Structured Reporting in Radiology.

Radiology reports are vital for patient care as referring physicians depend upon them for deciding appropriate patient management. Traditional narrative reports are associated with excessive variability in the language, length, and style, which can minimize report clarity and make it difficult for referring clinicians to identify key information needed for patient care. Structured reporting has been advocated as a potential solution for improving the quality of radiology reports. The Association of University Radiologists-Radiology Research Alliance Structured Reporting Task Force convened to explore the current and future role of structured reporting in radiology and summarized its finding in this article. We review the advantages and disadvantages of structured radiology reports and discuss the current prevailing sentiments among radiologists regarding structured reports. We also discuss the obstacles to the use of structured reports and highlight ways to overcome some of those challenges. We also discuss the future directions in radiology reporting in the era of personalized medicine.

The Roles of Organized Radiology in Career Development for Trainees and Junior Attending Radiologists: A Road Map.

OBJECTIVE: The full spectrum of organized radiology consists of numerous organizations with varied missions targeting their respective members. CONCLUSION: This article highlights many of these organizations, discusses the benefits they can provide to radiology trainees and junior faculty, and provides a road map for progressive participation among trainees to junior faculty as they advance through training.

A Picture of Burnout: Case Studies and Solutions Toward Improving Radiologists' Well-being.

This article uses case fictional case vignettes as a vehicle to discuss the complex way organizational and individual factors contribute to physician burnout. The article incorporates a review of the current literature on physician burnout focusing on work place inefficiency and ineffective leadership.

Behavioral Interviewing: Integrating ACGME Competency-Based Questions Into the Radiology Resident Selection Process.

The practice of radiology is continually evolving with external pressures increasing the involvement of the radiologist as an integrated member of the multidisciplinary care delivery team and not just image interpreters working in isolation. Radiologists need to be comfortable interacting directly with patients and practicing "patient and family-centered care" and "value-based medicine." Despite this evolving role of the radiologist, medical training and the residency selection process have not significantly adapted to accommodate these new demands. In order to develop and hire radiologists who can excel in this role, the selection and interview process must be adapted to prospectively identify those candidates who can thrive in this changing role. Behavior-based interviewing is a tool that can help identify those candidates who may excel in the future.1-3 Though there are reports of it being used in the United States medical schools and residency programs across the nation, it has not become a mainstay for medical residency and professional medical interviewing.

Percutane Image-Guided Cryoablation of Painful Osseous Metastases: A Retrospective Single-Center Review.

PURPOSE: Painful osseous metastases are a common problem in patients with malignancy, and they can be associated with significant morbidity owing to immobility, pain, pathologic fracture, or neurovascular compromise or all of these. We retrospectively evaluated pain levels and tumor enhancement in patients who underwent palliative percutaneous cryoablation for painful bone metastasis. METHODS: In this institutional review board-approved, health insurance portability and accountability act-compliant study, we retrospectively searched our department׳s picture archiving system for patients who underwent computed tomography (CT)-guided percutaneous cryoablation for treatment of painful metastatic osseous disease over a 6-year period (1/1/2005-12/31/2011). The preprocedure and postprocedure images and imaging reports, primary tumor type, CT-guided cryoablation procedure details, treated tumor response, immediate and 3-month postprocedure complications, reported pain response to cryoablation, postprocedural tumor imaging characteristics, and imaging response of noncryoablated systemically treated metastatic lesions were reviewed in patients with metastatic osseous disease who underwent cryoablation. RESULTS: All 16 patients reported improvement in pain within 1 week after the procedure and at 3-month clinical follow-up. A total of 6.2% had tumor growth and 93.8% had tumor arrest or shrinkage on follow-up CT, although all study patients had progression of noncryoablated metastases at other sites despite systemic therapy. A total of 62.5% of patients with posttreatment contrasted CT demonstrated marginal enhancement at the ablation site, although only single patient had interval growth. CONCLUSION: Most of our patients had tumor arrest or shrinkage on follow-up imaging, despite progression of noncryoablated metastases treated with preprocedure and postprocedure systemic therapy. Radiation therapy, chemotherapy, and analgesics have a moderate failure rate and require repeat treatments where quality of life is the foremost objective. CT-guided cryoablation is a safe palliative treatment to reduce pain in patients with painful osseous metastatic disease, achieve effective local tumor control, and in some cases, provide a curative option for a target lesion.

Pellegrini-Stieda ossification can also involve the posterior attachment of the MPFL.

PURPOSE: To evaluate for development of Pellegrini-Stieda (PS)-type ossification following injury to the posterior attachment of the medial patellofemoral ligament (MPFL). MATERIALS AND METHODS: This retrospective study evaluated 27 patients with acute knee injury with initial radiographs, magnetic resonance imaging within 1 week of injury, and follow-up radiographs assessing for development of PS. RESULTS: Of the 27 patients who developed PS ossification, 7 patients (25.9%) had isolated MPFL injury with the ossification slightly more proximal than the traditional PS. CONCLUSION: Isolated injury to the posterior MPFL also leads to PS ossification, which is slightly superior in location to the traditional PS.

Parturition pit: the bony imprint of vaginal birth.

PURPOSE: To retrospectively evaluate for pits along the dorsum of the pubic body in females and compare the presence/absence of these pits to vaginal birth data. MATERIALS AND METHODS: We retrospectively reviewed females with vaginal birth data who underwent pelvic CT. The presence of pits along the dorsum of the pubic body, pit grade (0 = not present; 1 = faintly imperceptible; 2 = present; 3 = prominent), and the presence of osteitis condensans ilii, preauricular sulcus, and sacroiliac joint vacuum phenomenon were assessed on imaging. Musculoskeletal radiologists who were blinded to the birth data evaluated the CTs. 48 males were also evaluated for the presence of pits. RESULTS: 482 female patients underwent CT pelvis and 171 were excluded due to lack of vaginal birth data. Of the 311 study patients, 262 had prior vaginal birth(s) and 194 had pits on CT. Only 7 of the 49 patients without prior vaginal birth had pits. There was a statistically significant association between vaginal birth and presence of pits (p < 0.0001). Patients with more prominent pits (grades 2/3) had a greater number of vaginal births. As vaginal deliveries increased, the odds of having parturition pits greatly increased, adjusting for age and race at CT (p < 0.0001). No males had pits. CONCLUSION: Our study indicates that parturition pits are associated with prior vaginal birth and should be considered a characteristic of the female pelvis. The lytic appearance of prominent pits on imaging can simulate disease and create a diagnostic dilemma for interpreting radiologists.

Pelvic Floor Symptoms and Spinal Curvature in Women.

OBJECTIVES: To characterize the association between thoracic (T) and lumbar (L) spinal curvature and pelvic floor (PF) symptoms (pelvic organ prolapse, urinary incontinence [UI], fecal incontinence [FI]). METHODS: Of women undergoing a bone mineral density scan from January 2007 to October 2010, patients who completed PF symptom questionnaires and had T and/or L spine radiographs or computed tomography examinations within 3 years of questionnaire completion were included in this study. The spine angles were measured using the Cobb angle method. The T and L curvatures were categorized as hypokyphosis (<20°), normal T kyphosis (20-40°), hyperkyphosis (>40°), hypolordosis (<40°), normal L lordosis (40-70°), and hyperlordosis (>70°). The presence and type of UI were identified with the 3 Incontinence Questionnaire and FI with the Modified Manchester Questionnaire. Pelvic organ prolapse was defined as a positive response to the presence of a bulge question from the PF Distress Inventory-20. RESULTS: Of 1665 eligible women, 824 and 302 (mean age 64 ± 10 for both) had T and L spine images, respectively. No differences in PF symptoms were observed in the T or L spine groups categorized by hypo-, normal, and hyperkyphosis/lordosis except for urgency UI being more prevalent in the hypolordosis group (P = 0.01). However, upon further characterization using logistic regression, no association was noted between PF symptoms and T or L spine angles; no differences in the mean angles were found between women with versus without PF symptoms (P ≥ 0.05). CONCLUSIONS: The current study shows that the T and L spinal curvatures are not associated with the presence of PF symptoms.

Opportunities for Patient-centered Outcomes Research in Radiology.

Recently created in 2010, the Patient-Centered Outcomes Research Institute (PCORI) supports patient-centered comparative effectiveness research with a focus on prioritizing high-impact studies and improving trial design methodology. The Association of University Radiologists Radiology Research Alliance Task Force on patient-centered outcomes research in Radiology aims to review recently funded imaging-centric projects that adhere to the methodologies established by PCORI. We provide an overview of the successful application of PCORI standards to radiology topics, highlight how these methodologies differ from other forms of radiology research, and identify opportunities for new projects as well as potential barriers for involvement. Our hope is that review of specific case examples in radiology will clarify the use and value of PCORI methods mandated and supported nationally by the Affordable Care Act.

CT evaluation of common duct dilation after cholecystectomy and with advancing age.

PURPOSE: To evaluate common duct (CD) dilation by computed tomography (CT) in patients with intact gallbladders and diameter change over time in remote and interval cholecystectomy patients, frequency of visualization of the CD, and its relationship to age. METHODS: This IRB-approved retrospective study evaluated baseline CD diameter, intrahepatic biliary dilation, and interval duct diameter change in patients with CTs ≥ 2 years apart (n = 324), in block-randomized order by two blinded board-certified radiologists. 272 patients were divided into three groups: (1) prior cholecystectomy before the first CT, (2) cholecystectomy between the first and last CTs, and (3) no cholecystectomy. A subset of 191 nonoperated patients was evaluated for age-related dilation. RESULTS: Group 1 ducts were significantly larger than the other groups at both baseline and follow-up CTs (p < 0.001). Group 2 showed a greater increase in duct size than the other groups at follow-up (p < 0.001). The CD was measurable in 89% of the CT studies. In nonoperated patients, there was a statistically significant correlation between CD size and increasing age (p < 0.001), although the CD size remained within normal size limits. CONCLUSION: Remote cholecystectomy patients have larger CD diameters than the nonoperated and interval cholecystectomy groups. Greater increase in ductal diameter occurred between studies in the interval cholecystectomy patients, suggesting that dilation occurs after cholecystectomy. Also, the CD dilates slightly with age in nonoperated patients.

The role of pubic symphyseal CT arthrography in the imaging of athletic pubalgia.

OBJECTIVE: The purpose of this article is to describe the results of pubic symphyseal CT arthrography compared with MRI in patients with suspected athletic pubalgia. MATERIALS AND METHODS: In this study, two musculoskeletal radiologists retrospectively searched our department's PACS to identify patients who had undergone CT-guided injection with concurrent pubic symphyseal CT arthrography for evaluation and treatment of groin pain, sports hernia, or athletic pubalgia over a 5.5-year period (January 1, 2007-July 1, 2012). The MR and CT arthrography images and reports, clinical findings at presentation, pain response to injection, and operative findings were reviewed using the electronic medical record. RESULTS: Twelve patients underwent CT-guided injection and pubic symphyseal CT arthrography at our institution during the 5.5-year study period. Nine of the 12 patients had undergone MRI before the procedure. In two of the three patients who had not undergone MRI, CT arthrography revealed secondary clefts. Three of four patients who had secondary clefts on MRI had contrast extravasation reproducing the cleft at CT. Three patients had MRI findings suggestive of athletic pubalgia without MRI evidence of a secondary cleft; in all three of these patients, CT arthrography showed a secondary cleft. In four patients, CT arthrography revealed tendon tears at the adductor origin that were not apparent on MRI. All 12 patients reported decreased groin pain after injection. CONCLUSION: Pubic symphyseal CT arthrography is a useful technique for the diagnosis and short-term pain relief of athletic pubalgia. It can be used to identify secondary clefts and to detect tendon tears that can potentially be overlooked on MRI.

The common duct dilates after cholecystectomy and with advancing age: reality or myth?

OBJECTIVES: To evaluate changes in the common duct diameter on sonography over time in patients with and without cholecystectomy. METHODS: We retrospectively evaluated the common duct diameter, central biliary dilatation, and interval change in 1079 patients who underwent sonography at least 2 years apart over a 6-year period. A board-certified radiologist, blinded to clinical and laboratory data, measured the duct diameter. A total of 893 patients (568 female and 325 male) were divided into 3 groups: group 1, remote cholecystectomy before sonography (mean, 9.7 years before sonography; n = 117); group 2, interval cholecystectomy between the first and second sonographic examinations (n = 56); and group 3, no cholecystectomy (n = 720). All groups were stratified by age, and group 3 was also stratified by the absence (n = 528) or presence (n=192) of gallstones. RESULTS: Duct diameters at baseline and follow-up averaged 4.5 and 5.2, 3.6 and 4.9, and 3.5 and 3.9 mm in groups 1, 2, and 3, respectively. Group 1 ducts were larger at baseline than in the other groups (P < .001). At follow-up, group 2 ducts showed a greater interval diameter increase than the other groups (P < .001). In a subanalysis of each group based on age, there was a mild increase in duct size with increasing age, although not clinically significant and within normal limits. In group 3 patients who never had gallstones, there was a significant small increase in duct size over decades (P < .001). The baseline duct sizes for patients with gallstones were not significantly different from those who never had gallstones (P = .15). CONCLUSIONS: Patients with remote cholecystectomy have larger common duct diameters than those with no or interval cholecystectomy. Most asymptomatic patients with or without cholecystectomy have a normal common duct diameter.

Effect of display magnification on perceived growth of liver lesions on computed tomography.

Our goal was to investigate the effect of displayed image magnification on perception of the size of hepatic lesions on abdominal computed tomography (CT) scans. Institutional review board approval and informed observer consent were obtained. Three experienced radiologists reviewed 90 CT image pairs in one session. Each image pair demonstrated a solitary, well-defined hypodense hepatic lesion measuring greater than 1 cm obtained at two points in time. The image pairs were presented three times in random order, once with the left image magnified, once with the right image magnified, and once with neither image magnified. The radiologists were asked to determine on which image the lesion was smaller or if there was no difference. The responses were analyzed statistically. The proportion of correct responses increased significantly as the difference in lesion size increased (p < 0.001). The percent of correct responses was higher when neither CT image was magnified. Magnification of one image decreased the accuracy of the readers' performance, especially at smaller differences, both of which were statistically significant (p < 0.001). Thus, accuracy of detecting lesion size differences was degraded when the images were presented at differing magnification. This should be kept in mind when evaluating serial CT scans for growth or regression of tumors and other lesions.

High venous pressure in the main renal vein causing development of peritransplant venous collaterals in renal transplant patients: a rare finding.

We will show the sonographic appearance of peritransplant venous collaterals in renal transplants with renal venous hypertension. Three cases of renal transplants with pericapsular vessels were identified at our institution. Two cases were related to renal vein thrombosis. The third case had pericapsular vessels secondary to venous hypertension from arterialization of the transplant renal vein by a preexisting right thigh arteriovenous graft. The development of high venous pressures in renal transplants leading to the collaterals' venous drainage has been rarely described. This finding should be recognized as a rare complication of renal transplants but does not necessarily lead to transplant failure.