Effects of patient education to reduce antibiotic prescribing rates for upper respiratory infections in primary care.

BACKGROUND: Antibiotic stewardship programs in primary care are necessary to reduce the estimated 30% of inappropriately written antibiotic prescriptions and reduce the spread of microbial resistance. Most programs focus on educating prescribers, but this intervention focused on educating patients. OBJECTIVES: To develop and implement an antibiotic stewardship program in a primary care clinic to educate patients with upper respiratory infections (URIs) about antibiotic use and to assess the effectiveness of the program through antibiotic prescribing rates. METHODS: Using materials from the Centers for Disease Control and Prevention (CDC) Be Antibiotics Aware program, posters on antibiotic use were placed in the exam rooms, graphic interchange formats (GIFs) and memes were displayed on exam room monitors, patient-provider discussions on antibiotic use were held, and written information for symptom management of URIs was provided. Retrospective chart reviews were conducted to assess antibiotic prescribing rates by four prescribers in a primary care clinic for September and October 2020 and compared to the same time period for 2019. RESULTS: The rate of total antibiotic prescriptions decreased by 12.6% (P = 0.044) and the rate of repeat consultation antibiotic prescriptions decreased by 12.2% (P = 0.007), whereas the rate of antibiotics prescribed at the time of the visit remained unchanged (P = 0.937). All providers had decreased rates of antibiotic prescribing after the intervention. CONCLUSION: Results of this study indicate that providing education about antibiotics to patients in need of treatment for URIs may reduce the rate of antibiotics prescribed in primary care; however, further research is warranted.

Radiology perspective on anatomy teaching in Australia and New Zealand.

INTRODUCTION: Anatomy pedagogy and radiologists involvement in teaching undergraduate anatomy varies widely. We surveyed radiologists practising in Australia and New Zealand to establish their opinions on their own experience of undergraduate anatomy and their view on the role of radiology in anatomy teaching. We also sought their views on the role of radiologists in anatomy teaching. METHODS: A short survey was designed on the Survey Monkey platform using the website surveymonkey.com. The survey was distributed to members of the Royal Australian and New Zealand College of Radiologists (RANCZR) as a link attached to a monthly e-newsletter with a short paragraph outlining its aim. RESULTS: Sixty-seven responses were eligible for analysis. 33% (22/67) were dissatisfied with their own anatomy training and 55% (38/67) felt that current graduates had an inadequate level of anatomy. 55% (38/67) indicated that radiology had not been a major part of their own undergraduate anatomy training. 58% (39/67) of respondents felt that non-radiology medical and para-medical professionals were not suitably qualified to teach radiologic anatomy. 75% (42/67) were of the opinion that radiology with 3-D support platforms may replace cadaveric dissection in the future, yet most were not familiar with 3-D platforms in current usage.

Consensus Review of Discordant Imaging Findings after the Introduction of Digital Screening Mammography: Irish National Breast Cancer Screening Program Experience.

Background When there are discordant results between individual readers interpreting screening mammograms, consensus by independent readers may reduce unnecessary recalls for further work-up. Few studies have looked at consensus outcomes following the introduction of full-field digital mammography (FFDM). Purpose To determine outcomes of women discussed at consensus meetings during a 5-year period after introduction of FFDM, including recall rates, cancer detection, and interval cancers. Materials and Methods In this retrospective study from January 2010 to December 2014, the authors reviewed all screening mammograms from a single unit of a biennial Irish national breast screening program after the introduction of FFDM. Screening mammograms were double reported. Abnormalities detected at discordant screening mammography readings were discussed at biweekly consensus meetings. Outcomes of consensus meetings were reviewed in terms of referral for assessment, biopsy rates, cancer detection, and outcomes from later rounds of screening. Statistical analysis was performed by using a χ2 test to compare recall rate and cancer detection rates between FFDM and screen-film mammography based on a previously published study from the authors' institution. Results A total of 2565 women (age range, 50-64 years) with discordant mammographic findings were discussed at consensus meetings. Of these 2565 women, 1037 (40%) were referred for further assessment; 108 cancers were detected in these women. Of the 1285 women who returned to biennial screening, malignancy was detected at the site of original concern in 12 women at a further round of screening. Three true interval cancers were identified. Sensitivity (88.5% [108 of 122]; 95% confidence interval [CI]: 81.5%, 93.6%) and negative predictive value (99.1% [1528 of 1542]; 95% CI: 98.5%, 99.4%) of consensus review remained stable after the introduction of FFDM. Specificity of consensus review increased from 57.6% (729 of 1264; 95% CI: 54.9%, 60.4%) to 62.2% (1528 of 2457; 95% CI: 60.2%, 64.1%) (P = .008). Conclusion Consensus review of discordant mammographic screening-detected abnormalities remains a valuable tool after introduction of full-field digital mammography as it reduces recall for assessment and demonstrates persistently high sensitivity and negative predictive values. © RSNA, 2020 See also the editorial by Hofvind and Lee in this issue.

SpaceOAR hydrogel distribution and early complications in patients undergoing radiation therapy for prostate cancer.

OBJECTIVES: Hydrogel spacers aim to separate the rectum from the prostate during radiation therapy for patients with prostate cancer to decrease the radiation dose and thus toxicity to the rectum. The aim of this study was to evaluate the distribution of the hydrogel spacer between the rectum and the prostate, to assess for hydrogel rectal wall infiltration and to assess for immediate complications. METHODS: Retrospective study of 160 patients who had undergone hydrogel spacer placement. Distribution of the hydrogel was assessed on MRI. MRI images were reviewed for rectal wall injection or other malplacement of gel. Early post-procedure complications were recorded. RESULTS: 117 (73.1%) patients had a symmetrical distribution of the hydrogel spacer. The mean anteroposterior rectoprostatic separation was 10.2 ± 3.7 mm (range 0-27 mm). Seven (4.3%) patient had minimal rectal wall infiltration and one (0.6%) patient had moderate infiltration. One (0.6%) patient had an intraprostatic injection of hydrogel. Two (1.3%) patients required treatment in the emergency department: one for urinary retention and one for pain. CONCLUSIONS: Transperineal hydrogel placement separates the prostate from the rectum with a symmetrical distribution in the majority of cases prior to radiation therapy with a low rate of rectal wall injection and immediate complications. ADVANCES IN KNOWLEDGE: SpaceOAR hydrogel can be safely injected into radiation naive patients with low- or intermediate-risk organ-confined prostate cancer. The spacer separates the prostate from the rectum with a symmetrical distribution in the majority of cases prior to radiation therapy.

Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study.

BACKGROUND: The cricothyroid membrane (CTM) is the recommended site of access to the airway during cricothyroidotomy to provide emergency oxygenation. Despite the apparent simplicity of the technique, this rescue maneuver frequently fails to achieve its goals and complications are numerous. The reasons for this failure are unclear. We sought to determine the ability of physicians to correctly identify the CTM in female patients. METHODS: Using fluorescent "invisible" ink, the physician was asked to mark the CTM with the patient in the supine neutral position and then with the head extended. The actual level was identified using ultrasound and the distance between the actual and estimated margin of the CTM was measured. A correct estimation was defined as a mark made between the upper and lower limits of the membrane and within 5 mm of midline. Participants were also asked to assess the ease of CTM palpation using a 10-cm visual analog scoring (VAS) scale. RESULTS: Fifty-six patients participated of whom 15 were obese. In the supine neutral neck position, the CTM was identified in 10/41 vs 0/15 (P = 0.048) in nonobese versus obese, respectively. Of the 46 incorrectly identified CTMs in this position, 24 were above (maximum 3 cm) and 22 below (maximum 3 cm) the actual level. Similar results were observed when the patients were placed with the neck in the extended position; the CTM was identified correctly in 12/41 vs 1/15 nonobese and obese patients, respectively. The range of values was also extensive; the estimation of the position of the membrane was as high as 2.5 cm above and 4 cm below the actual level, and up to 1.6 cm laterally. Participating doctors found palpation of the CTM subjectively more difficult in the obese than nonobese groups; VAS score for palpation difficulty was 5.25 ± 2.5 vs 3.3 ± 2.5, respectively, P = 0.005. Using multiple linear regression, VAS scores for palpation correlated negatively with increased patient height (P < 0.001) and greater thyromental distance (P = 0.006), and correlated positively with increased sternomental distance (P = 0.011) and neck circumference (P = 0.001). CONCLUSIONS: Misidentification of the CTM in female patients is common and its localization is less precise in those who are obese. This has implications for the likely success of invasive airway access via the CTM.

Increased incidence of acute calculous cholecystitis observed during COVID-19 social restrictions.

PURPOSE: In response to the outbreak of COVID-19 in Ireland, the government implemented a nationwide stay-at-home order, with the closure of all non-essential businesses. During this period, there was a significant increase in supermarket expenditure. It has been shown that stress, anxiety and boredom are triggers for unhealthy eating habits. Fat consumption is a risk factor for both the development of gallstones and, additionally, the development of acute calculous cholecystitis. The aim of this study was to assess the incidence of acute calculous cholecystitis during the nationwide lockdown and compare it to the same period one year prior. METHODS: A retrospective review of all emergency abdominal imaging performed during the first 5 weeks of the lockdown was completed using the hospital PACS (picture archiving and communication system). All cases of acute calculous cholecystitis were identified and compared with the same period 1 year prior. RESULTS: Eighteen cases of acute calculous cholecystitis were identified from 24 March to 27 April 2020. Eleven cases were identified during the same period in 2019. This represented an increase of 63%. Non-COVID-19-related emergency presentations decreased during this period, and imaging of emergency presentations decreased by 24%. The rate of scans positive for acute cholecystitis more than doubled (p < 0.037). CONCLUSION: A statistically significant increase in cases of acute calculous cholecystitis was observed during a nationwide lockdown during the COVID-19 pandemic. It is hypothesised that this is due to increased consumption of fatty foods during this period due to stress, anxiety and boredom.

Transperineal ultrasound-guided prostate biopsy: what the radiologist needs to know.

Transperineal ultrasound-guided (TP) prostate biopsy has been shown to significantly decrease the risk of post-procedural sepsis when compared to transrectal ultrasound-guided (TRUS) prostate biopsy. With guidance from the European Urology Association favouring adoption of a TP biopsy route, it is clear that, despite being a more technically challenging procedure, TP biopsy in an outpatient setting will replace TRUS biopsy. This paper gives the reader a succinct summary of outpatient transperineal prostate biopsy under local anaesthetic utilising a free-hand ultrasound technique. Patient preparation and consent process is outlined. A comprehensive pictorial review of the procedure, pitfalls and common post-procedural outcomes is presented. This paper provides a framework and guide for those wishing to adopt the transperineal approach under local anaesthetic.

Consensus review of discordant findings maximizes cancer detection rate in double-reader screening mammography: Irish National Breast Screening Program experience.

PURPOSE: To assesses consensus review of discordant screening mammography findings in terms of its sensitivity, safety, and effect on overall performance in the first 6 years of operation of the Irish National Breast Screening Program (NBSP). MATERIALS AND METHODS: Women who participated in the Irish NBSP gave written informed consent for use of their data for auditing purposes. Local ethics committee approval was obtained. The study population consisted of women who participated in the Irish NBSP and underwent initial screening mammography at one of the two screening centers serving the eastern part of Ireland between 2000 and 2005. Independent double reading of mammograms was performed. When the readers disagreed regarding referral, the case was reviewed by a consensus panel. Of the 128 569 screenings performed, 1335 (1%) were discussed by consensus. RESULTS: Of the 1335 cases discussed by consensus, 606 (45.39%) were recalled for further assessment. This resulted in an overall recall rate of 4.41%. In those recalled to assessment, 71 cases of malignant disease were diagnosed (ductal carcinoma in situ, n = 24; invasive cancer, n = 47). The remaining 729 patients were returned to biennial screening. Of these 729 patients, seven had false-negative findings that were identified in the subsequent screening round. Use of the highest reader recall method, in which a patient is recalled if her findings are deemed abnormal by either reader, could potentially increase the cancer detection rate by 0.6 per 1000 women screened but would increase the recall rate by 12.69% and the number of false-positive findings by 15.37%. CONCLUSION: The consensus panel identified 71 (7.33%) of 968 cancers diagnosed. Consensus review substantially reduced the number of cases recalled and was associated with a low false-negative rate.

Modified prostate volume algorithm improves transrectal US volume estimation in men presenting for prostate brachytherapy.

PURPOSE: To evaluate the accuracy of the conventional transrectal ultrasonographic (US) prostate volume formula and determine whether a more accurate volume formula, calculated on the basis of prostate shape as observed at planimetry, can be described for the majority of prostate glands. MATERIALS AND METHODS: This retrospective study was institutional review board approved, with waiver of informed consent. A total of 138 consecutive patients who underwent prostate brachytherapy were included for analysis. Prostate volume was estimated by using the conventional prolate ellipsoid formula (length x height x width x [pi/6]). A reference standard for prostate volume was calculated by using planimetry. The mean prostate shape was assessed by using three-dimensional volume-rendering of the planimetric images. The prostate shapes were evaluated to determine the best-fit mathematic formula for accurate volume estimation. Statistical analyses were performed by using Pearson correlation, paired Student t test, Bland-Altman plots, and concordance correlation coefficient. RESULTS: Planimetric data showed the majority of prostate glands to be more bullet-shaped than ellipsoid. Only 13.3% of volumes determined by using the conventional prolate ellipsoid formula were within 10% of the planimetric volume. The prolate ellipsoid formula underestimated volume by 17% on average (95% confidence interval: 14%, 19%). A mathematic formula representing a bullet shape (length x height x width x [pi/4.8]) was determined to best represent the majority of prostate glands presented for brachytherapy; 75% of volumes were within 10% of planimetric volume by using this formula. Concordance correlation coefficient increased from 0.87 to 0.95. Formula accuracy was particularly improved in prostate glands smaller than 55 cm(3) (P = .14). CONCLUSION: A modified prostate volume formula that closely represents the shape of the prostate smaller than 55 cm(3) demonstrated improved volume measurement accuracy compared with the prolate ellipsoid formula used in men presenting for brachytherapy.

Comparison of digital mammography and screen-film mammography in breast cancer screening: a review in the Irish breast screening program.

OBJECTIVE: Clinical trials to date into the use of full-field digital mammography (FFDM) for breast cancer screening have shown variable results. The aim of this study was to review the use of FFDM in a population-based breast cancer screening program and to compare the results with screen-film mammography. MATERIALS AND METHODS: The study included 188,823 screening examinations of women between 50 and 64 years old; 35,204 (18.6%) mammograms were obtained using FFDM. All films were double read using a 5-point rating scale to indicate the probability of cancer. Patients with positive scores were recalled for further workup. The recall rate, cancer detection rate, and positive predictive value (PPV) of FFDM were compared with screen-film mammography. RESULTS: The cancer detection rate was significantly higher for FFDM than screen-film mammography (6.3 vs 5.2 per 1,000, respectively; p = 0.01). The cancer detection rate for FFDM was higher than screen-film mammography for initial screening and subsequent screening, for invasive cancer and ductal carcinoma in situ, and across all age groups. The cancer detection rate for cancers presenting as microcalcifications was significantly higher for FFDM than for screen-film mammography (1.9 vs 1.3 per 1,000, p = 0.01). The recall rate was significantly higher for FFDM than screen-film mammography (4.0% vs 3.1%, p < 0.001). There was no significant difference in the PPVs of recall to assessment for FFDM and screen-film mammography (15.7% and 16.7%, p = 0.383). CONCLUSION: FFDM resulted in significantly higher cancer detection and recall rates than screen-film mammography in women 50-64 years old. The PPVs of FFDM and screen-film mammography were comparable. The results of this study suggest that FFDM can be safely implemented in breast cancer screening programs.

Impact of full field digital mammography on the classification and mammographic characteristics of interval breast cancers.

OBJECTIVE: Full field digital mammography (FFDM) is increasingly replacing screen film mammography (SFM) in breast screening programs. Interval breast cancers are an issue in all screening programs and the purpose of our study is to assess the impact of FFDM on the classification of interval breast cancers at independent blind review and to compare the mammographic features of interval cancers at FFDM and SFM. MATERIALS AND METHODS: This study included 138 cases of interval breast cancer, 76 following an FFDM screening examination and 62 following screening with SFM. The prior screening mammogram was assessed by each of five consultant breast radiologists who were blinded to the site of subsequent cancer. Subsequent review of the diagnostic mammogram was performed and cases were classified as missed, minimal signs, occult or true interval. Mammographic features of the interval cancer at diagnosis and any abnormality identified on the prior screening mammogram were recorded. RESULTS: The percentages of cancers classified as missed at FFDM and SFM did not differ significantly, 10.5% (8 of 76) at FFDM and 8.1% (5 of 62) at SFM (p=.77). There were significantly less interval cancers presenting as microcalcifications (alone or in association with another abnormality) following screening with FFDM, 16% (12 of 76) than following a SFM examination, 32% (20 of 62) (p=.02). CONCLUSION: Interval breast cancers continue to pose a problem at FFDM. The switch to FFDM has changed the mammographic presentation of interval breast cancer, with less interval cancers presenting in association with microcalcifications.