Sociodemographic Factors and Screening CT Colonography Use Among Medicare Beneficiaries.

BACKGROUND. Approximately one-third of the eligible U.S. population have not undergone guideline-compliant colorectal cancer (CRC) screening. Guidelines recognize various screening strategies to increase adherence. CMS provides coverage for all recommended screening tests except CT colonography (CTC). OBJECTIVE. The purpose of this study was to compare CTC and other CRC screening tests in terms of associations of utilization with income, race and ethnicity, and urbanicity in Medicare fee-for-service beneficiaries. METHODS. This retrospective study used CMS Research Identifiable Files from January 1, 2011, through December 31, 2020. These files contain claims information for 5% of Medicare fee-for-service beneficiaries. Data were extracted for individuals 45-85 years old, and individuals with high CRC risk were excluded. Multivariable logistic regression models were constructed to determine the likelihood of undergoing CRC screening tests (as well as of undergoing diagnostic CTC, a CMS-covered test with similar physical access as screening CTC) as a function of income, race and ethnicity, and urbanicity while controlling for sex, age, Charlson comorbidity index, U.S. census region, screening year, and related conditions and procedures. RESULTS. For 12,273,363 beneficiary years (mean age, 70.5 ± 8.2 [SD] years; 2,436,849 unique beneficiaries: 6,774,837 female beneficiaries, 5,498,526 male beneficiaries), there were 785,103 CRC screenings events, including 645 for screening CTC. Compared with individuals living in communities with per capita income of less than US$25,000, individuals in communities with income of US$100,000 or more had OR for undergoing screening CTC of 5.73, optical colonoscopy (OC) of 1.36, sigmoidoscopy of 1.03, guaiac fecal occult blood test or fecal immunochemical test of 1.50, stool DNA of 1.43, and diagnostic CTC of 2.00. The OR for undergoing screening CTC was 1.00 for Hispanic individuals and 1.08 for non-Hispanic Black individuals compared with non-Hispanic White individuals. Compared with the OR for undergoing screening CTC for residents of metropolitan areas, the OR was 0.51 for residents of micropolitan areas and 0.65 for residents of small or rural areas. CONCLUSION. The association with income was substantially larger for screening CTC than for other CRC screening tests or for diagnostic CTC. CLINICAL IMPACT. Medicare's noncoverage for screening CTC may contribute to lower adherence with CRC screening guidelines for lower-income beneficiaries. Medicare coverage of CTC could reduce income-based disparities for individuals avoiding OC owing to invasiveness, need for anesthesia, or complication risk.

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.

Update on The National Accreditation Program for Rectal Cancer (NAPRC): the radiologist's role.

The National Accreditation Program for Rectal Cancer (NAPRC) was established by the American College of Surgeons with the goal of standardizing care of rectal cancer patients in order to improve outcomes. NAPRC accreditation requires compliance with an established set of standards, many of which are directly related to radiology participation in multidisciplinary conference, rectal MR image acquisition, interpretation and reporting, and radiologist education. This paper outlines the pertinent standards/requirements for radiologists as part of the Rectal Cancer Multidisciplinary Team in the NAPRC guidelines, with proposed methods and tips for implementation of these standards from the perspective of the radiologist.

Ultrasound Evaluation for Extremity Deep Vein Thrombus in COVID-19-Positive Patients: Exam Positivity Rate and Association With D-Dimer Level.

OBJECTIVES: Determine the rate of positive extremity ultrasound exams for DVT in patients with COVID-19 and assess for differences in laboratory values in patients with and without DVT, which could be used as a surrogate to decide the need for further evaluation with ultrasound. METHODS: Retrospective case control study with 1:2 matching of cases (COVID-19+ patients) to controls (COVID-19- patients) based on age, gender, and race. Laboratory values assessed were serum D-dimer, fibrinogen, prothrombin time, international normalized ratio, and C-reactive protein. Demographic variables, comorbidities, and clinical variables including final disposition were also evaluated. P-values for categorical variables were calculated with the chi-square test or Fisher's exact test. P-values for continuous variables were compared with the use of a two-tailed unpaired t-test. RESULTS: The rate of extremity ultrasound exams positive for DVT were similar in patients with (14.7%) and without (19.3%) COVID-19 (P = .423). No significant difference was observed in laboratory values including the D-dimer level in COVID-19 patients without (mean 9523.9 ng/mL (range 339 to >60,000)) or with DVT (mean 13,663.7 ng/mL (range 1193->60,000)) (P = .475). No differences were found in demographic variabilities or co-morbidities among COVID-19 patients with and without extremity DVT. CONCLUSIONS: We found no statistically significant difference in rate of positive DVT studies between COVID-19+ and COVID-19- patients. D-dimer levels are elevated, in some cases markedly, in COVID-19 patients with and without DVTs and therefore these data do not support their use as a surrogate when assessing the need for ultrasound evaluation.

Gender of Department Chair and Paid Parental Leave Benefits in Academic Radiology Residency Programs.

RATIONALE AND OBJECTIVES: Residency training often overlaps with prime childbearing years, yet variability in availability and duration of parental leave in residency can complicate the decision to become parents. Gender disparities in attitudes towards parenthood in residency is well recognized, with females generally reporting more concerns surrounding prolonged training, hindrance of future career plans, and negative perception from peers. However, gender of the department chair has not yet been examined as a factor influencing parental leave policies for residents in Radiology. MATERIALS AND METHODS: The gender of the department chair and parental leave policies for residents in 209 ACGME accredited diagnostic radiology programs across the United States were procured from their websites. These programs were stratified into 6 geographical regions to identify regional differences. Chi-squared analyses were used to compare availability of paid parental benefits with the gender of department chairs. RESULTS: Seventy-seven percent of diagnostic radiology program department chairs were male. 34 of 49 programs (69%) with female department chairs advertised paid parental benefits, compared to 61 of 160 programs (38%) chaired by males (P < 0.001). When stratified by region, this gender difference remained statistically significant in the mid-Atlantic and New England. CONCLUSION: Female gender of the department chair was associated with the increased availability of paid parental leave benefits for residents, yet females hold fewer academic leadership positions than males. Future discussions regarding parental leave policies for residents will have to consider the unique challenges in residency such as length of training and burden on coresidents.

U.S. Preventive Services Task Force Update and Computed Tomography for Colorectal Cancer Screening Among Privately Insured Population.

INTRODUCTION: The Affordable Care Act of 2010 mandated private health plans to fully cover the services recommended by the U.S. Preventive Services Task Force. In June 2016, the Task Force added computed tomography colonography to its list of recommended tests for colorectal cancer screening. This study evaluates the association among the updated recommendation, patient cost-sharing obligations, and the uptake of colorectal cancer screening through computed tomography colonography in the privately insured population. METHODS: Using individual claims from the 2010-2018 IBM MarketScan Commercial Database, monthly screening computed tomography colonography utilization rates per 100,000 privately insured beneficiaries aged 50-64 years and the monthly proportions of these services delivered by in-network providers for which patients had to bear a portion of the procedure costs were calculated, and an interrupted time series analysis was performed. The study was conducted between January and May 2020. RESULTS: Although the proportion of in-network procedures subject to patient cost sharing declined from 38.2% in 2010 to 10.2% in early 2016, the monthly utilization remained nearly constant. The announcement of the updated recommendation was associated with an immediate increase in the monthly screening computed tomography colonography utilization rate from 0.4 to 0.6 procedures per 100,000 individuals but with no change in the proportion of in-network procedures subject to patient cost sharing. CONCLUSIONS: In an environment of already largely eliminated patient cost sharing, the release of supportive evidence-based recommendations by a recognized credible body was associated with an immediate increase in computed tomography colonography use for colorectal cancer screening in the privately insured population.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications.

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

Use of Screening CT Colonography by Age and Race: A Study of Potential Access Barriers Related to Medicare Noncoverage Based on Data From the ACR's National CT Colonography Registry.

OBJECTIVE: The primary objectives of this investigation were to evaluate the use of screening CT colonography (CTC) examinations by age comparing individuals of Medicare-eligible age to younger cohorts and to determine if the association between use of CTC and Medicare-eligible age varies by race. Although the Affordable Care Act requires commercial insurance coverage of screening CTC, Medicare does not cover screening CTC. MATERIALS AND METHODS: Using the ACR's CTC registry, the distribution of procedures by age was evaluated using a negative binomial model with patient age (to capture overall trend), indicator of Medicare-eligible age (to capture immediate changes in trend at age 65), and their interaction (to capture gradual changes after age 65) as independent variables. The association between the number of screening CTCs and age was compared by racial identity. RESULTS: The CTC registry contained data on 12,648 screening examinations. Between ages 52 and 64, the number of screening examinations increased; each additional age year was associated with a 5.3% (P < .001) increase in the number of screenings. However, after age 65, the number of screening examinations decreased by -6.9% per additional year of age above 65 compared with the trend between ages 52 and 64 (P < .001). The modal age group for CTC use was 65 to 69 years in white and 55 to 59 in black individuals. CONCLUSION: After age 65, the number of screening CTC examinations decreased, likely due, at least in part, to lack of Medicare coverage. Medicare noncoverage may have a disproportionate impact on black patients and other racial minorities.

Examining Gender Disparity in Academic Abdominal Radiology in North America.

BACKGROUND: Gender disparity exists in nearly every medical specialty, particularly in leadership roles and academia. Radiology is not exempt from this phenomenon, with women making up less than a third of radiology residents in the United States (US). This can have long-lasting effects on the career progression of female radiologists. Our search did not reveal any study on gender composition in academic abdominal radiology. PURPOSE: To evaluate the academic productivity and career advancement of female academic abdominal radiology faculty in the United States and Canada. MATERIALS AND METHODS: Parameters of academic achievement were measured, including the number of citations and publications, years of research, as well as H-index. Information regarding academic and leadership ranking among academic abdominal radiologists in the United States and Canada was also analyzed. RESULTS: In academic abdominal radiology, there were fewer females than males (34.9% vs 65.1%; p-value 0.256). Among the female radiologists, the greatest proportion held the rank of assistant professor (40%). Female representation decreased with increasing rank. Females had a lower H-index than males (P-value = 0.0066) and significantly fewer years of research than males (P-value = 0.0243). CONCLUSION: Male predominance in academic abdominal radiology is similar to many other medical specialties, and encompasses senior faculty rank, leadership roles and research productivity.

Abdominal Manifestations of Sickle Cell Disease.

Sickle cell disease is a debilitating hematologic process that affects the entire body. Disease manifestations in the abdomen most commonly result from vaso-occlusion, hemolysis, or infection due to functional asplenia. Organ specific manifestations include those involving the liver (eg, hepatopathy, iron deposition), gallbladder (eg, stone formation), spleen (eg, infarction, abscess formation, sequestration), kidneys (eg, papillary necrosis, infarction), pancreas (eg, pancreatitis), gastrointestinal tract (eg, infarction), reproductive organs (eg, priapism, testicular atrophy), bone (eg, marrow changes, avascular necrosis), vasculature (eg, vasculopathy), and lung bases (eg, acute chest syndrome, infarction). Imaging provides an important clinical tool for evaluation of acute and chronic disease manifestations and complications. In summary, there are multifold abdominal manifestations of sickle cell disease. Recognition of these sequela helps guide management and improves outcomes. The purpose of this article is to review abdominal manifestations of sickle cell disease and discuss common and rare complications of the disease within the abdomen.

CT colonography's role in the COVID-19 pandemic: a safe(r), socially distanced total colon examination.

PURPOSE: To describe the favorable procedural profile of CT colonography (CTC) during the COVID-19 pandemic. CONCLUSION: Postponement of cancer screening due to COVID-19 has resulted in a backlog of individuals needing to undergo structural examination of the colon. The experience during the initial COVID-19 surge with urgent evaluation of the colon for transplant patients prior to transplant suggests that CTC can be done in a lower risk manner as compared to other structural examinations. The procedural profile of CTC is advantageous during this pandemic as maintaining social distancing and preserving healthcare supplies including PPE are of paramount importance. CTC is an important option to utilize in the screening armamentarium to allow effective screening of average risk asymptomatic individuals in the COVID-19 era.

Gallbladder Carcinoma and Its Differential Diagnosis at MRI: What Radiologists Should Know.

Gallbladder carcinoma is the most common cancer of the biliary system. It is challenging to diagnose because patients are often asymptomatic or present with nonspecific symptoms that mimic common benign diseases. Surgical excision is the only curative therapy and is best accomplished at early non-locally advanced stages. Unfortunately, gallbladder cancer often manifests at late locally advanced stages, precluding cure. Early tumors are often incidentally detected at imaging or at cholecystectomy performed for another indication. Typical imaging features of localized disease include asymmetric gallbladder wall thickening, polyps larger than 1.0 cm, and a solid mass replacing the gallbladder lumen. Advanced tumors are often infiltrative and can be confusing at CT and MRI owing to their large size. Determination of the origin of the lesion is paramount to narrow the differential diagnosis but is often challenging. It is important to identify gallbladder cancer and distinguish it from other benign and malignant hepatobiliary processes. Since surgical resection is the only curative treatment option, radiologist understanding and interpretation of pathways of nodal and infiltrative tumor spread can direct surgery or preclude patients who may not benefit from surgery. While both CT and MRI are effective, MRI provides superior soft-tissue characterization of the gallbladder and biliary tree and is a useful imaging tool for diagnosis, staging, and evaluation of treatment response. ©RSNA, 2020.

Geographic Dispersion and Rural Versus Urban Utilization of CT Colonography in the United States.

OBJECTIVE: To assess the geographic dispersion of CT colonography (CTC) as well as differences in CTC utilization in rural versus urban areas in individuals with commercial insurance. METHODS: Claims data from approximately 18.5 million commercially insured individuals across the United States were used to determine CTC utilization based on geographic area. Geographic areas were defined as metropolitan statistical areas (MSAs) and statewide non-MSAs. Utilization rates per 100,000 covered person-years were calculated for each geographic area for both screening and diagnostic CTC using 2017 data (the most recent full-year data available). Differences in CTC utilization between MSAs (urban) and non-MSAs (rural) were evaluated using weighted multivariate logistic regression. RESULTS: CTC is widely dispersed across the United States with substantial geographic variability. Utilization of screening CTC was considerably lower among individuals residing in rural areas compared with those in urban areas (adjusted odds ratio = 0.353, P = .005). For individuals aged 50 to 64 years, screening CTC utilization was 2.38 per 100,000 in rural areas versus 6.67 per 100,000 in urban areas (P = .005). Utilization of diagnostic CTC was also lower in rural compared with urban areas, though this difference was not statistically significant (8.40 per 100,000 versus 13.11 per 100,000 respectively, P = .070). CONCLUSIONS: Although CTC is performed widely across the United States, utilization is generally low and varies substantially based on geographic region. CTC utilization is lower among individuals in rural compared with urban areas.

Nonfetal Imaging During Pregnancy: Acute Abdomen/Pelvis.

Abdominal pain is a common occurrence in pregnant women and may have a variety of causes, including those that are specific to pregnancy (eg, round ligament pain in the first trimester) and the wide range of causes of abdominal pain that affect men and women who are not pregnant (eg, appendicitis, acute cholecystitis). Noncontrast magnetic resonance (MR) imaging is increasingly performed to evaluate pregnant women with abdominal pain, either as the first-line test or as a second test following ultrasonography. The imaging appearance of causes of abdominal pain in pregnant women are reviewed with an emphasis on noncontrast MR imaging.

Impact of Overlying Personal Items on CT Dose with Use of Automated Tube Current Modulation-Pilot Investigation.

PURPOSE: To determine the incidence and impact of overlying radiopaque personal items (e.g., cellular phones, zippers) on CT dose and image quality with use of automated tube current modulation. METHODS: Topogram images from 100 consecutive adult outpatient CT abdomen pelvis studies were retrospectively reviewed, and the number and type of overlying radiopaque personal items were recorded. Additionally, an anthropomorphic phantom was imaged with overlying personal items 1) present in topogram and axial images; 2) present in topogram but removed prior to axial acquisition; and 3) present in topogram positioned outside the field of view of the axial acquisition. dose length product (DLP) and CT dose index volume (CTDIvol) were compared to acquisitions performed without overlying personal items. Image noise was evaluated by assessing the standard deviation of Hounsfield units at the level of the overlying personal item. RESULTS: Overlying personal items were visible in topogram images for 55% of CT exams and included underwires (38% of exams), zippers (7%), and cellular phones (1%). DLP increased when a cellular phone was present in the topogram whether or not it was removed before axial image acquisition (3.7% p = 0.002, combined AutomA and SmartmA), and image noise increased (144%, p = 0.002; AutomA). No increase in dose or image noise was observed with overlying zippers or underwires or when any object was visible in the topogram outside the field of view of the axial images. CONCLUSIONS: Overlying personal items were observed in the majority of abdominopelvic CT scans. Large overlying radiopaque personal items resulted in increased dose and increased image noise. Removal of all overlying personal items will result in optimized dose and image quality.

Rectal cancer lexicon: consensus statement from the society of abdominal radiology rectal & anal cancer disease-focused panel.

Standardized terminology is critical to providing consistent reports to referring clinicians. This lexicon aims to provide a reference for terminology frequently used in rectal cancer and reflects the consensus of the Society of Abdominal Radiology Disease Focused Panel in Rectal cancer. This lexicon divided the terms into the following categories: primary tumor staging, nodal staging, treatment response, anal canal anatomy, general anatomy, and treatments.

Secondary Hypertension and Complications: Diagnosis and Role of Imaging.

Hypertension is a common problem; if left untreated, it can result in significant complications, including those involving the cardiovascular system and end organs. Approximately 10% of patients with hypertension are classified as having secondary hypertension, defined as hypertension attributable to a specific and potentially remediable cause. The evaluation for secondary hypertension typically begins with acquiring the patient history and performing a physical examination and screening laboratory tests. Directed imaging may be performed, on the basis of laboratory test results, to assess for potential causes of secondary hypertension. The causes can be broadly classified as endocrine (eg, hyperaldosteronism, pheochromocytoma, hyperparathyroidism) and nonendocrine (eg, aortic coarctation, renal vascular hypertension). In addition, patients with hypertension can develop significant complications that also are diagnosed with imaging, including conditions involving the cardiovascular system (eg, aortic aneurysm, acute aortic syndrome) and central nervous system (eg, stroke, subarachnoid hemorrhage, and posterior reversible encephalopathy syndrome). The imaging workup and imaging appearances of some of the causes of secondary hypertension are reviewed, treatment options are discussed, and the imaging appearances of hypertension-related complications are described. It is important for radiologists to accurately diagnose the secondary causes of hypertension, as many of them are treatable, and treatment may result in improved symptoms or resolution of hypertension. ©RSNA, 2019.

Locally recurrent rectal cancer: what the radiologist should know.

Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.