MRI with DWI improves detection of liver metastasis and selection of surgical candidates with pancreatic cancer: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis to evaluate if magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) adds value compared to contrast-enhanced computed tomography (CECT) alone in the preoperative evaluation of pancreatic cancer. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched for relevant published studies through October 2022. Studies met eligibility criteria if they evaluated the per-patient diagnostic performance of MRI with DWI in the preoperative evaluation of newly diagnosed pancreatic cancer compared to CECT. Our primary outcome was the number needed to treat (NNT) to prevent one futile surgery using MRI with DWI, defined as those in which CECT was negative and MRI with DWI was positive for liver metastasis (i.e., surgical intervention in metastatic disease missed by CECT). The secondary outcomes were to determine the diagnostic performance and the NNT of MRI with DWI to change management in pancreatic cancer. RESULTS: Nine studies met the inclusion criteria with a total of 1121 patients, of whom 172 had liver metastasis (15.3%). The proportion of futile surgeries reduced by MRI with DWI was 6.0% (95% CI, 3.0-11.6%), yielding an NNT of 16.6. The proportion of cases that MRI with DWI changed management was 18.1% (95% CI, 9.9-30.7), corresponding to an NNT of 5.5. The per-patient sensitivity and specificity of MRI were 92.4% (95% CI, 87.4-95.6%) and 97.3% (95% CI, 96.0-98.1). CONCLUSION: MRI with DWI may prevent futile surgeries in pancreatic cancer by improving the detection of occult liver metastasis on preoperative CECT with an NNT of 16.6. CLINICAL RELEVANCE STATEMENT: MRI with DWI complements the standard preoperative CECT evaluation for liver metastasis in pancreatic cancer, improving the selection of surgical candidates and preventing unnecessary surgeries. KEY POINTS: • The NNT of MRI with DWI to prevent potential futile surgeries due to occult liver metastasis on CECT, defined as those in which CECT was negative and MRI with DWI was positive for liver metastasis, in patients with pancreatic cancer was 16.6. • The higher performance of MRI with DWI to detect liver metastasis occult on CECT can be attributed to an increased detection of subcentimeter liver metastasis.

Utilization of Chest and Abdominopelvic CT for Traumatic Injury From 2011 to 2018: Evaluation Using a National Commercial Database.

BACKGROUND. Increases in the use of CT to evaluate patients presenting with trauma have raised concern about inappropriate imaging. The evolving utilization of CT for trauma evaluation may be impacted by injury severity. OBJECTIVE. The purpose of this study was to explore patterns in utilization of chest and abdominopelvic CT among trauma-related emergency department (ED) visits across the United States. METHODS. This retrospective study was conducted with national commercial claims information extracted from the MarketScan Commercial Database. Trauma-related ED encounters were identified from the 2011-2018 MarketScan database files and classified by injury severity score (minor, intermediate, and major injuries) on the basis of International Classification of Diseases codes. ED encounters were also assessed for chest CT, abdominopelvic CT, and single-encounter chest and abdominopelvic CT examinations. Utilization per 1000 trauma-related ED encounters was determined. Multivariable Poisson regression models were used to determine incidence rate ratios (IRRs) as a measure of temporal changes in utilization. RESULTS. From 2011 to 2018, 8,369,092 trauma-related ED encounters were identified (5,685,295 for minor, 2,624,944 for intermediate, and 58,853 for major injuries). Utilization of chest CT per 1000 trauma-related ED encounters increased from 4.9 to 13.5 examinations (adjusted IRR, 1.15 per year; minor injuries, from 2.2 to 7.7 [adjusted IRR, 1.17]; intermediate injuries, from 8.5 to 21.5 [adjusted IRR, 1.16]; major injuries, from 117.8 to 200.1 [adjusted IRR, 1.08]). Utilization of abdominopelvic CT per 1000 trauma-related ED encounters increased from 7.5 to 16.4 (adjusted IRR, 1.12; minor injuries, 4.8 to 12.2 [adjusted IRR, 1.13]; intermediate injuries, 10.6 to 21.7 [adjusted IRR, 1.13]; major injuries, 134.8 to 192.6 [adjusted IRR, 1.07]). Utilization of single-encounter chest and abdominopelvic CT per 1000 trauma-related ED encounters increased from 3.4 to 8.9 [adjusted IRR, 1.16; minor injuries, 1.1 to 4.6 [adjusted IRR, 1.18]; intermediate injuries, 6.4 to 16.4 [adjusted IRR, 1.16]; major injuries, 99.6 to 179.9 [adjusted IRR, 1.08]). CONCLUSION. National utilization of chest and abdominopelvic CT for trauma-related ED encounters increased among commercially insured patients from 2011 to 2018, particularly for single-encounter chest and abdominopelvic CT examinations and for minor injuries. CLINICAL IMPACT. Given concerns about increased cost and detection of incidental findings, further investigation is warranted to explore the potential benefit of single-encounter chest and abdominopelvic CT examinations of patients with minor injuries and to develop strategies for optimizing appropriateness of imaging orders.

A New (Digital) Era in Medical Journalism: Leveraging Social Media and Other Online Tools to Increase Reach and Engagement.

Social media is a popular communication and marketing tool in modern society, with the power to reach and engage large audiences. Many members of the medical and radiology communities have embraced social media platforms, particularly X (formerly known as Twitter), as an efficient and economic means for performing patient outreach, disseminating research and educational materials, building networks, and promoting diversity. Editors of medical journals with a clear vision and relevant expertise can leverage social media and other digital tools to advance the journal's mission, further their interests, and directly benefit journal authors and readers. For editors, social media offers a means to increase article visibility and downloads, expand awareness of volunteer opportunities, and use metrics and other feedback to inform future initiatives. Authors benefit from broader dissemination of their work, which aids establishment of a national or international reputation. Readers can receive high-quality high-yield content in a digestible format directly on their devices while actively engaging with journal editors and authors in the online community. The authors highlight the multifaceted benefits of social media engagement and digital tool implementation in the context of medical journalism and summarize the activities of the RadioGraphics Social Media and Digital Innovation Team. By enumerating the social media activities of RadioGraphics and describing the underlying rationale for each activity, the authors present a blueprint for other medical journals considering similar initiatives. ©RSNA, 2023.

Abdominal Imaging Findings on Computed Tomography as a Tool for COVID-19 Mortality Risk Assessment: Comparison With Chest Radiograph Severity Scores.

OBJECTIVE: To quantify the association between computed tomography abdomen and pelvis with contrast (CTAP) findings and chest radiograph (CXR) severity score, and the incremental effect of incorporating CTAP findings into predictive models of COVID-19 mortality. METHODS: This retrospective study was performed at a large quaternary care medical center. All adult patients who presented to our institution between March and June 2020 with the diagnosis of COVID-19 and had a CXR up to 48 hours before a CTAP were included. Primary outcomes were the severity of lung disease before CTAP and mortality within 14 and 30 days. Logistic regression models were constructed to quantify the association between CXR score and CTAP findings. Penalized logistic regression models and random forests were constructed to identify key predictors (demographics, CTAP findings, and CXR score) of mortality. The discriminatory performance of these models, with and without CTAP findings, was summarized using area under the characteristic (AUC) curves. RESULTS: One hundred ninety-five patients (median age, 63 years; 119 men) were included. The odds of having CTAP findings was 3.89 times greater when a CXR score was classified as severe compared with mild (P = 0.002). When CTAP findings were included in the feature set, the AUCs for 14-day mortality were 0.67 (penalized logistic regression) and 0.71 (random forests). Similar values for 30-day mortality were 0.76 and 0.75. When CTAP findings were omitted, all AUC values were attenuated. CONCLUSIONS: The CTAP findings were associated with more severe CXR score and may serve as predictors of COVID-19 mortality.

Performing Quality Control on Magnetic Resonance Imaging Liver Fat/Iron Quantification Studies: A Critical Requirement.

OBJECTIVE: Nonalcoholic fatty liver and iron overload can lead to cirrhosis requiring early detection. Magnetic resonance (MR) imaging utilizing chemical shift-encoded sequences and multi-Time of Echo single-voxel spectroscopy (SVS) are frequently used for assessment. The purpose of this study was to assess various quality factors of technical acceptability and any deficiencies in technologist performance in these fat/iron MR quantification studies. METHODS: Institutional review board waived retrospective quality improvement review of 87 fat/iron MR studies performed over a 6-month period was evaluated. Technical acceptability/unacceptability for chemical shift-encoded sequences (q-Dixon and IDEAL-IQ) included data handling errors (missing maps), liver field coverage, fat/water swap, motion, or other artifacts. Similarly, data handling (missing table/spectroscopy), curve-fit, fat- and water-peak separation, and water-peak sharpness were evaluated for SVS technical acceptability. RESULTS: Data handling errors were found in 11% (10/87) of studies with missing maps or entire sequence (SVS or q-Dixon). Twenty-seven percent (23/86) of the q-Dixon/IDEAL-IQ were technically unacceptable (incomplete liver-field [39%], other artifacts [35%], significant/severe motion [18%], global fat/water swap [4%], and multiple reasons [4%]). Twenty-eight percent (21/75) of SVS sequences were unacceptable (water-peak broadness [67%], poor curve-fit [19%] overlapping fat and water peaks [5%], and multiple reasons [9%]). CONCLUSIONS: A high rate of preventable errors in fat/iron MR quantification studies indicates the need for routine quality control and evaluation of technologist performance and technical deficiencies that may exist within a radiology practice. Potential solutions such as instituting a checklist for technologists during each acquisition procedure and routine auditing may be required.

Imaging Informatics Fellowship Curriculum: Building Consensus on the Most Critical Topics and the Future of the Informatics Fellowship.

The existing fellowship imaging informatics curriculum, established in 2004, has not undergone formal revision since its inception and inaccurately reflects present-day radiology infrastructure. It insufficiently equips trainees for today's informatics challenges as current practices require an understanding of advanced informatics processes and more complex system integration. We sought to address this issue by surveying imaging informatics fellowship program directors across the country to determine the components and cutline for essential topics in a standardized imaging informatics curriculum, the consensus on essential versus supplementary knowledge, and the factors individual programs may use to determine if a newly developed topic is an essential topic. We further identified typical program structural elements and sought fellowship director consensus on offering official graduate trainee certification to imaging informatics fellows. Here, we aim to provide an imaging informatics fellowship director consensus on topics considered essential while still providing a framework for informatics fellowship programs to customize their individual curricula.

Increasing emergency department utilization of brain imaging in patients with primary brain cancer.

PURPOSE: To study changing emergency department (ED) brain imaging utilization in patients with primary brain cancers. METHODS: Using 2006-2014 data from the Nationwide Emergency Department Sample (NEDS), we identified all patients with primary brain cancers visiting EDs and evaluated trends of head CT and brain MRI utilization. Multivariable logistic regression analyses were used to determine patient- and hospital-specific factors associated with brain imaging utilization. RESULTS: A weighted cohort of 40,862 ED visits were included (mean age 55; 54% male), increasing from 3932 in 2006 to 5625 in 2014 (+ 43%). A total of 14.4% underwent brain imaging, with 13.2% undergoing CT, 2.3% undergoing MRI, and 1.1% undergoing both modalities. Between 2006 and 2014, there was a 104% increase in the rate of ED brain imaging (from 9.7% in 2006 to 19.8% in 2014). Factors associated with higher utilization of ED brain imaging in adults were non-teaching hospital status and Midwest and Northeast hospital regions (compared with the West). In pediatric patients, higher utilization was associated with older age, higher median household income of patient's ZIP code, and visits in rural, non-teaching hospitals located in the Midwest, South, and Northeast (compared with the West). CONCLUSION: In US patients with primary brain cancer, the number of ED visits increased annually, and the utilization of ED head imaging examinations doubled in a recent 9-year period. A variety of sociodemographic characteristics are associated with a higher likelihood of imaging in both adult and pediatric patients.

Risk Stratification Model: Lower-Extremity Ultrasonography for Hospitalized Patients with Suspected Deep Vein Thrombosis.

BACKGROUND: The Wells score for deep venous thrombosis (DVT) has a high failure rate and low efficiency among inpatients. OBJECTIVE: To create and validate an inpatient-specific risk stratification model to help assess pre-test probability of DVT in hospitalized patients. DESIGN: Prospective cohort study of hospitalized patients undergoing lower-extremity ultrasonography studies (LEUS) for suspected DVT. Demographics, physical findings, medical history, medications, hospitalization, and laboratory and imaging results were collected. Samples were divided into model derivation (patients undergoing LEUS 11/1/2012-12/31/2013) and validation cohorts (LEUS 1/1/2014-5/31/2015). A DVT prediction rule was derived using the recursive partitioning algorithm (decision tree-type approach) and was then validated. PARTICIPANTS: Adult inpatients undergoing LEUS for suspected DVT from November 2012 to May 2015, excluding those with DVT in the prior 3 months, at a 793-bed, urban academic quaternary-care hospital with ~50,000 admissions annually. MAIN MEASURES: The primary outcome was the presence of proximal DVT, and the secondary outcome was the presence of any DVT (proximal or distal). Model sensitivity and specificity for predicting DVT were calculated. KEY RESULTS: Recursive partitioning yielded four variables (previous DVT, active cancer, hospitalization ≥ 6 days, age ≥ 46 years) that optimized the prediction of proximal DVT and yield in the derivation cohort. From this decision tree, we stratified a scoring system using the validation cohort, categorizing patients into low- and high-risk groups. The incidence rates of proximal DVT were 2.9% and 12.0%, and of any DVT were 5.2% and 21.0%, for the low- and high-risk groups, respectively. The AUC for the discriminatory accuracy of the Center for Evidence-Based Imaging (CEBI) score for risk of proximal DVT identified on LEUS was 0.73. Model sensitivity was 98.1% for proximal and 98.1% for any DVT. CONCLUSIONS: In hospitalized adults, specific factors can help clinicians predict risk of DVT, identifying those with low pre-test probability, in whom ultrasonography can be safely avoided.

Current Clinical Practice Patterns of Self-Identified Nuclear Medicine Specialists.

OBJECTIVE: The objective of our study was to study patterns of services rendered by U.S. physicians who self-identify as nuclear medicine (NM) specialists. MATERIALS AND METHODS: Recent Medicare physician claims and demographic files were obtained and linked. NM specialists were defined as physicians self-identifying NM as their primary specialty on claims or as any of their specialties during enrollment. Using other self-identified specialties, we classified physicians as nuclear radiologists, nuclear cardiologists, exclusively NM physicians, or Others. Our primary outcome measure was the percentage of NM effort (in work relative value units [WRVUs]) per physician per specialty group. Secondary outcome measures included physician sociodemographic parameters and most common uniquely rendered services. RESULTS: Nationally, 1583 physicians self-identified as NM specialists during the calendar years 2012 through 2015. The distribution of WRVUs attributed to NM varied widely by specialty group; most nuclear radiologists and nuclear cardiologists devoted 10% or less of their effort to NM services whereas most NM physicians devoted 90% or more of their effort to NM services. NM specialists were most commonly nuclear radiologists (52.2%) and men (80.3%) and practiced in urban (98.4%) and nonacademic settings (62.9%). NM physicians interpreted more general NM studies, nuclear radiologists interpreted more cross-sectional imaging studies, and nuclear cardiologists interpreted mostly nuclear cardiology studies, with a majority of their overall work attributed to clinical evaluation and management (E/M). E/M services accounted for less than 2% of WRVUs for both nuclear radiologists and NM physicians. CONCLUSION: The work patterns of U.S. NM specialists is highly variable. Most NM physicians practice 90% or more NM, whereas most nuclear radiologists and nuclear cardiologists practice 10% or less NM. Commonly performed services vary considerably by specialty group.

Current Clinical Practice Patterns of Self-Identified Interventional Radiologists.

OBJECTIVE: The purpose of this study was to assess patterns of procedural, clinical evaluation and management (E/M), and diagnostic imaging services rendered by self-identified interventional radiologists (IRs) across the United States. MATERIALS AND METHODS: Recent Medicare Physician and Other Supplier Public Use and Physician Compare national downloadable files were linked. IRs were defined as physicians self-identifying interventional radiology as their primary specialty on Medicare claims or as a specialty during Medicare enrollment. The primary outcome measure was percentage of work (in work relative value units [WRVU]) attributed to interventional services (both procedural and E/M) per IR. Secondary outcome measures included sociodemographic factors per interventional WRVU quartile and percentage of E/M service units per IR. Statistical analysis included chi-square and t tests and logistic regression. RESULTS: Overall, 3132 physicians nationally self-identified to Medicare as IRs. The distribution of WRVU attributed to interventional services was strongly bimodal. Procedures and E/M together accounted for ≥ 91% and ≤ 5% of total work for the most and least intervention-oriented quartiles, respectively, but were widely distributed in the middle two quartiles. The most intervention-oriented self-identified IRs were more likely out of medical school ≤ 30 years (odds ratio [OR], 2.5; p < 0.0001), men (OR, 2.2; p < 0.0001), and in academic practice (OR, 4.3; p < 0.0001). E/M accounted for only 1.4% of all billed services. CONCLUSION: Although most self-identified IRs perform both interventional and diagnostic imaging services, the subspecialty distribution is strongly bimodal, one-quarter each focusing ≤ 5% and ≥ 91% of work on interventional services. Despite ongoing emphasis on clinically focused interventional radiology, E/M services remain rarely reported.

Assessing Documentation of Critical Imaging Result Follow-up Recommendations in Emergency Department Discharge Instructions.

To facilitate follow-up of critical test results across transitions in patient care settings, we implemented an electronic discharge module that enabled care providers to include follow-up recommendations in the discharge instructions. We assessed the impact of this module on documentation of follow-up recommendations for critical imaging findings in Emergency Department (ED) discharge instructions. We studied 240 patients with critical imaging findings discharged from the ED before (n = 80) and after (n = 160) implementation of the module. We manually reviewed hand-written forms and electronic discharge instructions to determine if follow-up recommendations were documented. Follow-up recommendations in ED discharge instructions increased from 60.0% (48/80) to 73.8% (118/160) post-module implementation (p = 0.03), a relative increase of 23%. There was no significant change in the rate of documented critical imaging findings in the discharge instructions (77.5% [62/80] before the intervention and 76.9% [123/160] after the intervention; p = 0.91). Implementation of a discharge module was associated with increased documentation of critical imaging finding follow-up recommendations in ED discharge instructions. However, one in four patients still did not receive adequate follow-up recommendations, suggesting further opportunities for performance improvement exist.

Trainees May Add Value to Patient Care by Decreasing Addendum Utilization in Radiology Reports.

OBJECTIVE: The purpose of this study was to evaluate the impact of trainee involvement and other factors on addendum rates in radiology reports. MATERIALS AND METHODS: This retrospective study was performed in a tertiary care pediatric hospital. From the institutional radiology data repository, we extracted all radiology reports from January 1 to June 30, 2016, as well as trainee (resident or fellow) involvement, imaging modality, patient setting (emergency, inpatient, or outpatient), order status (routine vs immediate), time of interpretation (regular work hours vs off-hours), radiologist's years of experience, and sex. We grouped imaging modalities as advanced (CT, MRI, and PET) or nonadvanced (any modality that was not CT, MRI, or PET) and radiologist experience level as ≤ 20 years or > 20 years. Our outcome measure was the rate of addenda in radiology reports. Statistical analysis was performed using multivariate logistic regression. RESULTS: From 129,033 reports finalized during the study period, 418 (0.3%) had addenda. Reports generated without trainees were 12 times more likely than reports with trainee involvement to have addenda (odds ratio [OR] = 12.2, p < 0.001). Advanced imaging studies were more likely than nonadvanced studies to be associated with addendum use (OR = 4.7, p < 0.001). Reports generated for patients in emergency or outpatient settings had a slightly higher likelihood of addendum use than those in an inpatient setting (OR = 1.5, p = 0.04; and OR = 1.3, p = 0.04, respectively). Routine orders had a slightly higher likelihood of addendum use compared with immediate orders (OR = 1.3, p = 0.01). We found no difference in addendum use by radiologist's sex, radiologist's years of experience, emergency versus outpatient setting, or time of interpretation. CONCLUSION: Trainees may add value to patient care by decreasing addendum rates in radiology reports.

Medicare Imaging Demonstration: Assessing Attributes of Appropriate Use Criteria and Their Influence on Ordering Behavior.

OBJECTIVE: Persistent concern exists about the variable and possibly inappropriate utilization of high-cost imaging tests. The purpose of this study is to assess the influence of appropriate use criteria attributes on altering ambulatory imaging orders deemed inappropriate. MATERIALS AND METHODS: This secondary analysis included Medicare Imaging Demonstration data collected from three health care systems in 2011-2013 via the use of clinical decision support (CDS) during ambulatory imaging order entry. The CDS system captured whether orders were inappropriate per the appropriate use criteria of professional societies and provided advice during the intervention period. For orders deemed inappropriate, we assessed the impact of the availability of alternative test recommendations, conflicts with local best practices, and the strength of evidence for appropriate use criteria on the primary outcome of cancellation or modification of inappropriate orders. Expert review determined conflicts with local best practices for 250 recommendations for abdominal and thoracic CT orders. Strength of evidence was assessed for the 15 most commonly triggered recommendations that were deemed inappropriate. A chi-square test was used for univariate analysis. RESULTS: A total of 1691 of 63,222 imaging test orders (2.7%) were deemed inappropriate during the intervention period; this amount decreased from 364 of 11,675 test orders (3.1%) in the baseline period (p < 0.00001). Of 270 inappropriate recommendations with alternative test recommendations, 28 (10.4%) were modified, compared with four of 1024 inappropriate recommendations without alternatives (0.4%) (p < 0.0001). Seventy-eight of 250 recommendations (31%) conflicted with local best practices, but only six of 69 inappropriate recommendations (9%) conflicted (p < 0.001). No inappropriate recommendations that conflicted with local best practices were modified. All 15 commonly triggered recommendations had an Oxford Centre for Evidence-Based Medicine level of evidence of 5 (i.e., expert opinion). CONCLUSION: Orders for imaging tests that were deemed inappropriate were modified infrequently, more often with alternative recommendations present and only for appropriate use criteria consistent with local best practices.