Communication of Incidental Imaging Findings on Inpatient Discharge Summaries After Implementation of Electronic Health Record Notification System.

OBJECTIVES: Inadequate follow-up of incidental imaging findings (IIFs) can result in poor patient outcomes, patient dissatisfaction, and provider malpractice. At our institution, radiologists flag IIFs during report dictation to trigger electronic health record (EHR) notifications to providers and patients. Nurse coordinators directly contact patients or their primary care physicians (PCPs) regarding IIFs if follow-up is not completed within the recommended time frame. Despite these interventions, many patients and their PCPs remain unaware of IIFs. In an effort to improve awareness of IIFs, we aim to investigate communication of IIFs on inpatient discharge summaries after implementation of our EHR notification system. METHODS: Inpatient records with IIFs from 2018 to 2021 were retrospectively reviewed to determine type of IIFs, follow-up recommendations, and mention of IIFs on discharge summaries. Nurse coordinators spoke to patients and providers to determine their awareness of IIFs. RESULTS: Incidental imaging findings were reported in 51% of discharge summaries (711/1383). When nurse coordinators called patients and PCPs regarding IIFs at the time follow-up was due, the patients and PCPs were aware of 79% of IIFs (1096/1383). CONCLUSIONS: With implementation of EHR notifications to providers regarding IIFs, IIFs were included in 51% of discharge summaries. Lack of inclusion of IIFs on discharge summaries could be related to transitions of care within hospitalization, provider alert fatigue, and many diagnostic testing results to distill. These findings demonstrate the need to improve communication of IIFs, possibly via automating mention of IIFs on discharge summaries, and the need for care coordinators to follow up on IIFs.

Impact of Predictive Text Clinical Decision Support on Imaging Order Entry in the Emergency Department.

PURPOSE: Imaging clinical decision support (CDS) is designed to assist providers in selecting appropriate imaging studies and is now federally required. The aim of this study was to understand the effect of CDS on decisions and workflows in the emergency department (ED). METHODS: The authors' institution's order entry platform serves up structured indications for imaging orders. Imaging orders are scored by CDS on the basis of appropriate use criteria (AUC). CDS triggers alerts for imaging orders with low AUC scores. Because free text alone cannot be scored by CDS, an artificial intelligence predictive text (AIPT) module was implemented to guide the selection of structured indications when free-text indications are entered. A total of 17,355 imaging orders in the ED over 6 months were retrospectively analyzed. RESULTS: CDS alerts for low AUC scores were triggered for 3% of all imaging study orders (522 of 17,355). Providers spent an average of 24 seconds interacting with alerts. In 18 of 522 imaging orders with alerts, alternative studies were ordered. After AIPT implementation, the percentage of unscored studies significantly decreased from 81% to 45% (P < .001). CONCLUSIONS: In a quaternary academic ED, CDS alerts triggered by low AUC scores caused minimal increase in time spent on imaging order entry but had a relatively marginal impact on imaging study selection. AIPT implementation increased the number of scored studies and could potentially enhance CDS effects. CDS implementation enables the collection of novel data regarding which imaging studies receive low AUC scores. Future work could include exploring alternative models of CDS implementation to maximize its impact.

Utilizing computed tomography volumetry for size matching prior to lung transplantation: a case series.

Background: Appropriate size matching between donor and recipient is critical for successful pulmonary transplantation. Although surrogate measurements such as height and gender are often utilized to approximate predicted lung volume, these methods provide only a gross estimation with wide variability and poor predictive value. Case Description: A single center exploratory study was conducted in which four patients underwent lung transplantation (LT) with pre-operative computed tomography (CT) volumetry obtained in both the donor and recipient to facilitate decision making regarding organ size and suitability. In four cases in which CT volumetry was used, the lung volumes calculated using surrogate measurements significantly overestimated both donor and recipient lung volumes quantified by CT volumetric analysis. All recipients underwent successful LT without necessary graft downsizing. Conclusions: This is an initial report of prospectively utilizing CT volumetry as an adjunct to decision-making regarding suitability of donor lungs. In these cases, CT volumetry facilitated the confident acceptance of donor lungs that were initially predicted to be oversized based on other clinical measures.

Potential Role of Computed Tomography Volumetry in Size Matching in Lung Transplantation.

BACKGROUND: Accumulated knowledge on the outcomes related to size mismatch in lung transplantation derives from predicted total lung capacity equations rather than individualized measurements of donors and recipients. The increasing availability of computed tomography (CT) makes it possible to measure the lung volumes of donors and recipients before transplantation. We hypothesize that CT-derived lung volumes predict a need for surgical graft reduction and primary graft dysfunction. METHODS: Donors from the local organ procurement organization and recipients from our hospital from 2012 to 2018 were included if their CT exams were available. The CT lung volumes and plethysmography total lung capacity were measured and compared with predicted total lung capacity using Bland Altman methods. We used logistic regression to predict the need for surgical graft reduction and ordinal logistic regression to stratify the risk for primary graft dysfunction. RESULTS: A total of 315 transplant candidates with 575 CT scans and 379 donors with 379 CT scans were included. The CT lung volumes closely approximated plethysmography lung volumes and differed from the predicted total lung capacity in transplant candidates. In donors, CT lung volumes systematically underestimated predicted total lung capacity. Ninety-four donors and recipients were matched and transplanted locally. Larger donor and smaller recipient lung volumes estimated by CT predicted a need for surgical graft reduction and were associated with higher primary graft dysfunction grade. CONCLUSION: The CT lung volumes predicted the need for surgical graft reduction and primary graft dysfunction grade. Adding CT-derived lung volumes to the donor-recipient matching process may improve recipients' outcomes.

Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation.

Background: Errors in measuring chest X-ray (CXR) lung heights could contribute to the occurrence of size-mismatched lung transplant procedures. Methods: We first used Bland-Altman analysis for repeated measures to evaluate contributors to measurement error of chest X-ray lung height. We then applied error propagation theory to assess the impact of measurement error on size matching for lung transplantation. Results: A total 387 chest X-rays from twenty-five donors and twenty-five recipients were measured by two raters. Individual standard deviation for lung height differences were independent of age, sex, donor vs. recipient, diagnostic group and race/ethnicity and all were pooled for analysis. Bias between raters was 0.27 cm (±0.03) and 0.22 cm (±0.06) for the right and left lung respectively. Within subject variability was the biggest contributor to error in measurement, 2.76 cm (±0.06) and 2.78 cm (±0.2) for the right and left lung height. A height difference of 4.4 cm or more (95% CI: ±4.2, ±4.6 cm) between the donor and the recipient right lung height has to be accepted to ensure matching for at least 95% of patients with the same true lung height. This difference decreases to ±1.1 cm (95% CI: ±0.9, ±1.3 cm) when the average from all available chest X-rays is used. The probability of matching a donor and a recipient decreases with increasing true lung height difference. Conclusions: Individual chest X-ray lung heights are imprecise for the purpose of size matching in lung transplantation. Averaging chest X-rays lung heights reduced uncertainty.

Implementation of a peer-learning program in an academic abdominal radiology practice and comparison with a traditional peer-review system.

OBJECTIVE: The purpose of this study was to transition from a traditional score-based peer-review system to an education-oriented peer-learning program in our academic abdominal radiology practice. MATERIAL AND METHODS: This retrospective study compared our experience with a score-based peer-review model used prior to September 2020 and a peer-learning model implemented and used exclusively beginning in October of 2020. In peer review, a web-based peer-review tool randomly generated a list of cases, which were blindly reviewed in consensus. Comparison of the consensus interpretation with the original report was used to categorize each reviewed case and to calculate the rates of significant and minor discrepancies. Only cases with a discrepancy were considered to represent a learning opportunity. In peer learning, faculty prospectively identified and submitted cases for review in several categories, including case interpretations with a discrepancy from subsequent opinion or result, interpretations considered to represent a great call, and interesting or challenging cases meriting further discussion. The peer-learning coordinator showed each case to the group in a manner which blinded the group to both submitting and interpreting radiologist and invited discussion during various stages of the case. RESULTS: During peer review, a total of 172 cases were reviewed over 16 sessions occurring between April 2016 and September 2020. Only 3 cases (1.8%) yielded significant discrepancies whereas 13 (7.6%) yielded minor discrepancies, representing a total of 16 learning opportunities (3.6 per year). In peer learning, 64 cases were submitted and 52 reviewed over 7 sessions occurring between October 2020 and October 2021. 29 (56%) were submitted as an interesting or challenging case meriting further discussion, 18 (35%) were submitted for a discrepancy, and 5 (10%) were submitted for a great call. All 52 presented cases represented learning opportunities (48 per year). CONCLUSION: An education-focused peer-learning program provided a platform for continuous quality improvement and yielded substantially more learning opportunities compared to score-based peer review.

Impact of Pretransplantation CT on Liver Donation in Potential Deceased Organ Donors.

BACKGROUND: Computed tomography (CT) is routinely used to determine the suitability of potential living donor liver transplants, providing important information about liver size, vascular anatomy, and the presence of other diseases that would preclude it from safe donation. CT is not routinely used, however, when evaluating eligible deceased organ donors after brain death, a group which comprises most orthotopic liver transplants. After the installation of a CT scanner at a local procurement facility, CTs have been performed on potential deceased organ donors and used, in conjunction with other evaluative protocols, to help direct donation decisions and assist in procurement procedures. STUDY DESIGN: A retrospective analysis of data from 373 cases spanning 5 years was systematically collected and analyzed, including information pertaining to patient's medical histories, biopsy results, operative findings, and CT results. RESULTS: CT findings directly impacted the directive decision-making process in 29% of cases in this patient cohort, likely an underestimate, and reliably evaluated important factors including variant vascular anatomy and the presence and severity of hepatic steatosis and cirrhosis. CONCLUSION: Overall, this study suggests that CT has the potential to play a significant role in procurement procedures and the directive decision-making process, thereby improving the efficiency and accuracy by which potential deceased organ donors are evaluated.

Transplantation of Donor Lung With Partial Anomalous Pulmonary Venous Return Using a Carrel Patch.

Partial anomalous pulmonary venous return is a rare congenital aberrancy that involves oxygen-rich pulmonary venous drainage into the right atrium instead of into the systemic circulation. This report describes a case of isolated partial anomalous pulmonary venous return of the right upper lobe in a donor lung. Successful transplantation was performed with a Carrel patch technique for left atrial cuff reconstruction using a segment of donor vena cava. This report of partial anomalous pulmonary venous return in a right donor lung describes this reconstructive approach to restore physiologic venous drainage.

Chest CT and Coronavirus Disease (COVID-19): A Critical Review of the Literature to Date.

OBJECTIVE. Coronavirus disease (COVID-19) is a global pandemic. Studies in the radiology literature have suggested that CT might be sufficiently sensitive and specific in diagnosing COVID-19 when used in lieu of a reverse transcription-polymerase chain reaction test; however, this suggestion runs counter to current society guidelines. The purpose of this article is to critically review some of the most frequently cited studies on the use of CT for detecting COVID-19. CONCLUSION. To date, the radiology literature on COVID-19 has consisted of limited retrospective studies that do not substantiate the use of CT as a diagnostic test for COVID-19.

Apical Sparing Pattern of Longitudinal Strain and Positive Bone Scintigraphy in Metastatic Myocardial Calcification.

An apical sparing pattern of longitudinal strain and positive radionuclide bone scintigraphy are believed to be specific for the diagnosis of transthyretin cardiac amyloidosis. We report on a young woman with apical sparing of longitudinal strain and positive bone scintigraphy who was found to have metastatic myocardial calcification at autopsy. (Level of Difficulty: Intermediate.).

Image-guided Preoperative Localization of Pulmonary Nodules for Video-assisted and Robotically Assisted Surgery.

Video-assisted thoracic surgery (VATS) and robotically assisted surgery are used increasingly for minimally invasive diagnostic and therapeutic resection of pulmonary nodules. Unsuccessful localization of small, impalpable, or deep pulmonary nodules can necessitate conversion from VATS to open thoracotomy. Preoperative localization techniques performed by radiologists have improved the success rates of VATS resection for small and subsolid nodules. Any center at which VATS diagnostic resection of indeterminate pulmonary nodules is performed should be supported by radiologists who offer preoperative nodule localization. Many techniques have been described, including image-guided injection of radioisotopes and radiopaque liquids and placement of metallic wires, coils, and fiducial markers. These markers enable the surgeon to visualize the position of an impalpable nodule intraoperatively. This article provides details on how to perform each percutaneous localization technique, and a group of national experts with established nodule localization programs describe their preferred approaches. Special reference is made to equipment required, optimization of marker placement, prevention of technique-specific complications, and postprocedural treatment. This comprehensive unbiased review provides valuable information for those who are considering implementation or optimization of a nodule localization program according to workflow patterns, surgeon preference, and institutional resources in a particular center. ©RSNA, 2019.

No vascular calcification on cardiac computed tomography spanning asfotase alfa treatment for an elderly woman with hypophosphatasia.

Hypophosphatasia (HPP) is the inborn-error-of-metabolism characterized enzymatically by insufficient activity of the tissue-nonspecific isoenzyme of alkaline phosphatase (TNSALP) and caused by either mono- or bi-allelic loss-of-function mutation(s) of the gene ALPL that encodes this cell surface phosphomonoester phosphohydrolase. In HPP, the natural substrates of TNSALP accumulate extracellularly and include inorganic pyrophosphate (PPi), a potent inhibitor of biomineralization. This PPi excess leads to rickets or osteomalacia in all but the most mild "odonto" form of the disease. Adults with HPP understandably often also manifest calcium PPi dihydrate deposition, whereas enthesopathy and calcific periarthritis from hydroxyapatite (HA) crystal deposition can seem paradoxical in face of the defective skeletal mineralization. In 2015, asfotase alfa (AA), a HA-targeted TNSALP, was approved multinationally as an enzyme replacement therapy for HPP. AA hydrolyzes extracellular PPi (ePPi) and in HPP enables HA crystals to grow and mineralize skeletal matrix. In direct contrast to HPP, deficiency of ePPi characterizes the inborn-errors-of-metabolism generalized arterial calcification of infancy (GACI) and pseudoxanthoma elasticum (PXE). In GACI and PXE, deficiency of ePPi leads to ectopic mineralization including vascular calcification (VC). Therefore, in HPP, ectopic mineralization including VC could hypothetically result from, or be exacerbated by, the persistently high circulating TNSALP activity that occurs during AA treatment. Herein, using a routine computed tomography (CT) method to quantitate coronary artery calcium, we found no ectopic mineralization in the heart of an elderly woman with HPP before or after 8 months of AA treatment. Subsequently, investigational high-resolution peripheral quantitative CT and dual-energy X-ray absorptiometry showed absence of peripheral artery and aortic calcium after further AA treatment. Investigation of additional adults with HPP could reveal if the superabundance of ePPi protects against VC, and whether long-term AA therapy causes or exacerbates any ectopic mineralization.

Chest computed tomography imaging improves potential lung donor assessment.

OBJECTIVE: Chest computed tomography (CT) imaging is being increasingly used for potential lung donor assessment. However, the efficacy of CT imaging in this setting remains unknown. We hypothesize that chest CT imaging independently affects the decision-making process in donor lung utilization. METHODS: We conducted a retrospective cohort study of all adult donation after brain death donors managed through our local organ procurement organization from June 2011 to November 2016. An experienced thoracic radiologist independently reviewed donor chest CT and chest x-ray images in a blinded, standardized manner to determine the presence of structural lung disease (eg, emphysema, interstitial lung disease [ILD]) and acute abnormalities (eg, traumatic lung injury [TLI]). Distinct models of lung utilization were fit to groups with initial partial pressure of oxygen (iPaO2) ≤300 mm Hg (suboptimal) and iPaO2 >300 mm Hg (optimal). RESULTS: The organ procurement organization managed 753 donors during the study period, with a lung utilization rate ([lung donors/all organ donors] × 100) of 36.5% (275 of 753). Four hundred forty-five (59.1%) donors received chest CT imaging, revealing emphysema (13.7%), ILD (2.5%), and TLI (7.2%). In univariate analysis, findings of TLI (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.08-4.61) were positively associated with lung utilization, whereas findings of emphysema (OR, 0.18; CI, 0.08-0.40) were negatively associated with utilization. In multivariate analysis, CT findings of emphysema (OR, 0.21; CI 0.08-0.54) remained negatively associated with utilization. No potential donors with CT findings of ILD became lung donors. After controlling for chest x-ray findings, chest CT imaging findings of structural lung disease remained negatively associated with utilization (P = .0001). Lung utilization rate in the suboptimal and optimal iPaO2 populations was 35.1% and 41.4%, respectively, and CT findings of emphysema had a significant association with nonutilization in both groups. CONCLUSIONS: In the evaluation of potential lung donors, chest CT imaging findings of structural lung disease, such as emphysema and ILD, have a significant negative association with lung utilization. Our findings suggest that chest CT imaging might be an important adjunct to conventional lung donor assessment criteria.

Technical Considerations for Lung Transplantation in Kartagener's Syndrome.

Kartagener's syndrome is a rare genetic disorder of ciliated epithelial cells associated with recurrent respiratory tract infections, bronchiectasis, and situs inversus. In some patients, the accumulation of airway secretions and recurrent infections lead to end-stage lung disease, for which lung transplantation is the only effective treatment. Anatomical variations, such as dextrocardia and pulmonary situs inversus, make the procedure challenging, yet feasible with certain technical modifications and careful preparation of donor lungs. We report a case of bilateral lung transplantation without the use of cardiopulmonary bypass in a patient with Kartagener's syndrome while describing important technical details of the operation.

Anomalous Origin of Left Pulmonary Artery From the Aorta: A Rare Entity in Congenital Heart Disease.

Anomalous origin of the left pulmonary artery (ALPA) from the aorta is a rare form of congenital heart disease, leading to long-term morbidity if not treated early. There is a reported association of this anomaly with 22q11 microdeletion syndrome. Surgical repair is commonly performed by direct reimplantation to the main pulmonary artery with or without patch or flap techniques. This report presents two unique cases of ALPA, describing embryologic considerations for morphogenesis of ALPA with 22q11 microdeletion syndrome and a novel surgical technique involving unroofing of the unique anatomy of the common wall between the left and main pulmonary arteries.

Transplantation of Lungs Procured From a Donor With an Atrioesophageal Fistula.

Lung transplantation continues to be limited by a shortage of donor organs. We report the case of procurement and transplantation of lungs from a young donor who died from an atrioesophageal fistula, complicating catheter ablation for atrial fibrillation. Our case illustrates that structural damage to the left atrium is not an absolute contraindication to lung donation. As atrioesophageal fistulas are being increasingly recognized as a rare but often lethal complication of catheter ablation, such donors can contribute to the expansion of the donor pool.