Cybersecurity in radiology: Cautionary Tales, Proactive Prevention, and What to do When You Get Hacked.

To improve awareness and understanding of cybersecurity threats to radiology practice and better equip healthcare practices to manage cybersecurity risks associated with medical imaging, this article reviews topics related to cybersecurity in healthcare, with emphasis on common vulnerabilities in radiology operations. This review is intended to assist radiologists and radiology administrators who are not information technology specialists to attain an updated overview of relevant cybersecurity concepts and concerns relevant to safe and effective practice of radiology and provides a succinct reference for individuals interested in learning about imaging-related vulnerabilities in healthcare settings. As cybersecurity incidents have become increasingly common in healthcare, we first review common cybersecurity threats in healthcare and provide updates on incidence of healthcare data breaches, with emphasis on the impact to radiology. Next, we discuss practical considerations on how to respond to a healthcare data breach, including notification and disclosure requirements, and elaborate on a variety of technical, organizational, and individual actions that can be adopted to minimize cybersecurity risks applicable to radiology professionals and administrators. While emphasis is placed on specific vulnerabilities within radiology workflow, many of the preventive or mitigating strategies are also relevant to cybersecurity within the larger digital healthcare arena. We anticipate that readers, upon completing this review article, will gain a better appreciation of cybersecurity issues relevant to radiology practice and be better equipped to mitigate cybersecurity risks associated with medical imaging.

ACR Appropriateness Criteria® Chronic Elbow Pain.

Chronic elbow pain can be osseous, soft tissue, cartilaginous, and nerve related in etiology. Imaging plays an important role in differentiating between these causes of chronic elbow pain. This document provides recommendations for imaging of chronic elbow pain in adult patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Osteonecrosis: 2022 Update.

Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Mitigation Tactics Discovered During COVID-19 with Long-Term Report Turnaround Time and Burnout Reduction Benefits.

RATIONALES AND OBJECTIVES: The purpose is to describe a hybrid teleradiology solution utilized in an academic medical center and its outcomes on radiology report turnaround time (RTAT) and physician wellness. MATERIALS AND METHODS: During coronavirus disease 2019, we utilized an alternating teleradiology solution with procedural and education attendings working in the hospital and other faculty remote to keep the worklist clean. RTAT data was collected for remote vs. in house emergency department (ED) and inpatient cases over a 6-month period. Pre and post implementation burnout surveys were administered. RESULTS: RTAT significantly improved for ED and inpatient MR and CT, and inpatient US and radiographs when interpreted remotely compared to in-hospital. Physician wellness scores improved and open-ended comments reflected positive feedback about the hybrid work solution. 74% enjoyed the autonomy and flexibility, and 51% said the solution positively influences my desire to remain in my current institution and improves their clinical and/or academic productivity. CONCLUSION: Hybrid work from home solutions allow faculty autonomy and flexibility with work-life balance, improving wellness. It is important to alternate the at-home faculty to maintain interdepartmental relations, particularly for junior faculty, and prevent isolation. The hybrid solution also demonstrated improved patient care metrics, possibly due to decreased distractions at home compared to the reading room.

System approach to prevent lost studies and improve radiology report turnaround time.

PURPOSE: On our picture archiving and communication system worklist, there was no way to differentiate body imaging (BI) from musculoskeletal (MSK) MR pelvis examinations. They were listed on only the BI worklist. This resulted in 'lost' MSK MR pelvis studies with high report turnaround time (TAT). Some exams had preliminary reports with substantiative changes made days later when found. The goals of this project were to create a solution to prevent 'lost' exams and improve TAT. METHODS: A report of 3 months of MR pelvis studies was reviewed to determine time to first view by MSK radiologists, time of completion, time of preliminary report and time of final signature. Mean TAT was calculated and exams with delays in reporting resident misinterpretation recorded.An MSK reserve flag was created for the BI radiologists to use when they found an MSK study on their worklist. The flag moved them onto the MSK reserve worklist. A second intervention included technologists placing the reserve on examination completion. After this, another 3 months of data was analysed. RESULTS: There was a significant improvement (p=0.0018) in time to view by MSK from preintervention mean of 1125 min (n=107) to postintervention mean of 526 min (n=127). There was also a significant improvement (p=0.0033) in time to view inpatient and Emergency department cases from 927 min to 357 min. Time from study completion to final signature also improved from a mean of 1764 min to 838 min, though not statistically significant (p=0.08). There were five cases of delay in reporting resident misinterpretation preintervention and none postintervention. CONCLUSION: Our intervention shows the importance of modifying human and informatics factors to solve a patient safety issue.

Best Practices: Best Imaging Modality for Surveillance of Metal-on-Metal Hip Arthroplasty.

OBJECTIVE. Metal-on-metal hip arthroplasty has been shown to result in soft-tissue complications in some patients, making revision surgery necessary. Imaging is critical in the detection and surveillance of soft-tissue complications, which are collectively termed adverse reaction to metal debris (ARMD) and adverse local tissue reaction. Studies have investigated the use of ultrasound, MRI, and CT for detecting ARMD, and each modality has advantages and disadvantages. This article provides evidence-based recommendations for imaging surveillance of ARMD. CONCLUSION. Compared with ultrasound, MRI has been found to be a better imaging modality for surveillance of ARMD. In addition, MRI is not operator dependent, allows visualization of soft-tissue details, and allows more consistent measurement of fluid collections on follow-up examinations. Limitations of ultrasound include operator skill, the inability to visualize osseous structures, and the challenge of visualizing posterior soft tissues for synovitis and fluid collections in larger patients. Finally, CT is only useful for focused evaluation of osteolysis or periprosthetic fracture.

ACR Appropriateness Criteria® Acute Trauma to the Ankle.

Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Acute Trauma to the Knee.

Acute trauma to the knee is a common presentation seen in the emergency department. After a routine clinical examination, imaging is frequently performed to facilitate the diagnosis and almost always starts with radiographs. If clinically indicated, advanced cross-sectional imaging may then be performed for further evaluation. CT is often performed for preoperative planning of the complex tibial plateau and distal femur fractures. Currently, MRI is the study of choice for evaluation of bone marrow, internal derangements, and other soft-tissue injuries about the knee joint. In patients with knee dislocations, MR angiography may be performed simultaneously with MRI for evaluation of internal derangements and vascular injuries with less morbidity compared to conventional angiography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Acute Trauma to the Foot.

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Radiologic Update on Arthroplasties in the Wrist and Hand.

Arthritis involving the hand and wrist can significantly impair functions of daily living. Although arthrodesis provides pain relief, it limits range of motion at the affected joint. Arthroplasty is an alternative surgical treatment for hand and wrist arthritis, providing both pain relief and restoration of a range of motion. Over the past decade, several advances have occurred in hand and wrist arthroplasty designs. This article reviews component design, normal imaging appearance, and common complications of arthroplasty used in the wrist and hand. It also introduces readers to newer arthroplasty designs.

Radiologic Guide to Surgical Treatment of Kienbock's Disease.

Kienbock's disease, or avascular necrosis of the lunate, is a progressive disease ultimately resulting in end-stage arthrosis of the wrist. Various surgical treatments are available for different Lichtman stages of disease. We review the surgical options and indications, expected radiologic post-operative appearance, as well as detail potential surgical complications, as they relate to Kienbock's disease.

Surgical Correction of Articular Damage in the Knee: Osteoarticular Transplantation to Joint Reconstruction.

Injuries of the articular cartilage remain difficult to treat and can range from small articular cartilage defects to end-stage severe osteoarthritis. In this review, we discuss various surgical treatment options including imaging features and associated complications. Specifically, we review microfracture, acellular matrix-induced microfracture, autologous osteochondral transplantation, osteochondral allograft transplantation, autologous chondrocyte implantation, along with various forms of knee arthroplasties.

Quality metrics currently used in academic radiology departments: results of the QUALMET survey.

OBJECTIVE: We present the results of the 2015 quality metrics (QUALMET) survey, which was designed to assess the commonalities and variability of selected quality and productivity metrics currently employed by a large sample of academic radiology departments representing all regions in the USA. METHODS: The survey of key radiology metrics was distributed in March-April of 2015 via personal e-mail to 112 academic radiology departments. RESULTS: There was a 34.8% institutional response rate. We found that most academic departments of radiology commonly utilize metrics of hand hygiene, report turn around time (RTAT), relative value unit (RVU) productivity, patient satisfaction and participation in peer review. RTAT targets were found to vary widely. The implementation of radiology peer review and the variety of ways in which peer review results are used within academic radiology departments, the use of clinical decision support tools and requirements for radiologist participation in Maintenance of Certification also varied. Policies for hand hygiene and critical results communication were very similar across all institutions reporting, and most departments utilized some form of missed case/difficult case conference as part of their quality and safety programme, as well as some form of periodic radiologist performance reviews. CONCLUSION: Results of the QUALMET survey suggest many similarities in tracking and utilization of the selected quality and productivity metrics included in our survey. Use of quality indicators is not a fully standardized process among academic radiology departments. Advances in knowledge: This article examines the current quality and productivity metrics in academic radiology.

Total elbow arthroplasty: a radiographic outcome study.

OBJECTIVES: Total elbow arthroplasty (TEA) is becoming a popular alternative to arthrodesis for patients with end-stage elbow arthrosis and comminuted distal humeral fractures. Prior outcome studies have primarily focused on surgical findings. Our purpose is to determine the radiographic outcome of TEA and to correlate with clinical symptoms such as pain. MATERIALS AND METHODS: This is an IRB-approved retrospective review from 2005 to 2015 of all patients with semiconstrained TEA. All available elbow radiographs and clinical data were reviewed. Data analysis included descriptive statistics and Kaplan-Meier survival curves for radiographic and clinical survival. RESULTS: A total of 104 total elbow arthroplasties in 102 patients were reviewed; 75 % were in women and the mean patient age was 63.1 years. Mean radiographic follow-up was 826 days with average of four radiographs per patient. Seventy TEAs (67 %) developed radiographic complications, including heterotopic ossification (48 %), perihardware lucency (27 %), periprosthetic fracture (23 %), hardware subluxation/dislocation (7 %), polyethylene wear (3 %), and hardware fracture/dislodgement (3 %); 56 patients (55 %) developed symptoms of elbow pain or instability and 30 patients (30 %) underwent at least one reoperation. In patients with radiographic complications, 66 % developed elbow pain, compared to 19 % of patients with no radiologic complications (p = 0.001). Of the patients with radiographic complications, 39 % had at least one additional surgery compared to 0 % of patients without radiographic complications (p = 0.056). CONCLUSIONS: Radiographic complications are common in patients after total elbow arthroplasty. There is a strong positive association between post-operative radiographic findings and clinical outcome. Knowledge of common postoperative radiographic findings is important for the practicing radiologist.

Imaging findings of adiposis dolorosa vs. massive localized lymphedema.

PURPOSE: Adiposis dolorosa (Dercum's disease) is a condition of benign, painful subcutaneous lipomatous lesions associated with weakness, endocrine and lipid abnormalities, and mental disturbances. There is little information documenting the cross-sectional imaging findings that differentiate it from lipomatous and neoplastic soft tissue masses, or massive localized lymphedema. The purpose of this study was to provide a radiological case series of adiposis dolorosa. METHODS: A 10-year retrospective review of the picture archiving and communications system was performed. Two musculoskeletal radiologists reviewed images to confirm and document imaging features, location, size, and patient demographics. Medical records were reviewed to characterize patients into three groups: one group met at least three of the four criteria of Dercum's syndrome, the second group met less than three criteria, and the third group had clinical diagnosis of cellulitis of the lower extremity. RESULTS: Seventeen cases (25 masses) of adiposis dolorosa were found, nine cases of which met at least three criteria of Dercum's syndrome. All cases in the first two groups demonstrated skin thickening and lymphedema of subcutaneous fat, which was fluid attenuation on CT and low or intermediate T1-weighted and high STIR/T2-weighted MR signal. Two cases with pathology showed mild fatty infiltration with fibrous septa, and the third case showed massive localized lymphedema. The third group of ten cellulitis patients demonstrated non-mass-like subcutaneous edema with similar CT attenuation and MR signal characteristics to the first two groups, but differed by the presence of post-contrast enhancement and non-mass-like appearance in 90%. CONCLUSION: Imaging findings of adiposis dolorosa and massive localized lymphedema overlap, as do the symptoms and pathological features. Due to the mass-like engorgement of the soft tissues and pain, patients will often undergo imaging to exclude neoplasm or infection. Knowledge of these conditions and the characteristic imaging findings is important to prevent unnecessary biopsy and misdiagnosis.

Unlocking the jaw: advanced imaging of the temporomandibular joint.

OBJECTIVE: Temporomandibular joint (TMJ) dysfunction is a common condition, affecting up to 28% of the population. The TMJ can be affected by abnormal dynamics of the disk-condyle complex, degenerative arthritis, inflammatory arthritis, and crystal arthropathy. Less commonly, neoplasms and abnormal morphologic features of the condyle are causes of TMJ symptoms. Cross-sectional imaging is frequently used for diagnosis. CONCLUSION: Knowledge of the normal imaging appearance of the TMJ, its appearance on radiological examination, and interventional techniques are useful for providing a meaningful radiologic contribution. This article will review normal TMJ anatomy; describe the normal ultrasound, CT, and MRI appearances of TMJ; provide imaging examples of abnormal TMJs; and illustrate imaging-guided therapeutic TMJ injection.

Imaging of current spinal hardware: lumbar spine.

OBJECTIVE: The purposes of this article are to review the indications for and the materials and designs of hardware more commonly used in the lumbar spine; to discuss alternatives for each of the types of hardware; to review normal postoperative imaging findings; to describe the appropriateness of different imaging modalities for postoperative evaluation; and to show examples of hardware complications. CONCLUSION: Stabilization and fusion of the lumbar spine with intervertebral disk replacement, artificial ligaments, spinous process distraction devices, plate-and-rod systems, dynamic posterior fusion devices, and newer types of material incorporation are increasingly more common in contemporary surgical practice. These spinal hardware devices will be seen more often in radiology practice. Successful postoperative radiologic evaluation of this spinal hardware necessitates an understanding of fundamental hardware design, physiologic objectives, normal postoperative imaging appearances, and unique complications. Radiologists may have little training and experience with the new and modified types of hardware used in the lumbar spine.

Imaging current spine hardware: part 1, cervical spine and fracture fixation.

OBJECTIVE: The goals of this article are to review the indications for use, the materials, and the designs of hardware more commonly used in the cervical spine; to discuss alternatives for each of the different types of hardware; to review normal postoperative imaging findings; to describe the appropriateness of different imaging modalities for postoperative evaluation; and to illustrate examples of hardware complications. This article will also review vertebral body fracture fixation. CONCLUSION: Stabilization and fusion of the spine with intervertebral disk replacement, artificial ligaments, spinous process distraction devices, plate-and-rod systems, dynamic posterior fusion devices, and implants composed of new types of material are increasingly more common in the contemporary surgical practice. These spinal hardware devices will be seen more often in radiology practice. Successful postoperative radiologic evaluation of spinal hardware necessitates an understanding of the fundamental design of the hardware, the physiologic objective of the hardware, normal and abnormal postoperative imaging appearances, and complications unique to the hardware.

Soft-tissue myxomatous lesions: review of salient imaging features with pathologic comparison.

Myxoid soft-tissue lesions are a heterogeneous group of benign and malignant mesenchymal tumors with an abundance of extracellular mucoid material. These lesions may mimic cysts on radiologic evaluation because of the high water content, and histopathologic features also overlap. Benign myxoid lesions include intramuscular myxoma, synovial cyst, bursa, ganglion, and benign peripheral nerve sheath tumor, including neurofibroma and schwannoma. Malignant entities include myxoid liposarcoma, myxoid leiomyosarcoma, myxoid chondrosarcoma, ossifying fibromyxoid tumor, and myxofibrosarcoma. Some syndromes are associated with myxoid soft-tissue lesions, such as Mazabraud syndrome in patients with soft-tissue myxomas and fibrous dysplasia. Certain discriminating features, such as intralesional fat in a myxoid liposarcoma, perilesional edema and a rim of fat in soft-tissue myxoma, and the swirled T2-weighted signal intensity and enhancement pattern of aggressive angiomyxoma, assist the radiologist in differentiating these lesions. The presence of an internal chondroid matrix or incomplete peripheral ossification may suggest myxoid chondrosarcoma or ossifying fibromyxoid tumor, respectively. The entering-and-exiting-nerve sign is suggestive of a peripheral nerve sheath tumor. Communication with a joint or tendon sheath and peripheral enhancement may indicate a ganglion or synovial cyst. This article (a) reviews the magnetic resonance, computed tomographic, and ultrasonographic imaging characteristics of soft-tissue myxomatous lesions, emphasizing imaging findings that can help differentiate benign and malignant lesions; (b) presents differential diagnoses; and (c) provides pathologic correlation.

The "open letter": radiologists' reports in the era of patient web portals.

Historically, radiologists' official written reports have functionally been proprietary communications between radiologists and referring providers. Although never secret, these reports have traditionally been archived in the medical record, with tightly controlled access. Patients rarely viewed reports directly. As patient-centered care, transparent communication, and electronic archiving have converged, however, radiologists' reports, like many other medical record components, are increasingly accessible to patients via web-based "portals." Many radiologists harbor justified anxiety about whether and how radiology reports should change in response to these portals. Direct patient access to radiology reports raises several questions, including: who are reports really for, what is their essential purpose, what content should they include or omit, what limits should be placed on their accessibility, and what ethical and legal ramifications arise from the reports' unfettered accessibility. In this paper, we outline the challenges and opportunities that arise from direct patient access to radiology reports via web-based portals, and propose an approach to optimizing radiologists' reports in an era of enhanced transparency. We conclude that, in effect, the health information web portal is a "train which has left the station"; patient portals are a nationwide reality, and transparency is now a public and professional expectation. Radiologists urgently need to consider quality implications for their report writing in order to address the challenges these developments pose, and to best harness the potential benefits for patients and providers.