MRI of common penile pathologies and penile prostheses.

MRI can delineate finer details of penile anatomy and pathology due to inherent higher soft-tissue contrast and spatial resolution. It can characterize inflammation and identify abscesses, localize penile fractures, guide surgical planning in penile fibrosis and Peyronie's disease, and depict components of the penile prosthesis and its complications. MRI is a great investigative tool for penile neoplasms, including locally infiltrative neoplasms where clinical examination is limited, and local staging is crucial for surgical planning.

ACR TI-RADS: Pitfalls, Solutions, and Future Directions.

The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. Risk classification models based on US features have been created by multiple professional societies, including the American College of Radiology (ACR), which published the Thyroid Imaging Reporting and Data System (TI-RADS) in 2017. ACR TI-RADS uses a standardized lexicon for assessment of thyroid nodules to generate a numeric scoring of features, designate categories of relative probability of benignity or malignancy, and provide management recommendations, with the aim of reducing unnecessary biopsies and excessive surveillance. Adopting ACR TI-RADS may require practice-level changes involving image acquisition and workflow, interpretation, and reporting. Significant resources should be devoted to educating sonographers and radiologists to accurately recognize features that contribute to the scoring of a nodule. Following a system that uses approved terminology generates reproducible and relevant reports while providing clarity of language and preventing misinterpretation. Comprehensive documentation facilitates quality improvement efforts. It also creates opportunities for outcome data and other performance metrics to be integrated with research. The authors review ACR TI-RADS, describe challenges and potential solutions related to its implementation based on their experiences, and highlight possible future directions in its evolution. ©RSNA, 2019 See discussion on this article by Hoang.

Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach.

Certain inflammatory pancreatic abnormalities may mimic pancreatic ductal adenocarcinoma at imaging, which precludes accurate preoperative diagnosis and may lead to unnecessary surgery. Inflammatory conditions that may appear masslike include mass-forming chronic pancreatitis, focal autoimmune pancreatitis, and paraduodenal pancreatitis or "groove pancreatitis." In addition, obstructive chronic pancreatitis can mimic an obstructing ampullary mass or main duct intraductal papillary mucinous neoplasm. Secondary imaging features such as the duct-penetrating sign, biliary or main pancreatic duct skip strictures, a capsulelike rim, the pancreatic duct-to-parenchyma ratio, displaced calcifications in patients with chronic calcific pancreatitis, the "double duct" sign, and vessel encasement or displacement can help to suggest the possibility of an inflammatory mass or a neoplastic process. An awareness of the secondary signs that favor a diagnosis of malignant or inflammatory lesions in the pancreas can help the radiologist to perform the differential diagnosis and determine the degree of suspicion for malignancy. Repeat biopsy or surgical resection may be necessary to achieve an accurate diagnosis and prevent unnecessary surgery for inflammatory conditions. Online supplemental material and DICOM image stacks are available for this article. ©RSNA, 2019.

Hepatic complications of oral contraceptive pills and estrogen on MRI: Controversies and update - Adenoma and beyond.

Hepatic complications of oral contraceptive pills and exogenous estrogens include intrahepatic canalicular cholestasis, neoplasm formation and vascular pathologies. While it remains controversial as to whether estrogen plays a role in focal nodular hyperplasia, hemangioma or hamartoma, exposure to oral contraceptive pills and estrogen has a strong association with hepatic adenomas. Four different subgroups of adenomas have been described: Inflammatory, HNF-1α-mutated, ß-catenin-mutated and unclassified. Vascular complications may include Budd-Chiari syndrome, vascular thrombosis, dilated sinusoids and peliosis.

The LACSEMS: what radiologists need to know.

Endoscopic drainage is increasingly used in lieu of percutaneous or surgical drainage of pancreatitis-related fluid collections. The lumen-apposing, covered, self-expanding, metallic stent (LACSEMS) is a newly produced stent for the transmural drainage of such fluid collections. The use of LACSEMS devices requires close coordination between knowledgeable radiologic and gastrointestinal providers. We review pancreatitis-related fluid collections and show examples from our experience with LACSEMS and the appropriate case selection, planning, deployment, and follow-up for this novel device.

New Job, New Challenges: Life After Radiology Training.

OBJECTIVE: Beginning a new job after radiology training is exciting but can also be nerve-racking. The key challenge remains making the strange familiar and assimilating with the new practice as soon as possible. This process is complicated and may require learning new policies, getting to know new colleagues, adapting to new surroundings, and learning new skills. CONCLUSION: This article provides strategies to navigate professionally and adapt to a new environment.

Diagnostic Error Categorization at Abdominal Imaging Peer Learning Conference.

Recognizing and preventing diagnostic errors is an increasingly emphasized topic across medicine, and abdominal imaging is no exception. Peer-learning strives for quality improvement through understanding why errors occur and identifying opportunities to prevent errors from recurring. In an effort to learn from mistakes, our abdominal imaging section initiated a Peer Learning Conference, where errors are discussed and compartmentalized into one or more of the following categories: Observation, Interpretation, Communication, and Inadequate Data Gathering. In this manuscript, the structure of our Peer Learning Conference is introduced and the components of each discrepancy category are described in detail. Images are included to highlight learning points through exemplary cases from the conference.

The Incentive Dilemma: Intrinsic Motivation and Workplace Performance.

Incentive plans are a core component of many radiology positions and are often considered a major factor in the ability to recruit and retain high-performing radiologists. Financial incentives are widely thought to be effective at motivating individuals, but there is considerable evidence to the contrary. In this report, the authors examine basic assumptions about financial incentives and debate the potential negative impact of financial incentive systems on performance at radiology practices.

Overnight Resident versus 24-hour Attending Radiologist Coverage in Academic Medical Centers.

Academic medical centers have long relied on radiology residents to provide after-hours coverage, which means that they essentially function with autonomy. In this approach, attending radiologist review of resident interpretations occurs the following morning, often by subspecialist faculty. In recent years, however, this traditional coverage model in academic radiology departments has been challenged by an alternative model, the 24-hour attending radiologist coverage. Proponents of this new model seek to improve patient care after hours by increasing report accuracy and the speed with which the report is finalized. In this article, we review the traditional and the 24-hour attending radiologist coverage models. We summarize previous studies that indicate that resident overnight error rates are sufficiently low so that changing to an overnight attending model may not necessarily provide a meaningful increase in report accuracy. Whereas some centers completely replaced overnight residents, we note that most centers use a hybrid model, and overnight residents work alongside supervising attending radiologists, much as they do during the day. Even in this hybrid model, universal double reading and subspecialist final review, typical features of the traditional autonomous resident coverage model, are generally sacrificed. Because of this, changing from resident coverage to coverage by an attending radiologist that is 24 hours/day, 7 days/week may actually have detrimental effects to patient safety and quality of care provided. Changing to an overnight attending radiologist model may also have negative effects on the quality of radiology resident training, and it significantly increases cost.

Fundamentals of Diagnostic Error in Imaging.

Imaging plays a pivotal role in the diagnostic process for many patients. With estimates of average diagnostic error rates ranging from 3% to 5%, there are approximately 40 million diagnostic errors involving imaging annually worldwide. The potential to improve diagnostic performance and reduce patient harm by identifying and learning from these errors is substantial. Yet these relatively high diagnostic error rates have persisted in our field despite decades of research and interventions. It may often seem as if diagnostic errors in radiology occur in a haphazard fashion. However, diagnostic problem solving in radiology is not a mysterious black box, and diagnostic errors are not random occurrences. Rather, diagnostic errors are predictable events with readily identifiable contributing factors, many of which are driven by how we think or related to the external environment. These contributing factors lead to both perceptual and interpretive errors. Identifying contributing factors is one of the keys to developing interventions that reduce or mitigate diagnostic errors. Developing a comprehensive process to identify diagnostic errors, analyze them to discover contributing factors and biases, and develop interventions based on the contributing factors is fundamental to learning from diagnostic error. Coupled with effective peer learning practices, supportive leadership, and a culture of quality, this process can unquestionably result in fewer diagnostic errors, improved patient outcomes, and increased satisfaction for all stakeholders. This article provides the foundational elements for implementing this type of process at a radiology practice, with examples to help radiologists and practice leaders achieve meaningful practice improvement. ©RSNA, 2018.

Knife wielding radiologist: A case report of primary pancreatic lymphoma.

Majority of malignant pancreatic neoplasms are epithelial in origin and mostly arise from exocrine gland. Ductal adenocarcinoma compromises the major histological type of such tumors. Primary non-epithelial tumors of exocrine pancreatic gland are extremely rare and incorporate lymphoma and sarcoma. Primary pancreatic lymphoma compromises less than 0.5% of pancreatic malignancies. Primary pancreatic lymphoma can be difficult to differentiate from pancreatic adenocarcinoma and other neoplasms on imaging, and a correct diagnosis is crucial for appropriate patient management.

Gastropericardial fistula: radiologic findings and literature review.

BACKGROUND: Gastropericardial fistula, a rare condition characterized by an abnormal communication between the stomach and the pericardium, is an emergency as sequelae such as cardiac tamponade and sepsis may lead to hemodynamic instability and death. We aimed to summarize the surgical and radiologic findings of the reported cases published to date, describe their pertinent surgical history, and present an algorithm for diagnosis. METHODS: The Pubmed database was searched using the terms: gastropericardial, pericardiogastric, pneumopericardium, pericardial, and pneumopericardium with the term "fistula" added to each term. The search was limited to January 2000-October 2015 and English language publications. RESULTS: Thirty five cases were identified. The most common etiology was prior esophageal and/or gastric surgery (80% of cases; esophagectomy = 26%/gastrointestinal reflux disease associated surgery = 23%/bariatric surgery = 11%/partial gastrectomy = 6%/other = 20%). The average duration between presentation and surgery was 7.3 ± 6.2 years (SD). Radiology typically played a crucial role in diagnosis with computed tomography most commonly demonstrated to be the most appropriate modality to demonstrate the fistula and assist in surgical planning. Contrast studies were frequently helpful to confirm the diagnosis. Chest x-ray findings including pneumopericardium and pericardial thickening were contributory but nonspecific. Esophagoduodenoscopy characterized the fistula in cases where imaging was equivocal and may provide therapeutic options. CONCLUSIONS: We present the clinical radiologic findings of the 35 cases of gastropericardial fistula reported. This is the first literature review of gastropericardial fistula to focus on the effectiveness of these various diagnostic modalities and to present an algorithm for diagnosis.

Risk factors for the development of an incisional hernia after sigmoid resection for diverticulitis: an analysis of 33 patients, operative and disease-associated factors.

Incisional hernia (IH) is a relatively common sequelae of sigmoidectomy for diverticulitis. The aim of this study was to investigate factors that may predict IH in diverticulitis patients. Two hundred and one diverticulitis patients undergoing sigmoidectomy between January 2002 and December 2012 were identified (mean follow-up 5.15 ± 2.33 years). Patients with wound infections were excluded. Thirteen patient-associated, three diverticular disease-related, and 17 operative variables were evaluated in patients with and without IH. Volumetric fat was measured on preoperative CTs. Fischer's exact, χ(2), and Mann-Whitney tests and multivariate regression analysis were used for statistics. Thirty-four (17%) patients had an IH. On multivariate analysis, wound packing (OR 3.4, P = 0.017), postoperative nonwound infection (OR 7.4, P = 0.014), and previous hernia (OR 3.6, P = 0.005) were as independent predictors of IH. Fifteen of 34 (44%) patients who developed a hernia had a history of prior hernia. Of 33 potential risk factors analyzed, including smoking, chronic obstructive pulmonary disease, and obesity, the only patient factor present preoperatively associated with increased risk of a postsigmoidectomy hernia after multivariate analysis was a history of a previous hernia. Preoperative identification of patients with a history of hernia offers the opportunity to employ measures to decrease the likelihood of IH.

Surgical diverticulitis is not associated with defects in the expression of wound healing genes.

PURPOSE: The development of diverticuli may represent defects in collagen vascular tissue integrity possibly from a genetic predisposition. We evaluated the tissue expression of wound healing genes in sigmoid tissue from youthful patients undergoing surgery for diverticulitis and thus would more likely suffer from a genetic predisposition (SD mean age 39 ± 0.9) versus controls in the form of patients over the age of 50 (mean age 52.9 ± 10.5 years) without evidence of diverticular disease. METHODS: The mRNA expression of 84 genes associated with the extracellular matrix, cellular adhesion, growth factors, inflammatory cytokines, and signal transduction was evaluated in 16 SD and 15 control tissues using a Qiagen Wound Healing Array. Vitronectin, the gene protein with the highest potential significance on raw analysis, was further investigated using a Taqman assay with an additional 11 SD (total n = 27) and four control (total n = 19) samples. Statistics were by Student's t and Mann-Whitney tests with Bonferroni correction. RESULTS: No significant differences in mRNA expression between the SD and control tissue in the 84 measured genes were demonstrated after correction. Vitronectin mRNA expression was downregulated 2.7-fold in SD tissue vs. tissue from non-neoplastic control patients (p = 0.001 raw/0.08 corrected). However, on vitronectin TaqMan analysis, no difference in expression was seen in SD vs. all controls or in all subset comparisons. CONCLUSIONS: The lack of significant alteration in mRNA expression of traditionally associated wound healing genes/proteins in young SD patients suggests that such genes play a minor role in the genetic predisposition to youthful diverticulitis.

Measurement of visceral fat on preoperative computed tomography predicts complications after sigmoid colectomy for diverticular disease.

BACKGROUND: Visceral and subcutaneous abdominal fat parameters have been associated with worse surgical outcomes in colorectal cancer but have not been investigated in diverticulitis. METHODS: Volumetric fat parameters were measured on preoperative computed tomography scans from 211 diverticulitis patients. Primary outcome was a serious postoperative complication (Clavien-Dindo grades 2-4). Variables including age, disease duration, American Society of Anesthesiology score, ostomy, immunosuppression, body mass index, and volumetric fat parameters were examined. SPSS was used for statistics. RESULTS: The serious postoperative complication rate was 12.7%. On univariate analysis, several factors including older age (P = .0001), ostomy creation (P = .02), higher visceral fat (VF, P = .01), emergent surgery (P = .05), and higher American Society of Anesthesiology score (P = .05) were associated with complications. On multivariate regression analysis, only VF was independently associated with complications. CONCLUSIONS: Diverticulitis patients with high VF are more likely to develop complications after sigmoidectomy. VF measurement may potentially be used as a tool to assist in surgical decision making and prediction of outcomes.