Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis.

OBJECTIVE: To determine the safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for retrocalcaneal bursitis. MATERIALS AND METHODS: After IRB approval, all fluoroscopically guided and ultrasound-guided retrocalcaneal bursa injections (2013-2019) were retrospectively evaluated. Pre-procedure US and radiographs were scored by 2 blinded radiologists in consensus for Achilles tendinosis and retrocalcaneal bursitis (0-3 scale), Achilles enthesopathy (present/absent), and Haglund deformity (present/absent). Pre- and post-procedure pain scores (0-10 scale) evaluated short-term response at 1-4 weeks: excellent (7-10 point decline), good (4-6 point decline), fair (1-3 point decline), or no response. Paired t-test determined significance of short-term improvement. Kaplan-Meier method analyzed time to progression to surgery or complication at 6-month minimum follow-up. Logistic regression analysis evaluated for association between demographic and imaging variables and negative outcome. RESULTS: Two hundred eighteen injections (181 female; mean 54.5 years) performed under ultrasonographic (157, 72%) or fluoroscopic (61, 28%) guidance were evaluated for complication and long-term outcomes. Injections with short-term follow-up (n = 62) yielded excellent or good response in 62.9% (p < 0.00001). Thirty patients (14%) had subsequent elective Achilles surgery. Bursal Doppler flow was associated with progression to surgery (p = 0.00042). No differences were identified in outcomes between US and fluoroscopic-guidance cohorts. Four Achilles ruptures (1.8%) were identified 15-59 days post-injection, each with immediately preceding acute injury. CONCLUSION: Image-guided retrocalcaneal bursa corticosteroid injection yields significant short-term decrease in pain score in majority (63%) of patients. Subsequent Achilles tendon rupture rate was 1.8%. Bursa Doppler flow was significantly correlated with progression to surgery and may represent a negative prognostic indicator.

Narrowing of ischiofemoral and quadratus femoris spaces in pediatric ischiofemoral impingement.

OBJECTIVE: To correlate MRI findings of quadratus femoris muscle edema (QFME) with narrowing of the ischiofemoral space (IFS) and quadratus femoris space (QFS) in children, and to identify threshold values reflecting an anatomic architecture that may predispose to ischiofemoral impingement. MATERIALS AND METHODS: A case-control retrospective MRI review of 49 hips in 27 children (mean, 13 years) with QFME was compared to 49 hips in 27 gender and age-matched controls. Two radiologists independently measured IFS and QFS. Generalized linear mixed-effects models were fit to compare IFS and QFS values between cases and controls, and adjust for correlation in repeated measures from the same subject. Receiver operating characteristic (ROC) analysis determined optimal threshold values. RESULTS: Compared to controls, cases had significantly smaller IFS (p < 0.001, both readers) and QFS (reader 1: p < 0.001; reader 2: p = 0.003). When stratified as preteen (< 13) or teenage (≥ 13), lower mean IFS and QFS were observed in cases versus controls in both age groups. Area under ROC curve for IFS and QFS was high in preteens (0.77 and 0.71) and teens (0.94 and 0.88). Threshold values were 14.9 mm (preteens) and 19 mm (teens) for IFS and 11.2 mm (preteens) and 11.1 mm (teens) for QFS. IFS and QFS were modestly correlated with age among controls only. CONCLUSIONS: Pediatric patients with QFME had significantly narrower QFS and IFS compared with controls. IFS and QFS were found to normally increase in size with age. Optimal cutoff threshold values were identified for QFS and IFS in preteens and teenagers.

Survey of current trends in postgraduate musculoskeletal ultrasound education in the United States.

OBJECTIVE: To determine current trends in postgraduate musculoskeletal ultrasound education across various medical specialties in the United States. MATERIALS AND METHODS: A survey regarding musculoskeletal ultrasound education was sent to all program directors for diagnostic radiology and physical medicine rehabilitation residency programs, as well as adult rheumatology and sports medicine fellowship programs in the United States. The survey, sent in July 2015, queried the presence of formal musculoskeletal ultrasound training, the components of such training and case volume for trainees. RESULTS: Response rates were 23, 25, 28 and 33% for physical medicine and rehabilitation, radiology, rheumatology and sports medicine programs, respectively. Among respondents, musculoskeletal ultrasound training was present in 65% of radiology programs, 88% of sports medicine programs, 90% of rheumatology programs, and 100% of physical medicine and rehabilitation programs. Most programs utilized didactic lectures, followed by hands-on scanning. The majority of programs without current training intend to implement such training within 5 years, although radiology programs reported the lowest likelihood of this happening. Most program directors believed that musculoskeletal ultrasound education is important for their trainees, and is of greater importance than it was 10 years ago. Case volume was lowest for radiology trainees and highest for sports medicine trainees. CONCLUSION: Among respondents, the majority of diagnostic radiology programs offer musculoskeletal ultrasound training. However, this experience is even more widespread in other medical specialties, and hands-on training and experience tend to be greater in other specialties than in radiology.

Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes.

OBJECTIVE: To describe a lateral fluoroscopically guided retrocalcaneal bursa injection technique, report patient outcomes at 1-4 weeks after steroid/anesthetic retrocalcaneal bursal therapeutic injection, and correlate pre-injection diagnostic heel ultrasound variables with improvement in patient pain scores. MATERIALS AND METHODS: After IRB approval, fluoroscopically guided therapeutic retrocalcaneal bursa injections performed using a lateral approach were retrospectively reviewed. Pre-injection heel ultrasound results and pre- and post-injection patient VAS pain scores (scale 0-10) were recorded. The Wilcox matched-pair test compared pain scores, and Spearman's rho assessed for correlation between pain score changes and heel ultrasound results. RESULTS: Thirty-two injections were performed in 30 patients (25 females, 5 males; mean 56.5 ± 9.3 years, range 39-75 years; 21 left heel, 11 right heel) with technical success in 32 of 32 cases (100 %). Insertional Achilles tendon pathology and retrocalcaneal bursitis were present in 31 of 32 cases (97 %) and 16 of 32 cases (50 %), respectively. Median pre- and post-procedure pain scores were 8 (IQR 7, 10) and 1.75 (IQR 0, 6). A statistically significant decrease in pain score was observed following injection, with a median change of 4.75 (IQR 3, 8; p < 0.001). Clinically significant response (>50 % reduction in pain score) was present in 69 % (95 % CI, 0.52-0.86; p < 0.001). No significant correlation was identified between a decrease in pain score and a sonographically abnormal Achilles tendon or retrocalcaneal bursa. CONCLUSION: Fluoroscopically guided retrocalcaneal bursal steroid/anesthetic using a lateral approach is an effective technique. This technique yielded 100 % technical success and a clinically significant decrease in patient pain scores (p < 0.001).

Global Health Initiatives: International Physician-to-Physician Consultation Programs.

PURPOSE: The goal of this article is to provide technical and operational blueprints for two successful global telehealth programs. METHODS: The authors designed a physician-to-physician consultation program to provide subspecialty expertise to physicians in war-torn Ukraine. Leveraging secure web applications, telehealth platforms, and image-sharing platforms, the authors repeatedly iterated upon infrastructure and workflows, which in turn facilitated the development of a parallel international program for US Department of State (DOS) employees and families. The authors provide descriptive statistics and metrics of both programs' successes and failures and detail iterative improvements with workflow visuals. To measure the added value of subspecialty imaging consultation, two radiologists performed a retrospective comparative review of the DOS program imaging reports, comparing the initial report to the consult report in consensus, measuring diagnostic report agreement, and rating the clinical impact of identified discrepancies on a three-point scale (mild, moderate, or major). Bivariate analyses using χ2 tests were conducted to assess associations between diagnostic discrepancies and patient or imaging factors. P values <.05 were considered to indicate statistical significance. RESULTS: The Ukraine program (May 2022 to August 2023) provided 114 patient consultations with 77 subspecialty radiology consults, >50 WhatsApp chats, and >1,000 messages exchanged, with a 92% overall consult request response rate. The DOS program (November 2022 to July 2023) provided 275 consultations with 70 subspecialty radiology consults and a 36% to 38% rate of alternative diagnoses, with 20% rated as incurring moderate or major clinical impact. Bivariate analyses demonstrated no significant patient or imaging association with diagnostic disagreements (P > .05 for all). CONCLUSIONS: Global telehealth infrastructure and multiple applications and platforms can be optimized in a workflow to provide efficient, high-level clinical and imaging consultation services across the globe.

Current State of Peer Learning in Radiology: A Survey of ACR Members.

PURPOSE: Peer learning (PL) programs seek to improve upon the limitations of score-based peer review and incorporate modern approaches to improve patient care. The aim of this study was to further understand the landscape of PL among members of the ACR in the first quarter of 2022. METHODS: Members of the ACR were surveyed to evaluate the incidence, current practices, perceptions, and outcomes of PL in radiology practice. The survey was administered via e-mail to 20,850 ACR members. The demographic and practice characteristics of the 1,153 respondents (6%) were similar to those of the ACR radiologist membership and correspond to a normal distribution of the population of radiologists and can therefore be described as representative of that population. Therefore, the error range for the results from this survey is ±2.9% at a 95% confidence level. RESULTS: Among the total sample, 610 respondents (53%) currently use PL, and 334 (29%) do not. Users of PL are younger (mode age ranges, 45-54 years for users and 55-64 years for nonusers; P < .01), more likely to be female (29% vs 23%, P < .05), and more likely to practice in urban settings (52% vs 40%, P = .0002). Users of PL feel that it supports an improved culture of safety and wellness (543 of 610 [89%]) and fosters continuous improvement initiatives (523 of 610 [86%]). Users of PL are more likely than nonusers to identify learning opportunities from routine clinical practice (83% vs 50%, P < .00001), engage in programming inclusive of more team members, and implement more practice improvement projects (P < .00001). PL users' net promoter score of 65% strongly suggests that users of PL are highly likely to recommend the program to colleagues. CONCLUSIONS: Radiologists across a breadth of radiology practices are engaged in PL activities, which are perceived to align with emerging principles of improving health care and enhance culture, quality, and engagement.

Radiation dose management: part 2, estimating fetal radiation risk from CT during pregnancy.

OBJECTIVE: The purpose of this article is to review fetal radiation doses and associated risks resulting from CT performed during pregnancy. The scanning parameters that influence dose and the techniques for estimating and reducing dose are explained. CONCLUSION: Fetal radiation doses for CT examinations in which the fetus is not directly imaged-for example, head or chest CT-are minimal and need not figure in the risk-benefit analysis to perform the examination. In contrast, radiation dose should be considered with abdominopelvic CT because the fetus is likely to be exposed directly to the scanning beam. Safe implementation of CT in this setting requires an understanding of the factors influencing radiation dose. With this knowledge, when a risk-benefit analysis in a given clinical situation favors imaging using CT, the radiologist need not withhold or delay the examination and can achieve diagnostic-quality images while reducing radiation exposure.

Body CT during pregnancy: utilization trends, examination indications, and fetal radiation doses.

OBJECTIVE: The objective of our study was to analyze body CT utilization trends, indications, fetal radiation doses, and scanning parameters associated with high fetal radiation doses (defined as > 30 mGy). MATERIALS AND METHODS: A retrospective review of all chest and abdominopelvic CT examinations performed between 1998 and 2005 of patients known to be pregnant was conducted. Demographics, gestational age, examination indication, and scan parameters were recorded. Fetal radiation dose was calculated for those abdominopelvic examinations with direct fetal irradiation. RESULTS: From a database of more than 170,000 chest and more than 180,000 abdominopelvic CT examinations, 74 chest and 86 abdominopelvic examinations of pregnant patients were identified. Chest CT use increased on average 75%/y/1,000 deliveries in pregnancy versus 19%/y increase in all patients (p = 0.2700). Abdominopelvic CT utilization increase was on average 22%/y/1,000 deliveries in pregnant patients versus 13%/y increase in all patients (p = 0.1865). The most common indication for chest CT during pregnancy was suspected pulmonary embolism (85%, 63/74) and for abdominopelvic CT, suspected appendicitis (58%, 50/86). The average fetal dose from abdominopelvic CT was 24.8 mGy (range, 6.7-56 mGy); one examination exceeded the 50-mGy threshold for increased risk of childhood cancer. Scanning parameters associated with a dose of more than 30 mGy were a pitch of less than 1 (p = 0.0080) and more than one series acquisition (p = 0.0136). CONCLUSION: Growth of CT during pregnancy reflects the trend of increased CT utilization in the general population. Avoiding use of CT in pregnant patients with suspected appendicitis would significantly decrease fetal radiation exposure. Abdominopelvic CT during pregnancy should be carefully planned and monitored so as not to exceed the fetal radiation dose for negligible risk.

Lessons Learned From the COVID-19 Response in a Major New York City Hot Zone.

The COVID-19 pandemic had significant impact on radiology departments across the United States. Radiology departments have adjusted to the effects of the pandemic. This article presents the changes made by the Radiology department at the Montefiore Medical Center (MMC) of the Albert Einstein College of Medicine located in the Bronx, New York City which is one of the major hot spots of the COVID-19 pandemic.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions.

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

Abdominopelvic CT findings in patients with novel coronavirus disease 2019 (COVID-19).

PURPOSE: Some patients with novel coronavirus disease 2019 (COVID-2019) present with abdominal symptoms. Abdominal manifestations of COVID on imaging are not yet established. The goal of this study was to quantify the frequency of positive findings on abdominopelvic CT in COVID-positive patients, and to identify clinical factors associated with positive findings to assist with imaging triage. MATERIALS AND METHODS: This retrospective study included adult COVID-positive patients with abdominopelvic CT performed within 14 days of their COVID PCR nasal swab assay from 3/1/2020 to 5/1/2020. Clinical CT reports were reviewed for the provided indication and any positive abdominopelvic findings. Demographic and laboratory data closest to the CT date were recorded. Multivariate logistic regression model with binary outcome of having no reported positive abdominopelvic findings was constructed. RESULTS: Of 141 COVID-positive patients having abdominopelvic CT (average age 64 years [± 16], 91 [64%] women), 80 (57%) had positive abdominopelvic findings. Abdominal pain was the most common indication, provided in 54% (43/80) and 74% (45/61) of patients with and without reported positive abdominopelvic findings, respectively (p = 0.015). 70% (98/141) of patients overall had reported findings in the lung bases. Findings either typical or intermediate for COVID were reported in 50% (40/80) and 64% (39/61) of patients with and without positive abdominopelvic findings, respectively (p = 0.099). Of 80 patients with positive abdominopelvic findings, 25 (31%) had an abnormality of gastrointestinal tract, and 14 (18%) had solid organ infarctions or vascular thromboses. In multivariate analysis, age (OR 0.85, p = 0.023), hemoglobin (OR 0.83, p = 0.029) and male gender (OR 2.58, p = 0.032) were independent predictors of positive abdominopelvic findings, adjusted for race and Charlson comorbidity index. CONCLUSION: Abdominopelvic CT performed on COVID-positive patients yielded a positive finding in 57% of patients. Younger age, male gender, and lower hemoglobin were associated with higher odds of having reportable positive abdominopelvic CT findings.

Use of a Macro as Nudge Factor in Communication Between Radiologists and Referring Physicians.

INTRODUCTION/METHODS: Radiologists provide value through communication of imaging findings. We outline a quality improvement effort using a dedicated dictation macro as a behavioral nudge to increase direct communication between radiologists and referring physicians. Use of the macro was encouraged by departmental leadership and publicised widely prior to implementation. Monthly data regarding the use of the macro and corresponding departmental volumes were acquired over a 24 month period. RESULTS: Over the 24-month study period, there were 1,334,555 total exams performed and 52,276 total communications (3.90%; monthly range 2.21-4.67%). The greatest increase in adoption rate occurred during the initial 4-month period, with sustained rates of communication achieved after month 4. Results were more frequently communicated to a clinician when a resident trainee was involved in the dictation process. The greatest number of documented communications was for x-ray, followed by Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Ultrasound (US), and nuclear medicine. Inpatient studies (7.23%) were communicated at a statistically significantly higher rate than Emergency Department (ED) (3.86%) or Outpatient (OP) studies (1.31%), P < 0.0001 for all comparisons. The rate of documented communication steadily increased across all patient classes. CONCLUSION: Our findings demonstrate that simple interventions to increase the rate of documented communication can have durable results, and highlight the critical role radiologists play in timely and effective patient care delivery. Introduction of a communication macro coupled with departmental nudges resulted in increased direct communication of imaging results. This effort has promoted mutual engagement between radiologists and their colleagues, and demonstrates the active role of radiologists in direct imaging consultation.

Spectrum of common and uncommon causes of knee joint hyaline cartilage degeneration and their key imaging features.

Hyaline cartilage lining the surfaces of diarthrodial joints is an important construct for transmission of load and to reduce friction between the bones. Normal wear and tear accounts for about 3-5 percent knee cartilage loss ever year in otherwise healthy people after the age of 30 years. Several conditions and diseases lead to premature cartilage degeneration. Standardized description of cartilage loss, detailed evaluation of the joint health and determining the underlying etiology of cartilage loss are important for effective reporting, multidisciplinary communications and patient management. In this article, the authors discuss normal and abnormal imaging appearances of the hyaline cartilage of knee with focus on using controlled terminology and MRI classifications. The reader will benefit and learn key MR imaging features of a spectrum of common and uncommon conditions and diseases affecting the knee cartilage, such as trauma, secondary injury associated with meniscus and ligament injury related instability, arthritis, ischemia, idiopathic, and hereditary conditions including Matrix metalloproteinase-2 (MMP-2) mutations and mucopolysaccharidosis type IX disease with illustrative case examples.

Impact of Patient-Centered Care on the Patient Experience in Nuclear Medicine.

OBJECTIVE: To quantify the impact of direct patient-physician interaction within a nuclear medicine pretherapy consultation clinic on the patient experience. METHODS: Patients were asked to complete a survey before and after meeting with the nuclear medicine physician. During each visit, the physician provided disease-specific information, discussed the planned therapy, answered questions, and provided tip sheets and checklists to prepare the patient for therapy. RESULTS: Thirty-eight patients were included in the analysis. Before consultation, 17 patients (44.7%) were "somewhat" or "extremely" familiar with the term "nuclear medicine doctor," whereas after the consultation, 33 patients (86.8%) were "somewhat" or "extremely" familiar with the term "nuclear medicine doctor" (P < 0.001). Thirteen patients (37.1%) felt they had either no understanding or a vague understanding of the therapy and no understanding of the plan for follow-up before the consultation, whereas 2 patients (5.4%) chose this response after the consultation (P < 0.001). More patients responded that they felt "generally" or "perfectly calm" toward the therapy overall after their consultation: 26 patients (68.4%) before vs 34 patients (91.9%) after consultation (P < 0.001). DISCUSSION: Patient- and family-centered care in radiology includes direct physician participation in care delivery. In this report, we evaluate and measure the impact of our nuclear medicine pretherapy consultation clinic on the patient experience. We demonstrate significant impact of direct patient-physician encounters on patient anxiety, patient knowledge of the role of the nuclear medicine physician, and overall patient understanding of their treatment plan.

Forty-One Million RADPEER Reviews Later: What We Have Learned and Are Still Learning.

ACR RADPEER® is the leading method of radiologic peer review in the United States. The program has evolved since its inception in 2002 and was most recently updated in 2016. In 2018, a survey was sent to RADPEER participants to gauge the current state of the program and explore opportunities for continued improvement. A total of 26 questions were included, and more than 300 practices responded. In this report, the ACR RADPEER Committee authors summarize the survey results and discuss opportunities for future iterations of the RADPEER program.

Adding Value in Radiology Reporting.

The major goal of the radiology report is to deliver timely, accurate, and actionable information to the patient care team and the patient. Structured reporting offers multiple advantages over traditional free-text reporting, including reduction in diagnostic error, comprehensiveness, adherence to national consensus guidelines, revenue capture, data collection, and research. Various technological innovations enhance integration of structured reporting into everyday clinical practice. This review discusses the benefits of innovations in radiology reporting to the clinical decision process, the patient experience, the cost of imaging, and the overall contributions to the health of the population. Future directions, including the use of artificial intelligence, are reviewed.

Implementing a Software Solution Across Multiple Ultrasound Vendors to Auto-fill Reports with Measurement Values.

Reliable transmission of ultrasound measurements into radiology reports is fraught with potential sources of error. In a conventional workflow, measurements are either written by hand on worksheets and/or dictated from worksheets or the images themselves into the radiology report. Valuable physician time is spent dictating, checking, and editing these values and this process is error-prone. Our approach was to use a transfer-software application to auto-populate measurements, with a goal of achieving >90% utilization rate by both technologists and radiologists. Implementation involved creating measurement fields for each measurement on each ultrasound unit of our multisite academic department. These fields were then mapped in both the transfer-software and the dictation software, to set up a 1:1:1 correspondence for each field. As a result, each measurement acquired by the technologist would automatically populate the radiology report within the dictation software. We created and mapped 128 fields for 39 exam templates. After implementation, technologist utilization rate was 86%-96% and overall radiologist utilization rate was 92%-93%. Radiology resident utilization rate was highest, at 95%-96%. We provide a guide for implementation and lessons learned.