 cm or ≥ 4 cm, myelolipomas, cysts, and hematomas. Multivariable logistic regression models were employed to predict follow-up imaging (FUI) and hormonal screening orders as a function of patient age and sex, nodule size, and CAR/DS use. CAR/DS reports were compared to conventional reports regarding ordering provider compliance with, frequency, and completeness of, guideline-warranted recommendations for FUI and hormonal screening of adrenal incidentalomas using Chi-square test. RESULT: Of 174 patients (mean age 62.4; 51.1% women) with adrenal incidentalomas, 62% (108/174) received CAR/DS-based recommendations versus 38% (66/174) unassisted recommendations. CAR/DS use was an independent predictor of provider compliance both with FUI (Odds Ratio [OR]=2.47, p = 0.02) and hormonal screening (OR=2.38, p = 0.04). CAR/DS reports recommended FUI (97.2%,105/108) and hormonal screening (87.0%,94/108) more often than conventional reports (respectively, 69.7% [46/66], 3.0% [2/66], both p <0.0001). CAR/DS recommendations more frequently included instructions for FUI time, protocol, and modality than conventional reports (all p <0.001). CONCLUSION: Ordering providers were at least twice as likely to comply with report recommendations for FUI and hormonal evaluation of adrenal incidentalomas generated using CAR/DS versus unassisted reporting. CAR/DS-directed recommendations were more adherent to guidelines than those generated without.

Non-operatively managed blunt and penetrating renal trauma: Does early follow up CT scan change management? A systematic review.

BACKGROUND: Renal injury accounts for 1-5% of all traumatic injuries. Non-operative management (NOM) of renal trauma has demonstrated higher renal salvage rates and reduced morbidity. AIMS: The aim of this review is to clarify the indications of early follow up CT scan for adult patients, with NOM, renal trauma, with a view to avoiding unnecessary CT scanning and radiation exposure in this cohort of patients. METHODS: A systematic search was conducted using PubMed (MEDLINE), Web of Science, Embase, and Cochrane library, with references from relevant articles also evaluated. Inclusion criteria were defined as studies reporting outcomes of patients ≥12 years of age, with NOM, renal trauma and early CT re-imaging. The outcomes of interest were renal complications requiring intervention, specifically collecting system and vascular complications. RESULTS: Five studies met the inclusion criteria. In total, 542 patients were included in this analysis; study sizes ranged from 48 to 207 patients. Early re-imaging was performed for 510 patients, including 489 CTs and 31 Ultrasounds (US). Mean time to re-imaging ranged from 1 - 35.9 days. Twenty three patients required intervention following re-imaging, all of which were for injuries grade ≥ 3 and presented with clinical deterioration prior to re-imaging, had a collecting system injury identified on initial CT scan or both. The number needed to re-image, in order to change the management of one patient, was 22. CONCLUSIONS: Although the findings of this review are based on retrospective data, they suggest routine early re-imaging can be safely omitted for all NOM, renal injuries which remain asymptomatic, with no collecting system injury diagnosed on initial CT, provided appropriate delayed phase imaging is available. Future prospective studies are required to further clarify the indications of early re-imaging, specifically for NOM penetrating injuries, and the appropriate modality and timing of early re-imaging for all NOM renal trauma.

Variation in Radiologists' Follow-Up Imaging Recommendations for Small Cystic Pancreatic Lesions.

OBJECTIVE: This study aimed to determine the incidence, identify imaging and patient factors, and measure individual radiologist variation associated with follow-up recommendations for small focal cystic pancreatic lesions (FCPLs), a common incidental imaging finding. METHODS: This institutional review board-approved retrospective study analyzed 146,709 reports from abdominal CTs and MRIs performed in a large academic hospital from July 1, 2016, to June 30, 2018. A trained natural language processing tool identified 4,345 reports with FCPLs, which were manually reviewed to identify those containing one or more <1.5-cm pancreatic cysts. For these patients, patient, lesion, and radiologist features and follow-up recommendations for FCPL were extracted. A nonlinear random-effects model estimated degree of variation in follow-up recommendations across radiologists at department and division levels. RESULTS: Of 2,872 reports with FCPLs < 1.5 cm, 708 (24.7%) had FCPL-related follow-up recommendations. Average patient age was 67 years (SD ± 11). In all, 1,721 (60.0%) reports were for female patients; 59.3% of patients had only one cyst. In multivariable analysis, older patients had slightly lower follow-up recommendation rates (odds ratio [OR]: 0.98 [0.98-1.00] per additional year), and lesions associated with main duct dilatation and septation were more likely to have a follow-up recommendation (ORs: 1.93 [1.11-3.36] and 2.88 [1.89-4.38], respectively). Radiologist years in practice (P = .51), trainee presence (P = .21), and radiologist gender (P = .52) were not associated with increased follow-up recommendations. There was significant interradiologist variation in the Abdominal Imaging Division (P = .04), but not in Emergency Radiology (P = .31) or Cancer Imaging Divisions (P = .29). DISCUSSION: Interradiologist variation significantly contributes to variability in follow-up imaging recommendations for FCPLs.

Surveillance in Older Women With Incidental Ovarian Cysts: Maximal Projected Benefits by Age and Comorbidity Level.

PURPOSE: The aim of this study was to estimate effects on life expectancy (LE) of imaging-based ovarian surveillance after detection of incidental postmenopausal ovarian cysts, under different assumptions of patient age, comorbidity level, and cancer risk and detection. METHODS: A decision-analytic Markov model was developed to estimate LE benefits. Hypothetical cohorts of postmenopausal women with simple ovarian cysts were evaluated, with varied age (66-80 years) and comorbidity level (none, mild, moderate, severe). For each cohort, imaging "follow-up" (2 years) and "no-follow-up" strategies were compared. Consistent with current evidence, increased cancer risk in patients with cysts was not assumed; however, incident ovarian cancers could be detected during follow-up. To estimate theoretical maximal LE gains from follow-up, perfect ovarian cancer detection and treatment during follow-up were assumed. This and other key assumptions were varied in sensitivity analysis. RESULTS: Projected LE gains from follow-up were limited. For 66-, 70-, 75-, and 80-year-old women with no comorbidities, LE gains were 5.1, 5.1, 4.5, and 3.7 days; with severe comorbidities, they were 3.5, 3.2, 2.7, and 2.1 days. With sensitivity of 50% for cancer detection, they were 3.7 days for 66-year-old women with no comorbidities and 1.3 days for 80-year-old women with severe comorbidities. When cancer risk for women with cysts was assumed to be elevated (1.1 times average risk), LE gains increased only modestly (5.6 and 2.3 days for analogous cohorts). CONCLUSIONS: Even in the circumstance of perfect ovarian cancer detection and treatment, surveillance of postmenopausal women (≥66 years of age) with simple cysts affords limited benefits, particularly in women with advanced age and comorbidities.

Radiologists' Self-Assessment Versus Peer Assessment of Perceived Probability of Recommending Additional Imaging.

OBJECTIVE: Determine radiologist ability to accurately select the probability of recommendation of additional imaging (RAI) for themselves and colleagues when arrayed in a feedback report. METHODS: In this institutional review board-approved study, we analyzed 318,366 diagnostic imaging reports from examinations performed in the radiology department of a large quaternary teaching hospital during calendar year 2016. A validated machine learning algorithm identified reports containing RAI. A multivariable logistic regression model was then used to determine the probability of RAI. In 2018, an e-mailed survey asked radiologists to identify their own RAI probability and that of their colleagues from a report arrayed lowest to highest. Radiologists were grouped into quartiles based on their RAI probability. χ2 Analysis compared self-assessment and assessment of colleagues between quartiles. RESULTS: Forty-eight of 57 radiologists completed the survey (84.2%). Fourteen (29.2%) accurately self-identified their RAI probability (chose the correct quartile); 34 (70.8%) did not. There was no statistically significant difference between quartiles of radiologists and their ability to self-identify their RAI probability (ie, radiologists in the bottom or top quartile of RAI probabilities did not correctly predict their RAI probability). However, radiologists were better able to identify the RAI probability of their colleagues who were in the top and bottom quartiles. DISCUSSION: Radiologists were unable to estimate their own RAI probability but were better at predicting the RAI probability of colleagues. Given that radiologists, and physicians in general, may be poor evaluators of their own performance, objective assessment tools are likely needed to help reduce unwarranted variation.

[Management and follow-up of renal injury-a 10-year experience at a Swiss level 1 trauma center]. / Therapie und Nachsorge traumatischer Nierenverletzungen ­ 10 Jahre Erfahrung eines Schweizer Level­1-Traumazentrums.

INTRODUCTION: The objective was to analyze patterns of injury, management, imaging, and follow-up care of renal trauma at a Swiss level 1 trauma center. METHODS: We examined 138 patients (>16 years) with renal organ injuries who presented to our institution between January 2008 and March 2018. Data on demographics, patterns of injury, clinical presentation, management, and follow-up were recorded. RESULTS: The injury grade of the 142 injured kidneys was grade 1 in 25% (n = 36), grade 2 in 16% (n = 23), grade 3 in 32% (n = 46), grade 4 in 24% (n = 34), and grade 5 in 2% (n = 3). The predominant injury mechanism was winter sports (45%). Conservative management was successful in all grade 1 renal injuries, and 91%, 86%, 35%, and 33% of grade 2, 3, 4, and 5 injuries, respectively. Early follow-up with CT or MRI scan was performed in 23% of grade 1-3 injuries and 57% of grade 4-5 injuries with clinical signs of complications as the most frequent indication for grade 1-3 injuries and routine follow-up imaging for grade 4-5 injuries, respectively. In follow-up care (1-9 months after injury) imaging showed persistent pathologies in 39% of grade 1-3 renal injuries and 62% of grade 4-5 injuries. CONCLUSIONS: Most minor renal injuries (grade 1-3) can be successfully managed conservatively. Early follow-up imaging is indicated for patients showing clinical signs of complications. Routine repeat imaging may not be justified for high-grade renal injuries without clinical symptoms. Re-imaging in follow-up care still lacks evidence-based recommendations.