Comparing Preliminary and Final Neuroradiology Reports: What Factors Determine the Differences?

BACKGROUND AND PURPOSE: Trainees' interpretations of neuroradiologic studies are finalized by faculty neuroradiologists. We aimed to identify the factors that determine the degree to which the preliminary reports are modified. MATERIALS AND METHODS: The character length of the preliminary and final reports and the percentage character change between the 2 reports were determined for neuroradiology reports composed during November 2012 to October 2013. Examination time, critical finding flag, missed critical finding flag, trainee level, faculty experience, imaging technique, and native-versus-non-native speaker status of the reader were collected. Multivariable linear regression models were used to evaluate the association between mean percentage character change and the various factors. RESULTS: Of 34,661 reports, 2322 (6.7%) were read by radiology residents year 1; 4429 (12.8%), by radiology residents year 2; 3663 (10.6%), by radiology residents year 3; 2249 (6.5%), by radiology residents year 4; and 21,998 (63.5%), by fellows. The overall mean percentage character change was 14.8% (range, 0%-701.8%; median, 6.6%). Mean percentage character change increased for a missed critical finding (+41.6%, P < .0001), critical finding flag (+1.8%, P < .001), MR imaging studies (+3.6%, P < .001), and non-native trainees (+4.2%, P = .018). Compared with radiology residents year 1, radiology residents year 2 (-5.4%, P = .002), radiology residents year 3 (-5.9%, P = .002), radiology residents year 4 (-8.2%, P < .001), and fellows (-8.7%; P < .001) had a decreased mean percentage character change. Senior faculty had a lower mean percentage character change (-6.88%, P < .001). Examination time and non-native faculty did not affect mean percentage character change. CONCLUSIONS: A missed critical finding, critical finding flag, MR imaging technique, trainee level, faculty experience level, and non-native-trainee status are associated with a higher degree of modification of a preliminary report. Understanding the factors that influence the extent of report revisions could improve the quality of report generation and trainee education.

Critical findings: timing of notification in neuroradiology.

BACKGROUND AND PURPOSE: Timely reporting of critical findings in radiology has been identified by The Joint Commission as one of the National Patient Safety Goals. Our aim was to determine the magnitude of delays between identifying a neuroradiologic critical finding and verbally notifying the caregiver in an effort to improve clinical outcomes. MATERIALS AND METHODS: We surveyed the time of critical finding discovery, attempted notification, and direct communication between neuroradiologists and caregivers for weekday, evening, overnight, and weekend shifts during an 8-week period. The data were collected by trained observers and/or trainees and included 13 neuroradiology attendings plus fellows and residents. Critical findings were based on a previously approved 17-item list. Summary and comparative t test statistics were calculated, and sources of delays were identified. RESULTS: Ninety-one critical findings were recorded. The mean time from study acquisition to critical finding discovery was 62.2 minutes, from critical finding discovery to call made 3.7 minutes, and from call made to direct communication, 5.2 minutes. The overall time from critical finding discovery to caregiver notification was within 10 minutes in 72.5% (66/91) and 15 minutes in 93.4% (85/91) of cases. There were no significant differences across shifts except for daytime versus overnight and weekend shifts, when means were 2.4, 5.6, and 8.7 minutes, respectively (P < .01). If >1 physician was called, the mean notification time increased from 3.5 to 10.1 minutes (P < .01). Sources of delays included inaccurate contact information, physician unavailability (shift change/office closed), patient transfer to a different service, or lack of responsiveness from caregivers. CONCLUSIONS: Direct communication with the responsible referring physician occurred consistently within 10-15 minutes after observation of a critical finding. These delays are less than the average interval from study acquisition to critical finding discovery (mean, 62.2 minutes).

Neuroradiology critical findings lists: survey of neuroradiology training programs.

BACKGROUND AND PURPOSE: The Joint Commission has identified timely reporting of critical results as one of the National Patient Safety Goals. We surveyed directors of neuroradiology fellowships to assess and compare critical findings lists across programs. MATERIALS AND METHODS: A 3-question survey was e-mailed to directors of neuroradiology fellowships with the following questions: 1) Do you currently have a "critical findings" list that you abide by in your neuroradiology division? 2) How is that list distributed to your residents and fellows for implementation, if at all? and 3) Was this list vetted by neurology, neurosurgery, and otolaryngology departments? Programs with CF lists were asked for a copy of the list. Summary and comparative statistics were calculated. RESULTS: Fifty-one of 89 (57.3%) programs responded. Twenty-one of 51 (41.2%) programs had CF lists. Lists were distributed during orientation, sent via Web sites and e-mails, and posted in work areas. Eleven of 21 lists were developed internally, and 5 of 21, with the input from other departments. The origin of 5 of 21 lists was unknown. Forty CF entities were seen in 20 submitted lists (mean, 9.1; range, 2-23). The most frequent entities were the following: cerebral hemorrhage (18 of 20 lists), acute stroke (15 of 20), spinal cord compression (15 of 20), brain herniation (12 of 20), and spinal fracture/instability (12 of 20). Programs with no CF lists called clinicians on the basis of "common sense" and "clinical judgment." CONCLUSIONS: Less than a half (41.2%) of directors of neuroradiology fellowships that responded have implemented CF lists. CF lists have variable length and content and are predominantly developed by radiology departments without external input.

Quality control in neuroradiology: impact of trainees on discrepancy rates.

BACKGROUND AND PURPOSE: Prior studies have found a 2%-8% clinically significant error rate in radiology practice. We compared discrepancy rates of studies interpreted by subspecialty-trained neuroradiologists working with and without trainees. MATERIALS AND METHODS: Subspecialty-trained neuroradiologists reviewed 2162 studies during 41 months. Discrepancies between the original and "second opinion" reports were scored: 1, no change; 2, clinically insignificant detection discrepancy; 3, clinically insignificant interpretation discrepancy; 4, clinically significant detection discrepancy; and 5, clinically significant interpretation discrepancy. Faculty alone versus faculty and trainee discrepancy rates were calculated. RESULTS: In 87.6% (1894/2162), there were no discrepancies with the original report. The neuroradiology division had a 1.8% (39/2162; 95% CI, 1.3%-2.5%) rate of clinically significant discrepancies. In cases reviewed solely by faculty neuroradiologists (16.2% = 350/2162 of the total), the rate of discrepancy was 1.7% (6/350). With fellows (1232/2162, 57.0% of total) and residents (580/2162, 26.8% of total), the rates of discrepancy were 1.6% (20/1232) and 2.2% (13/580), respectively. The odds of a discrepant result were 26% greater (OR = 1.26; 95% CI, 0.38-4.20) when reading with a resident and 8% less (OR = 0.92; 95% CI, 0.35-2.44) when reading with a fellow than when reading alone. CONCLUSIONS: There was a 1.8% rate of clinically significant detection or interpretation discrepancy among academic neuroradiologists. The difference in the discrepancy rates between faculty only (1.7%), fellows and faculty (1.6%), and residents and faculty (2.2%) was not statistically significant but showed a trend indicating that reading with a resident increased the odds of a discrepant result.

Utilization rates of neuroradiology across neuroscience specialties in the private office setting: who owns or leases the scanners on which studies are performed?

BACKGROUND AND PURPOSE: Recent literature shows an increasing portion of imaging studies being conducted and interpreted by nonradiologists, especially across the modalities with the highest RVUs. We examined the trends in the Medicare technical charges for private office neuroradiology studies submitted by subspecialists to identify utilization trends among MR and CT scanner owners or lessees over the last decade. MATERIALS AND METHODS: The number of neuroradiology studies performed on MR and CT machines owned or leased in private offices was determined from the CMS PSPSMF for 1998-2008. Studies billed through technical and global charges were aggregated. Utilization rates and utilization rate CAGRs were computed by specialty and by imaging study. RESULTS: Between 1998 and 2008, MR studies grew by a factor of 2.5 and CT studies grew by 2.1. In 2008, radiologists charged the technical/global fee in 1,386,669 (56.6%), neurologists in 82,360 (3.4%), neurosurgeons in 29,218 (1.2%), multi/IDTF in 617,933 (25.2%), and other specialists in 334,843 (13.7%) of neuroradiology cases. Changes from the 1998 base rate to the 2008 rate per 1000 Medicare beneficiaries were 24.1 to 39.7 for radiologists, 1.03 to 2.4 for neurologists, 0.15 to 0.84 for neurosurgeons, 2.2 to 17.7 for multi/IDTF, and 1.3 to 9.6 for other specialists. All specialties, except for multi/IDTF, showed greater MR utilization increases than CT. Neurology (CAGR of 10.6%), neurosurgery (22.1%), multi/IDTF (23.2%), and other specialists' (24.6%) MR growth outpaced that of radiology's (5.3%). CONCLUSIONS: All nonradiologists showed greater overall utilization growth in private office neuroradiology than did radiology. Also, nonradiologists generally showed greater utilization increases in MR than CT. Radiologists' private office neuroradiology technical fee share shrank from 83.6% to 56.6% between 1998 and 2008.

Quality control in neuroradiology: discrepancies in image interpretation among academic neuroradiologists.

Prior studies have found a 3%-6% clinically significant error rate in radiology practice. We set out to assess discrepancy rates between subspecialty-trained university-based neuroradiologists. Over 17 months, university neuroradiologists randomly reviewed 1000 studies and reports of previously read examinations of patients in whom follow-up studies were read. The discrepancies between the original and "second opinion" reports were scored according to a 5-point scale: 1, no change; 2, clinically insignificant detection discrepancy; 3, clinically insignificant interpretation discrepancy; 4, clinically significant detection discrepancy; and 5, clinically significant interpretation discrepancy. Of the 1000 studies, 876 (87.6%) showed agreements with the original report. The neuroradiology division had a 2.0% (20/1000; 95% CI, 1.1%-2.9%) rate of clinically significant discrepancies involving 8 CTs and 12 MR images. Discrepancies were classified as vascular (n = 7), neoplastic (n = 9), congenital (n = 2), and artifacts (n = 2). Individual neuroradiologist's scores ranged from 0% to 7.7% ± 2.3% (n = 18). Both CT and MR imaging studies had a discrepancy rate of 2.0%. Our quality assessment study could serve as initial data before intervention as part of a PQI project.

Contrast-enhanced MR angiography is not more accurate than unenhanced 2D time-of-flight MR angiography for determining > or = 70% internal carotid artery stenosis.

BACKGROUND AND PURPOSE: Internal carotid artery (ICA) atheromatous disease is an important cause of ischemic stroke, and endarterectomy or stent placement is typically indicated for symptomatic patients with > or = 70% stenosis. Our purpose was to compare contrast-enhanced MR angiography (CE-MRA) with unenhanced 2D time-of-flight MR angiography (2D TOF MRA) in detecting hemodynamically significant ICA stenosis, by using CT angiography (CTA) as the reference standard. MATERIALS AND METHODS: This was an institutional review board-approved retrospective study. We identified 177 consecutive patients (354 ICAs) who received correlative CE-MRA, 2D TOF MRA, and CTA. Two neuroradiologists blinded to the CTA data graded the degree of ICA stenosis according to a 5-point scale. Additionally, luminal signal-intensity characteristics including 1) signal intensity drop-out, 2) distal-vessel narrowing, and 3) distal-vessel signal-intensity reduction were recorded. MRA results were correlated with those of CTA, and receiver-operating-characteristic (ROC) curves were constructed. RESULTS: On CTA, there were 55 ICAs with and 299 without > or = 70% stenosis. CE-MRA was 84% sensitive and 96% specific for detecting > or = 70% stenosis; 2D TOF MRA was 80% sensitive and 95% specific. The area under the ROC curve was 0.97 for CE-MRA and 0.95 for 2D TOF MRA (P = .51, not significant). For both MRA studies, each of the luminal signal-intensity characteristics had high specificity (> 98%) but poor-to-mild sensitivity (35%-66%) in detecting > or = 70% stenosis. CONCLUSIONS: Although it is established that CE-MRA more accurately delineates neurovascular anatomy than does unenhanced 2D TOF MRA, the administration of gadolinium did not offer a significant advantage in distinguishing surgically treatable ICA stenosis. This conclusion may be important in patients with contraindications to gadolinium.

Modulation of microphthalmia-associated transcription factor gene expression alters skin pigmentation.

The microphthalmia-associated transcription factor is implicated in melanocyte development and in the regulation of melanogenesis. Microphthalmia-associated transcription factor is thought to bind to the M-box promoter elements of tyrosinase, tyrosinase-related protein-1 and dopachrome tautomerase/tyrosinase-related protein-2 and transactivate these genes, resulting in increased pigmentation. Using a luciferase reporter construct driven by the microphthalmia-associated transcription factor promoter, we identified agents that modulate microphthalmia-associated transcription factor promoter activity. Changes in endogenous microphthalmia-associated transcription factor expression levels upon treatment with these agents were confirmed using northern and western blots, and their pigmentary modulating activities were demonstrated. Ultraviolet B irradiation and traditional Chinese medicine-1, a natural extract used in traditional Chinese medicine, upregulated microphthalmia-associated transcription factor gene expression and enhanced tyrosinase activity in vitro. Dihydrolipoic acid, lipoic acid, and resveratrol reduced microphthalmia-associated transcription factor and tyrosinase promoter activities. These agents also inhibited the forskolin- and ultraviolet B-stimulated promoter activities of these genes and significantly reduced tyrosinase activity in melanocyte cultures, resulting in depigmentation. Overexpressed microphthalmia-associated transcription factor was capable of rescuing the repressive effects of these compounds on the cotransfected tyrosinase promoter. Dark-skinned Yucatan swine treated with these agents showed visible skin lightening, which was confirmed histologically, whereas ultraviolet B-induced tanning of light-skinned swine was inhibited using these agents. Our findings suggest that modulation of microphthalmia-associated transcription factor expression can alter skin pigmentation and further confirm the central role of microphthalmia-associated transcription factor in melanogenesis.

Soymilk reduces hair growth and hair follicle dimensions.

We have recently shown that soybean-derived serine protease inhibitors and soybean extracts alter skin pigmentation, suggesting that soymilk could be used as a natural alternative to skin lightening. The present studies were initiated to examine the possible effect of STI, BBI and soymilk on hair pigmentation. Interestingly, these agents were found to affect not only hair pigmentation, but also the rate of hair growth, the dimensions of the hair follicle and hair shaft, and the appearance of the hair. The studies presented here provide first evidence, at the morphological and histological level, that soymilk and the soybean-derived serine protease inhibitors could be used as effective agents for hair care and management. These agents could reduce the rate of hair growth, decrease hair shaft dimensions and alter the pattern of melanogenic gene expression.

Protease-activated receptor 2, a receptor involved in melanosome transfer, is upregulated in human skin by ultraviolet irradiation.

Previous studies have shown that the protease-activated receptor 2 is involved in skin pigmentation through increased phagocytosis of melanosomes by keratinocytes. Ultraviolet irradiation is a potent stimulus for melanosome transfer. We show that protease-activated receptor 2 expression in human skin is upregulated by ultraviolet irradiation. Subjects with skin type I, II, or III were exposed to two or three minimal erythema doses of irradiation from a solar simulator. Biopsies were taken from nonexposed and irradiated skin 24 and 96 h after irradiation and protease-activated receptor 2 expression was detected using immunohistochemical staining. In nonirradiated skin, protease-activated receptor 2 expression was confined to keratinocytes in the lower one-third of the epidermis. After ultraviolet irradiation protease-activated receptor 2 expression was observed in keratinocytes in the upper two-thirds of the epidermis or the entire epidermis at both time points studied. Subjects with skin type I showed delayed upregulation of protease-activated receptor 2 expression, however, compared with subjects with skin types II and III. Irradiated cultured human keratinocytes showed upregulation in protease-activated receptor 2 expression as determined by immunofluorescence microscopy and Western blotting. Cell culture supernatants from irradiated keratinocytes also exhibited a dose-dependent increase in protease-activated receptor-2 cleavage activity. These results suggest an important role for protease-activated receptor-2 in pigmentation in vivo. Differences in protease-activated receptor 2 regulation in type I skin compared with skin types II and III suggest a potential mechanism for differences in tanning in subjects with different skin types.

The protease-activated receptor-2 upregulates keratinocyte phagocytosis.

The protease-activated receptor-2 (PAR-2) belongs to the family of seven transmembrane domain receptors, which are activated by the specific enzymatic cleavage of their extracellular amino termini. Synthetic peptides corresponding to the tethered ligand domain (SLIGRL in mouse, SLIGKV in human) can activate PAR-2 without the need for receptor cleavage. PAR-2 activation is involved in cell growth, differentiation and inflammatory processes, and was shown to affect melanin and melanosome ingestion by human keratinocytes. Data presented here suggest that PAR-2 activation may regulate human keratinocyte phagocytosis. PAR-2 activation by trypsin, SLIGRL or SLIGKV increased the ability of keratinocytes to ingest fluorescently labeled microspheres or E. coli K-12 bioparticles. This PAR-2 mediated increase in keratinocyte phagocytic capability correlated with an increase in actin polymerization and *-actinin reorganization, cell surface morphological changes and increased soluble protease activity. Moreover, addition of serine protease inhibitors downmodulated both the constitutive and the PAR-2 mediated increases in phagocytosis, suggesting that serine proteases mediate this functional activity in keratinocytes. PAR-2 involvement in keratinocyte phagocytosis is a novel function for this receptor.