Automation of Protocoling Advanced MSK Examinations Using Natural Language Processing Techniques.

Imaging examination selection and protocoling are vital parts of the radiology workflow, ensuring that the most suitable exam is done for the clinical question while minimizing the patient's radiation exposure. In this study, we aimed to develop an automated model for the revision of radiology examination requests using natural language processing techniques to improve the efficiency of pre-imaging radiology workflow. We extracted Musculoskeletal (MSK) magnetic resonance imaging (MRI) exam order from the radiology information system at Henry Ford Hospital in Detroit, Michigan. The pretrained transformer, "DistilBERT" was adjusted to create a vector representation of the free text within the orders while maintaining the meaning of the words. Then, a logistic regression-based classifier was trained to identify orders that required additional review. The model achieved 83% accuracy and had an area under the curve of 0.87.

Ultrasound shear wave elastography and its association with rotator cuff tear characteristics.

BACKGROUND: Approximately 20-60% of rotator cuff repairs fail with higher failure rates in patients with larger or more chronic tears. Although MRI provides an objective estimate of tear size, it can only provide qualitative descriptions of tear chronicity. By contrast, ultrasound shear wave elastography (SWE) may assess tear chronicity by estimating tissue mechanical properties (ie, shear modulus). Furthermore, SWE imaging does not share many of the challenges associated with MRI (eg, high cost, risk of claustrophobia). Therefore, the objective of this study was to determine the extent to which estimated supraspinatus shear modulus is associated with conventional MRI-based measures of rotator cuff tear size and chronicity. METHODS: Shear modulus was estimated using ultrasound SWE in two regions of the supraspinatus (intramuscular tendon, muscle belly) under two contractile conditions (passive, active) in 22 participants with full-thickness rotator cuff tears. The extent to which estimated supraspinatus shear modulus is associated with conventional MRI measures of tear size and chronicity was assessed using correlation coefficients and Kruskal-Wallis tests, as appropriate. RESULTS: Estimated shear modulus was not significantly associated with anterior/posterior tear size (P > .09), tear retraction (P > .20), occupation ratio (P > .11), or fatty infiltration (P > .30) under any testing condition. DISCUSSION: Although ultrasound SWE measurements have been shown to be altered in the presence of various tendinopathies, the findings of this study suggest the utility of ultrasound SWE in this population (ie, patients with a small to medium supraspinatus rotator cuff tear) before surgical rotator cuff repair remains unclear.

Operational Radiology Recovery in Academic Radiology Departments After the COVID-19 Pandemic: Moving Toward Normalcy.

This article presents a current snapshot in time, describing how radiology departments around the country are planning recovery from the baseline of the coronavirus disease 2019 pandemic, with a focus on different domains of recovery such as managing appointment availability, patient safety and workflow changes, and operational data and analytics. An e-mail survey was sent through the Society of Chairs of Academic Radiology Departments list server to 114 academic radiology departments. On the basis of data reported by the 38 survey respondents, best practices and shared experience are described for three key areas: (1) planning for recovery, (2) creating a new normal, and (3) measuring and forecasting. Radiology practices should be aware of the common approaches and preparations academic radiology departments have taken to reopening imaging in the post-coronavirus disease 2019 world. This should all be done when maintaining a safe and patient-centric environment and preparing to minimize the impact of future outbreaks or pandemics.

Order Entry Protocols Are an Amenable Target for Workflow Automation.

PURPOSE: Order entry protocol selection of advanced imaging studies is labor-intensive, can disrupt workflow, and may displace staff from more valuable tasks. The aim of this study was to explore and compare the behaviors of radiologic technologists and radiologists when determining protocol to identify opportunities for workflow automation. METHODS: A data set of over 273,000 cross-sectional examination orders from four hospitals within our health system was created. From this data set, we isolated the 12 most frequently requested examinations, which represent almost 50% of the entirety of advanced imaging volume. Intergroup comparisons were made between behavior of radiologic technologists and radiologists or residents when determining protocol. Frequencies of changes were calculated. Common parameters of changed examinations were identified. RESULTS: The overall change rate for both radiologists and residents (4%) is very low and comparable to the overall change rate of radiologic technologists (1%). The change rates for the 12 most ordered examinations were calculated and compared individually. Most examinations that underwent change involved a patient with a low estimated glomerular filtration rate, a patient with a contrast allergy, or a provider ordering a general examination but in fact wanting an organ-specific protocol or an angiographic study. CONCLUSION: Order entry protocol selection of the most frequently ordered advanced imaging examinations was rarely a value-added activity because these examinations are rarely changed. Changes follow predictable patterns that make order entry protocol selection of most radiology orders for advanced imaging amenable to workflow automation.

Association Between Years of Competition and Shoulder Function in Collegiate Swimmers.

BACKGROUND: Shoulder injuries are common among competitive swimmers, and the progression of shoulder pathology is not well understood. The objective of this study was to assess the extent to which years of competitive swim training were associated with physical properties of the supraspinatus muscle and tendon, shoulder strength, and self-reported assessments of shoulder pain and function. HYPOTHESIS: Increasing years of competition will be associated with declining physical properties of the supraspinatus muscle/tendon and declining self-reported assessments of pain and function. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: After institutional approval, 18 collegiate female swimmers enrolled in the study. For each swimmer, supraspinatus tendon thickness was measured; tendinosis was assessed using ultrasound imaging, supraspinatus muscle shear wave velocity was assessed using shear wave elastography, isometric shoulder strength was measured using a Biodex system, and self-reported assessments of pain/function were assessed using the Western Ontario Rotator Cuff (WORC) score. All subjects were tested before the start of the collegiate swim season. Linear regression was used to assess the association between years of competition and the outcome measures. RESULTS: Years of participation was positively associated with tendon thickness ( P = 0.01) and negatively associated with shear wave velocity ( P = 0.04) and WORC score ( P < 0.01). Shoulder strength was not associated with years of participation ( P > 0.39). CONCLUSION: Long-term competitive swim training is associated with declining measures of supraspinatus muscle/tendon properties and self-reported measures of pain and function. Although specific injury mechanisms are still not fully understood, these findings lend additional insight into the development of rotator cuff pathology in swimmers. CLINICAL RELEVANCE: Lengthy swimming careers may lead to a chronic condition of reduced mechanical properties in the supraspinatus muscle and tendon, thereby increasing the likelihood of rotator cuff pathology.

Effects of age and pathology on shear wave speed of the human rotator cuff.

Rotator cuff tears are common and often repaired surgically, but post-operative repair tissue healing, and shoulder function can be unpredictable. Tear chronicity is believed to influence clinical outcomes, but conventional clinical approaches for assessing tear chronicity are subjective. Shear wave elastography (SWE) is a promising technique for assessing soft tissue via estimates of shear wave speed (SWS), but this technique has not been used extensively on the rotator cuff. Specifically, the effects of age and pathology on rotator cuff SWS are not well known. The objectives of this study were to assess the association between SWS and age in healthy, asymptomatic subjects, and to compare measures of SWS between patients with a rotator cuff tear and healthy, asymptomatic subjects. SWE images of the supraspinatus muscle and intramuscular tendon were acquired from 19 asymptomatic subjects and 11 patients with a rotator cuff tear. Images were acquired with the supraspinatus under passive and active (i.e., minimal activation) conditions. Mean SWS was positively associated with age in the supraspinatus muscle and tendon under passive and active conditions (p ≤ 0.049). Compared to asymptomatic subjects, patients had a lower mean SWS in their muscle and tendon under active conditions (p ≤ 0.024), but no differences were detected under passive conditions (p ≥ 0.783). These findings identify the influences of age and pathology on SWS in the rotator cuff. These preliminary findings are an important step toward evaluating the clinical utility of SWE for assessing rotator cuff pathology. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:282-288, 2018.

Understanding and Applying the Concept of Value Creation in Radiology.

The concept of value in radiology has been strongly advocated in recent years as a means of advancing patient care and decreasing waste. This article explores the concept of value creation in radiology and offers a framework for how radiology practices can create value according to the needs of their referring clinicians. Value only exists in the eyes of a customer. We propose that the primary purpose of diagnostic radiology is to answer clinical questions using medical imaging to help guide management of patient care. Because they are the direct recipient of this service, we propose that referring clinicians are the direct customers of a radiology practice and patients are indirect customers. Radiology practices create value as they understand and fulfill their referring clinicians' needs. To narrow those needs to actionable categories, we propose a framework consisting of four major dimensions: (1) how quickly the clinical question needs to be answered, (2) the degree of specialization required to answer the question, (3) how often the referring clinician uses imaging, and (4) the breadth of imaging that the referring clinician uses. We further identify three major settings in which referring clinicians utilize radiological services: (1) emergent or urgent care, (2) primary care, and (3) specialty care. Practices best meet these needs as they engage with their referring clinicians, create a shared vision, work together as a cohesive team, structure the organization to meet referring clinicians' needs, build the tools, and continually improve in ways that help referring clinicians care for patients.

Effects of asymptomatic rotator cuff pathology on in vivo shoulder motion and clinical outcomes.

BACKGROUND: The incidence of asymptomatic rotator cuff tears has been reported to range from 15% to 39%, but the influence of asymptomatic rotator cuff pathology on shoulder function is not well understood. This study assessed the effects of asymptomatic rotator cuff pathology on shoulder kinematics, strength, and patient-reported outcomes. METHODS: A clinical ultrasound examination was performed in 46 asymptomatic volunteers (age: 60.3 ± 7.5 years) with normal shoulder function to document the condition of their rotator cuff. The ultrasound imaging identified the participants as healthy (n = 14) or pathologic (n = 32). Shoulder motion was measured with a biplane x-ray imaging system, strength was assessed with a Biodex (Biodex Medical Systems, Inc., Shirley, NY, USA), and patient-reported outcomes were assessed using the Western Ontario Rotator Cuff Index and visual analog scale pain scores. RESULTS: Compared with healthy volunteers, those with rotator cuff pathology had significantly less abduction (P = .050) and elevation (P = .041) strength, their humerus was positioned more inferiorly on the glenoid (P = .018), and the glenohumeral contact path length was longer (P = .007). No significant differences were detected in the Western Ontario Rotator Cuff Index, visual analog scale, range of motion, or acromiohumeral distance. CONCLUSIONS: The differences observed between the healthy volunteers and those with asymptomatic rotator cuff pathology lend insight into the changes in joint mechanics, shoulder strength, and conventional clinical outcomes associated with the early stages of rotator cuff pathology. Furthermore, these findings suggest a plausible mechanical progression of kinematic and strength changes associated with the development of rotator cuff pathology.

Shear wave elastography of the supraspinatus muscle and tendon: Repeatability and preliminary findings.

Shear wave elastography (SWE) is a promising tool for estimating musculoskeletal tissue properties, but few studies have rigorously assessed its repeatability and sources of error. The objectives of this study were to assess: (1) the extent to which probe positioning error and human user error influence measurement accuracy, (2) intra-user, inter-user, and day-to-day repeatability, and (3) the extent to which active and passive conditions affect shear wave speed (SWS) repeatability. Probe positioning and human usage errors were assessed by acquiring SWE images from custom ultrasound phantoms. Intra- and inter-user repeatability were assessed by two users acquiring five trials of supraspinatus muscle and tendon SWE images from ten human subjects. To assess day-to-day repeatability, five of the subjects were tested a second time, approximately 24h later. Imaging of the phantoms indicated high inter-user repeatability, with intraclass correlation coefficient (ICC) values of 0.68-0.85, and RMS errors of no more than 4.1%. SWE imaging of the supraspinatus muscle and tendon had high repeatability, with intra- and inter-user ICC values of greater than 0.87 and 0.73, respectively. Day-to-day repeatability demonstrated ICC values greater than 0.33 for passive muscle, 0.48 for passive tendon, 0.65 for active muscle, and 0.94 for active tendon. This study indicates the technique has good to very good intra- and inter-user repeatability, and day-to-day repeatability is appreciably higher when SWE images are acquired under a low level of muscle activation. The findings from this study establish the feasibility and repeatability of SWE for acquiring data longitudinally in human subjects.

Effects of Rotator Cuff Pathology and Physical Therapy on In Vivo Shoulder Motion and Clinical Outcomes in Patients With a Symptomatic Full-Thickness Rotator Cuff Tear.

BACKGROUND: Physical therapy (PT) is often prescribed for patients with rotator cuff tears. The extent to which PT influences strength, range of motion (ROM), and patient-reported outcomes has been studied extensively, but the effect of PT on in vivo joint kinematics is not well understood. PURPOSE: To assess the influence of symptomatic rotator cuff pathology and the effects of PT on shoulder motion, strength, and patient-reported outcomes. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-five patients with a symptomatic rotator cuff tear and 25 age-matched asymptomatic control subjects were recruited. Shoulder motion was measured using a biplane radiography imaging system, strength was assessed with a Biodex dynamometer, and patient-reported outcomes were assessed using the Western Ontario Rotator Cuff Index and visual analog scale (VAS) pain scores. Data were acquired from the patients before and after 8 weeks of physical therapy. Data were acquired at 1 time point for the control subjects. RESULTS: Compared with the control subjects, patients with a symptomatic rotator cuff tear had significantly worse pain/function scores (P < .01); less ROM (P < .01); lower abduction (ABD), external rotation (ER), and internal rotation (IR) strength (P < .01); less scapulothoracic posterior tilt (P = .05); and lower glenohumeral joint elevation (P < .01). Physical therapy resulted in improved pain/function scores (P < .01), increased ROM (P < .02), increased scapulothoracic posterior tilt (P = .05), increased glenohumeral joint elevation (P = .01), and decreased acromiohumeral distance (AHD) (P = .02). CONCLUSION: Compared with age-matched controls, patients had worse pain/function scores, less ROM, and lower ABD, ER, and IR strength. Patients also had less scapulothoracic anteroposterior tilt, less glenohumeral joint elevation, and an altered glenohumeral joint contact path. PT resulted in improved pain/function scores, increased ROM, greater posterior scapulothoracic tilt, increased glenohumeral joint elevation, an increased range of superoinferior joint contact, and a lower mean AHD. Of these differences, PT only returned scapulothoracic tilt to control levels. CLINICAL RELEVANCE: This study documents the effects of PT on shoulder motion and conventional clinical outcomes. It is expected that understanding how changes in joint motion are associated with conventional clinical outcomes will lead to improved nonoperative interventions for patients with rotator cuff tears.

The advantages of tomosynthesis for evaluating bisphosphonate-related atypical femur fractures compared to radiography.

OBJECTIVE: To investigate the advantages of using tomosynthesis (TS) compared to radiographs in the detection, characterization, and follow-up of bisphosphonate-related atypical femur fractures (BP-AFF). SUBJECTS AND METHODS: Eight patients were identified retrospectively who underwent TS for radiographic findings suspicious for BP-AFF. Two radiologists independently interpreted 15 radiographs and 16 TS examinations, indicating the presence or absence of the following: (1) cortical "beaking" on radiographs, (2) radiolucent fracture line on radiographs, and (3) fracture lucency on TS corresponding to the site of radiographic abnormality. Radiation dose data were calculated for radiographs and TS using Monte Carlo analysis. RESULTS: There was agreement on 100 % of radiographs regarding the presence or absence of a cortical beak. Regarding the presence or absence of a fracture lucency, there was agreement on 100 % of TS examinations (Kappa = 1.0) and 73 % of radiographs (Kappa = 0.40 ± 0.24). For the 46 % of radiographs in which one or both radiologists did not visualize a fracture line, there was 100 % agreement for the presence of a fracture line on the corresponding TS. The interobserver agreement for fracture line detection was significantly higher for TS than for radiographs (p = 0.012). The effective radiation dose using TS was approximately 96 % lower compared to radiography. CONCLUSION: TS outperformed radiographs in the detection and characterization of BP-AFF. TS may also have advantages over radiography for BP-AFF follow-up through its unique ability to visualize fracture healing with lower effective radiation doses to the patient.

Datafish Multiphase Data Mining Technique to Match Multiple Mutually Inclusive Independent Variables in Large PACS Databases.

Retrospective data mining has tremendous potential in research but is time and labor intensive. Current data mining software contains many advanced search features but is limited in its ability to identify patients who meet multiple complex independent search criteria. Simple keyword and Boolean search techniques are ineffective when more complex searches are required, or when a search for multiple mutually inclusive variables becomes important. This is particularly true when trying to identify patients with a set of specific radiologic findings or proximity in time across multiple different imaging modalities. Another challenge that arises in retrospective data mining is that much variation still exists in how image findings are described in radiology reports. We present an algorithmic approach to solve this problem and describe a specific use case scenario in which we applied our technique to a real-world data set in order to identify patients who matched several independent variables in our institution's picture archiving and communication systems (PACS) database.

Can femoral rotation be localized and quantified using standard CT measures?

BACKGROUND: The terms "femoral anteversion" and "femoral torsion" have often been used interchangeably in the orthopaedic literature, yet they represent distinct anatomical entities. Anteversion refers to anterior tilt of the femoral neck, whereas torsion describes rotation of the femoral shaft. Together, these and other transverse plane differences describe what may be considered rotational deformities of the femur. Assessment of femoral rotation is now routinely measured by multiple axial CT methods. The most widely used radiographic technique (in which only two CT-derived axes are made, one through the femoral neck and one at the distal femoral condyles) may not accurately quantify proximal femoral anatomy nor allow identification of the anatomic locus of rotation. QUESTIONS/PURPOSES: (1) What CT methodology (a two-axis CT-derived technique, a three-axis technique adding an intertrochanteric axis--the "Kim method," or a volumetric three-dimensional reconstruction of the proximal femur) most accurately quantifies transverse plane femoral morphology; (2) localizes those deformities; and (3) is most reproducible across different observers? METHODS: We constructed a high-definition femoral sawbones model in which osteotomies were performed at either the intertrochanteric region or femoral shaft. Transverse plane deformity was randomly introduced and CT-derived rotational profiles were constructed using three different CT methods. Accuracy and consistency of measurements of femoral rotation were calculated using p values and Fisher's exact test and intraclass correlation coefficients (ICCs). RESULTS: All three CT methodologies accurately quantified overall transverse plane rotation (mean differences 0.69° ± 3.88°, 0.69° ± 3.88°, and -1.09° ± 4.44° for the two-plane, Kim, and volumetric methods, respectively). However, use of a single neck and single distal femoral axis does not reliably identify the anatomic locus of rotation, whereas the Kim and volumetric methods do (p < 0.0001). All three methods were highly reproducible between observers (ICCs of 0.9569, 0.9569, and 0.9359 for the traditional two-plane, Kim, and volumetric methods, respectively). CONCLUSIONS: Only the Kim and volumetric methods can identify the anatomic location of transverse plane rotation and we recommend using one of the two techniques. Accurate anatomic localization of transverse plane rotation enables using precise anatomic terminology ("femoral torsion" versus "femoral [ante]version"). CLINICAL RELEVANCE: Current descriptions and treatment of femoral rotational deformities do not discriminate the location of rotation. The transverse plane femoral rotation requires a precise definition based on its anatomic location to maintain consistent communication between clinicians, because version of the neck and torsion of the shaft may have different treatment.

Video: Common upper extremity injections utilizing musculoskeletal ultrasound.

OBJECTIVE: The purpose of this video article is to demonstrate the use of ultrasound for upper extremity musculoskeletal injections, covering general guidelines, preprocedure planning, needle selection, and basic technique. Several different upper-extremity injections are shown, including joint injections and aspirations, tendon sheath and bursal injections, and percutaneous treatment of calcific tendinitis. CONCLUSION: Musculoskeletal ultrasound is well suited for imaging-guided injections of the upper extremities. It is readily available, allows for high-resolution real-time imaging of the soft tissues and joints, and is adaptable for patient comfort and positioning. After viewing this video article, the observer should have an understanding of the applications for ultrasound in upper-extremity musculoskeletal interventions and should be able to apply that knowledge to advance their clinical practice.

Repetitive stress symptoms among radiology technologists: prevalence and major causative factors.

PURPOSE: The aims of this study were to determine the prevalence of repetitive stress symptoms among radiology technologists working in a fully digital radiology department and to ascertain which work-related factors contribute most to their symptoms. METHODS: A survey instrument was designed by occupational health specialists and administered to 225 technologists working in a large academic medical center radiology department. Data gathered included the presence of repetitive stress symptoms and prior diagnoses of repetitive stress syndrome. Respondents were also asked whether they spent >2 hours per day in an awkward posture (a screening question to identify individuals at risk for ergonomic injuries). Additionally, respondents were asked to identify which factors among a list of items contributed most to their symptoms. RESULTS: A total of 104 responses were received (response rate 46%). Repetitive stress symptoms were reported by 73 respondents (70%), and prior diagnoses of repetitive stress syndrome were reported by 44 (42%). Seventy-one respondents (68%) reported spending >2 hours per day in an awkward posture. Regarding the factors that were perceived to contribute most to repetitive stress symptoms, items related to patients and imaging equipment were cited much more frequently than those related to computers. The most commonly cited factors were patient transfer (33%), ultrasound probes (23%), heavy imaging equipment (20%), non-ergonomic chairs (19%), and lead aprons (10%). CONCLUSION: Repetitive stress symptoms are highly prevalent among radiology technologists working in a fully digital department but are primarily perceived to be related to tasks unrelated to computers. Thus, efforts to reduce the risk for injury should be focused primarily on improved ergonomics of patient transfer and imaging equipment.

Calcific tendinitis: a pictorial review.

Calcific tendinitis is caused by the pathologic deposition of calcium hydroxyapatite crystals in tendons and is a common cause of joint pain. The disease typically affects the shoulder and hip, with characteristic imaging findings; however, any joint can be involved. Occasionally, calcific tendinitis can mimic aggressive disorders, such as infection and neoplasm, especially on magnetic resonance imaging. Radiologists should be familiar with the imaging findings to distinguish calcific tendinitis from more aggressive processes. Image-guided percutaneous needle aspiration and steroid injection of calcific tendinitis are useful techniques performed by the radiologist for the treatment of symptomatic cases. Familiarity with these procedures and their imaging appearance is an important aspect in the management of this common disease.

Repetitive stress symptoms in radiology: prevalence and response to ergonomic interventions.

PURPOSE: To determine the prevalence of repetitive stress symptoms among radiologists working in a archiving and communication systems (PACS) environment and to assess their responses to ergonomic interventions. METHODS: A survey instrument was designed in conjunction with occupational health specialists and administered to 107 faculty members, fellows, and residents working in a PACS-based radiology department. Data gathered included the number of hours per day working at a personal computer or PACS monitor, the presence of repetitive stress symptoms, and prior diagnosis of repetitive stress syndrome. Additionally, respondents who had received ergonomic chairs, ergonomic workstations, or ergonomic training were asked to rank the impact of these interventions on the severity of repetitive stress symptoms using a 7-point, Likert-type scale ranging from -3 ("markedly worse") to 3 ("markedly better"). RESULTS: A total of 73 responses were received (a 68% response rate) from 33 faculty members and 40 trainees (residents and fellows). A majority of respondents (68%) reported working more than 8 hours per day at a personal computer or PACS monitor (55% of faculty members, 80% of trainees). Repetitive stress symptoms were reported by 58% of respondents (52% of faculty members, 63% of trainees), and prior diagnoses of repetitive stress syndrome were reported by 38% (39% of faculty members, 38% of trainees). Improvements in repetitive stress symptoms (scale ratings of 1 to 3) were reported by 70% of respondents who received ergonomic chairs (n = 54), 80% who received ergonomic workstations (n = 55), and 80% who underwent ergonomic training (n = 20). CONCLUSION: Repetitive stress symptoms are highly prevalent among radiologists working in a PACS-based environment but are responsive to ergonomic interventions. Radiology departments should implement ergonomic initiatives to reduce the risk for repetitive stress injuries.