Quality Improvement Report: Safety Program for Prevention of Central Line-associated Bloodstream Infections.

The increasing usage of peripherally inserted central catheters (PICCs) in medical imaging departments has led to a corresponding increase in cases of central line-associated bloodstream infection (CLABSI). However, this condition is preventable with proper monitoring and use of aseptic techniques. A Comprehensive Unit-based Safety Program (CUSP) is a quality improvement (QI) measure implemented by health care institutions to reduce the incidence of CLABSI. However, effective strategies have yet to be established. The authors describe a QI project that evaluated the implementation of CUSP at a teaching hospital to reduce PICC-associated bloodstream infection (BSI). The framework consists of a five-step process: understand and train staff on the science of safety, assemble a team, engage senior executives, identify defects through sensemaking, and implement teamwork and communication strategies in a series of related and sequential steps that use QI tools. Targets were identified for improvement from existing processes, and the workflow was reengineered. Nine months after the start of the CUSP intervention, PICC-associated BSI incidence in the hospital had been reduced from 3.4 to 2.7 per 1000 central lines days after intervention. The incidence of BSI was also reduced correspondingly from 8.8% to 5.9%. The QI processes in this study may be adopted by other hospitals, as they involve minimal cost with significant impact on patient safety and well-being. The QI sequential steps described capture the implementation processes that can be modified for use in other department settings where patient safety could be compromised. Online supplemental material is available for this article. ©RSNA, 2022.

Three-dimensional topological radiogenomics of epidermal growth factor receptor Del19 and L858R mutation subtypes on computed tomography images of lung cancer patients.

OBJECTIVES: To elucidate a novel radiogenomics approach using three-dimensional (3D) topologically invariant Betti numbers (BNs) for topological characterization of epidermal growth factor receptor (EGFR) Del19 and L858R mutation subtypes. METHODS: In total, 154 patients (wild-type EGFR, 72 patients; Del19 mutation, 45 patients; and L858R mutation, 37 patients) were retrospectively enrolled and randomly divided into 92 training and 62 test cases. Two support vector machine (SVM) models to distinguish between wild-type and mutant EGFR (mutation [M] classification) as well as between the Del19 and L858R subtypes (subtype [S] classification) were trained using 3DBN features. These features were computed from 3DBN maps by using histogram and texture analyses. The 3DBN maps were generated using computed tomography (CT) images based on the Cech complex constructed on sets of points in the images. These points were defined by coordinates of voxels with CT values higher than several threshold values. The M classification model was built using image features and demographic parameters of sex and smoking status. The SVM models were evaluated by determining their classification accuracies. The feasibility of the 3DBN model was compared with those of conventional radiomic models based on pseudo-3D BN (p3DBN), two-dimensional BN (2DBN), and CT and wavelet-decomposition (WD) images. The validation of the model was repeated with 100 times random sampling. RESULTS: The mean test accuracies for M classification with 3DBN, p3DBN, 2DBN, CT, and WD images were 0.810, 0.733, 0.838, 0.782, and 0.799, respectively. The mean test accuracies for S classification with 3DBN, p3DBN, 2DBN, CT, and WD images were 0.773, 0.694, 0.657, 0.581, and 0.696, respectively. CONCLUSION: 3DBN features, which showed a radiogenomic association with the characteristics of the EGFR Del19/L858R mutation subtypes, yielded higher accuracy for subtype classifications in comparison with conventional features.

Comparing catheter related bloodstream infection rate between cuffed tunnelled and non-cuffed tunnelled peripherally inserted central catheter.

OBJECTIVE: To compare catheter related blood stream infection (CRBSI) rate between cuffed tunnelled and non-cuffed tunnelled PICC. METHODS: We prospectively followed 100 patients (50:50 cuffed and non-cuffed PICC) and compared CRBSI rate between these groups. Daily review and similar catheter care were performed until a PICC-related complication, completion of therapy, death or defined end-of-study date necessitate removal. CRBSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of infection and from peripheral blood cultures. RESULTS: A total of 50 cuffed PICC were placed for 1864 catheter-days. Of these, 12 patients (24%) developed infection, for which 5 patients (10%) had a CRBSI for a rate of 2.7 per 1000 catheter-days. Another 50 tunnelled non-cuffed PICCs were placed for 2057 catheter-days. Of these, 7 patients (14%) developed infection, for which 3 patients (6%) had a CRBSI. for a rate of 1.5 per 1000 catheter-days. The mean time to development of infection is 24 days in cuffed and 19 days in non-cuffed groups. The mean duration of utilization was significantly longer in non-cuffed than in cuffed group (43 days in non-cuffed vs 37 days in cuffed group, p = 0.008). CONCLUSIONS: Cuffed PICC does not further reduce the rate of local or bloodstream infection. Tunnelled non-cuffed PICC is shown to be as effective if not better at reducing risk of CRBSI and providing longer catheter dwell time compared to cuffed PICC.

Chest Radiograph (CXR) Manifestations of the Novel Coronavirus Disease 2019 (COVID-19): A Mini-review.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is highly contagious and has claimed more than one million lives, besides causing hardship and disruptions. The Fleischner Society has recommended chest X-ray (CXR) in detecting cases at high risk of disease progression, for triaging suspected patients with moderate-to-severe illness, and for eliminating false negatives in areas with high pre-test probability or limited resources. Although CXR is less sensitive than real-- time reverse transcription-polymerase chain reaction (RT-PCR) in detecting mild COVID-19, it is nevertheless useful because of equipment portability, low cost and practicality in serial assessments of disease progression among hospitalized patients. OBJECTIVE: This study aims to review the typical and relatively atypical CXR manifestations of COVID-19 pneumonia in a tertiary care hospital. METHODS: The CXRs of 136 COVID-19 patients confirmed through real-time RT-PCR from March to May 2020 were reviewed. A literature search was performed using PubMed. RESULTS: A total of 54 patients had abnormal CXR whilst the others were normal. Typical CXR findings included pulmonary consolidation or ground-glass opacities in a multifocal, bilateral peripheral, or lower zone distribution, whereas atypical CXR features comprised cavitation and pleural effusion. CONCLUSION: Typical findings of COVID-19 infection in chest computed tomography studies can also be seen in CXR. The presence of atypical features associated with worse disease outcome. Recognition of these features on CXR will improve the accuracy and speed of diagnosing COVID-19 patients.

Robust radiogenomics approach to the identification of EGFR mutations among patients with NSCLC from three different countries using topologically invariant Betti numbers.

OBJECTIVES: To propose a novel robust radiogenomics approach to the identification of epidermal growth factor receptor (EGFR) mutations among patients with non-small cell lung cancer (NSCLC) using Betti numbers (BNs). MATERIALS AND METHODS: Contrast enhanced computed tomography (CT) images of 194 multi-racial NSCLC patients (79 EGFR mutants and 115 wildtypes) were collected from three different countries using 5 manufacturers' scanners with a variety of scanning parameters. Ninety-nine cases obtained from the University of Malaya Medical Centre (UMMC) in Malaysia were used for training and validation procedures. Forty-one cases collected from the Kyushu University Hospital (KUH) in Japan and fifty-four cases obtained from The Cancer Imaging Archive (TCIA) in America were used for a test procedure. Radiomic features were obtained from BN maps, which represent topologically invariant heterogeneous characteristics of lung cancer on CT images, by applying histogram- and texture-based feature computations. A BN-based signature was determined using support vector machine (SVM) models with the best combination of features that maximized a robustness index (RI) which defined a higher total area under receiver operating characteristics curves (AUCs) and lower difference of AUCs between the training and the validation. The SVM model was built using the signature and optimized in a five-fold cross validation. The BN-based model was compared to conventional original image (OI)- and wavelet-decomposition (WD)-based models with respect to the RI between the validation and the test. RESULTS: The BN-based model showed a higher RI of 1.51 compared with the models based on the OI (RI: 1.33) and the WD (RI: 1.29). CONCLUSION: The proposed model showed higher robustness than the conventional models in the identification of EGFR mutations among NSCLC patients. The results suggested the robustness of the BN-based approach against variations in image scanner/scanning parameters.

The clinical utility of fluoroscopic versus CT guided percutaneous transpedicular core needle biopsy for spinal infections and tumours: a randomized trial.

BACKGROUND CONTEXT: Biopsy is important to obtain microbiological and histopathological diagnosis in spine infections and tumors. To date, there have been no prospective randomized trials comparing fluoroscopic guided and computed tomography (CT) transpedicular biopsy techniques. The goal of this study was to evaluate the accuracy, safety, and diagnostic outcome of these two diagnostic techniques. PURPOSE: To evaluate the accuracy, safety, and diagnostic outcome of fluoroscopic guided and CT transpedicular biopsy techniques. STUDY DESIGN: Prospective randomized trial. PATIENT SAMPLE: Sixty consecutive patients with clinical symptoms and radiological features suggestive of spinal infection or malignancy were recruited and randomized into fluoroscopic or CT guided spinal biopsy groups. Both groups were similar in terms of patient demographics, distribution of spinal infections and malignancy cases, and the level of biopsies. OUTCOME MEASURES: The primary outcome measure was diagnostic accuracy of both methods, determined based on true positive, true negative, false positive, and false negative biopsy findings. Secondary outcome measures included radiation exposure to patients and doctors, complications, and postbiopsy pain score. METHODS: A transpedicular approach was performed with an 8G core biopsy needle. Specimens were sent for histopathological and microbiological examinations. Diagnosis was made based on biopsy results, clinical criteria and monitoring of disease progression during a 6-month follow up duration. Clinical criteria included presence of risk factors, level of inflammatory markers and magnetic resonance imaging findings. Radiation exposure to patients and doctors was measured with dosimeters. RESULTS: There was no significant difference between the diagnostic accuracy of fluoroscopic and CT guided spinal biopsy (p=0.67) or between the diagnostic accuracy of spinal infection and spinal tumor in both groups (p=0.402 for fluoroscopy group and p=0.223 for CT group). Radiation exposure to patients was approximately 26 times higher in the CT group. Radiation exposure to doctors in the CT group was approximately 2 times higher compared to the fluoroscopic group if a lead shield was not used. Lead shields significantly reduced radiation exposure to doctors anywhere from 2 to 8 times. No complications were observed for either group and the differences in postbiopsy pain scores were not significant. CONCLUSIONS: The accuracy, procedure time, complication rate and pain score for both groups were similar. However, radiation exposure to patients and doctors were significantly higher in the CT group without lead protection. With lead protection, radiation to doctors reduced significantly.

Automated detection and classification of liver fibrosis stages using contourlet transform and nonlinear features.

BACKGROUND AND OBJECTIVE: Liver fibrosis is a type of chronic liver injury that is characterized by an excessive deposition of extracellular matrix protein. Early detection of liver fibrosis may prevent further growth toward liver cirrhosis and hepatocellular carcinoma. In the past, the only method to assess liver fibrosis was through biopsy, but this examination is invasive, expensive, prone to sampling errors, and may cause complications such as bleeding. Ultrasound-based elastography is a promising tool to measure tissue elasticity in real time; however, this technology requires an upgrade of the ultrasound system and software. In this study, a novel computer-aided diagnosis tool is proposed to automatically detect and classify the various stages of liver fibrosis based upon conventional B-mode ultrasound images. METHODS: The proposed method uses a 2D contourlet transform and a set of texture features that are efficiently extracted from the transformed image. Then, the combination of a kernel discriminant analysis (KDA)-based feature reduction technique and analysis of variance (ANOVA)-based feature ranking technique was used, and the images were then classified into various stages of liver fibrosis. RESULTS: Our 2D contourlet transform and texture feature analysis approach achieved a 91.46% accuracy using only four features input to the probabilistic neural network classifier, to classify the five stages of liver fibrosis. It also achieved a 92.16% sensitivity and 88.92% specificity for the same model. The evaluation was done on a database of 762 ultrasound images belonging to five different stages of liver fibrosis. CONCLUSIONS: The findings suggest that the proposed method can be useful to automatically detect and classify liver fibrosis, which would greatly assist clinicians in making an accurate diagnosis.

Automated diagnosis of focal liver lesions using bidirectional empirical mode decomposition features.

Liver is the heaviest internal organ of the human body and performs many vital functions. Prolonged cirrhosis and fatty liver disease may lead to the formation of benign or malignant lesions in this organ, and an early and reliable evaluation of these conditions can improve treatment outcomes. Ultrasound imaging is a safe, non-invasive, and cost-effective way of diagnosing liver lesions. However, this technique has limited performance in determining the nature of the lesions. This study initiates a computer-aided diagnosis (CAD) system to aid radiologists in an objective and more reliable interpretation of ultrasound images of liver lesions. In this work, we have employed radon transform and bi-directional empirical mode decomposition (BEMD) to extract features from the focal liver lesions. After which, the extracted features were subjected to particle swarm optimization (PSO) technique for the selection of a set of optimized features for classification. Our automated CAD system can differentiate normal, malignant, and benign liver lesions using machine learning algorithms. It was trained using 78 normal, 26 benign and 36 malignant focal lesions of the liver. The accuracy, sensitivity, and specificity of lesion classification were 92.95%, 90.80%, and 97.44%, respectively. The proposed CAD system is fully automatic as no segmentation of region-of-interest (ROI) is required.

Observer performance in characterization of carotid plaque texture and surface characteristics with 3D versus 2D ultrasound.

OBJECTIVE: To determine the reproducibility of three-dimensional (3D) ultrasound (US) over two-dimensional (2D) US in characterizing atherosclerotic carotid plaques using inter- and intra-observer agreement metrics. METHODS: A Total of 51 patients with 105 carotid artery plaques were screened using 3D and 2D US probes attached to the same US scanner. Two independent observers characterized the plaques based on the morphological features namely echotexture, echogenicity and surface characteristics. The scores assigned to each morphological feature were used to determine intra- and inter-observer performance. The level of agreement was measured using Kappa coefficient. RESULTS: The first observer with 2D US showed fair (k=0.4-0.59) and very strong (k>0.8) with 3D US intra-observer agreements using three morphological features. The second observer indicated moderate strong (k=0.6-0.79) with 2D US and very strong with 3D US (k>0.8) intra-observer performances. Moderate strong (k=0.6-0.79) and very strong (k>0.8) inter-observer agreements were reported with 2D US and 3D US respectively. The results with 2D and 3D US were correlated 62% using only echotexture and 56% using surface morphology coupled with echogenicity. 3D US gave a lower score than 2D 71% of the time (p=0.005) in disagreement cases. CONCLUSION: High reproducibility in carotid plaque characterization was obtained using 3D US rather than 2D US. Hence, it can be a preferred imaging modality in routine or follow up plaque screening of patients with carotid artery disease.

Multiphase renal CT in the evaluation of renal masses: is the nephrographic phase necessary?

The aim of this study is to investigate the feasibility of eliminating the nephrographic phase from the four-phase renal computed tomography (CT) imaging to a three-phase protocol without affecting its diagnostic value. Thirty patients undergoing four-phase renal CT scans for assessment of renal lesions (>10 mm) were included in the study. A three-phase renal CT, without nephrographic phase, had similar diagnostic ability to a four-phase renal CT in the detection and characterization of renal lesions. A three-phase CT (plain, corticomedullary, and excretory phase) is therefore adequate in the clinical diagnosis of renal lesions.

Hook wire localization for testis sparing surgery.

OBJECTIVE: To describe a novel technique for localizing small testicular mass during testicular-sparing surgery (TSS). METHODS AND RESULTS: A 20-year-old man presented with bilateral testicular masses. Both alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (BHCG) levels were raised. Clinical and imaging studies revealed a 2.7 cm and 0.7 cm mass in the right and left testis, respectively. No metastatic disease was detected on staging scans. Right inguinal total orchiectomy was performed. For the left testis, the inguinal approach was used to deliver the testis to the surgical wound. Vascular clamping and cooling of the testis were performed. A hook wire (Ghiatas Beaded Breast Localization Wire, 20G) was then inserted through the small testicular tumor with the aid of on-table ultrasound imaging. Testicular-sparing surgery (TSS) was easily performed with the aid of the hook wire. Postoperative recovery was uneventful. The histology report revealed a mixed germ cell tumor with clear margin. Tumor markers returned to normal after surgery. Serum testosterone level was also within normal range. Follow-up ultrasound scan showed a viable left testis with normal vascularity. CONCLUSION: Hook wire localization of a small testicular mass under ultrasound guidance is an easy-to-perform technique that facilitates TSS in selected patients. This technique allows TSS to be performed in a more controlled and confident manner.