Optimizing integrated imaging service delivery by tier in low-resource health systems.

Access to imaging diagnostics has been shown to result in accurate treatment, management, and optimal outcomes. Particularly in low-income and low-middle-income countries (LICs, LMICs), access is limited due to a lack of adequate resources. To achieve Sustainable Development Goal (SDG) 3, access to imaging services is critical at every tier of the health system. Optimizing imaging services in low-resource settings is best accomplished by prescriptive, integrated, and coordinated tiered service delivery that takes contextual factors into consideration. To our knowledge, this is the first recommendation for optimized, specific imaging care delivery by tier. A model for tier-based essential imaging services informs and guides policymakers as they set priorities and make budgetary decisions. In this paper, we recommend a framework for tiered imaging services essential to reduce the global burden of disease and attain universal health coverage (UHC). A lack of access to basic imaging services, even at the lowest tier of the health system, can no longer be justified by cost. Worldwide, affordable modalities of modern ultrasound and X-ray are becoming an accessible mainstay for the investigation of common conditions such as pregnancy, pneumonia, and fractures, and are safely performed and interpreted by qualified professionals. Finally, given the vast gap in access to imaging resources between LMICs and high-income countries (HICs), a scale-up of tiered imaging services in low-resource settings has the potential to reduce health disparities between, and within countries. As the access to appropriately integrated imaging services improves, UHC may be achieved.

Hepatocellular carcinoma recurrence pattern following liver transplantation and a suggested surveillance algorithm.

PURPOSE: This study aims to evaluate the recurrence pattern of hepatocellular carcinoma (HCC) following liver transplantation. MATERIALS AND METHODS: A total of 54 patients underwent liver transplantation for HCC; 9 patients developed biopsy-proven recurrent HCC (16.6%). The site of HCC recurrence along with other factors was analyzed. RESULTS: Seven patients were diagnosed with HCC prior to liver transplantation and 2 patients had incidental HCC in the explanted liver. Two patients had locoregional recurrence, 4 patients had distant metastasis, and 3 patients had synchronous locoregional recurrence and distant metastasis. CONCLUSION: A significant proportion of HCC recurrence following liver transplantation is extrahepatic.

Effect of needle gauge and lobe laterality on parenchymal liver biopsy outcome: a retrospective analysis.

PURPOSE: To analyze the effect of lobe selection, needle gauge, and number of passes on procedure outcomes in terms of specimen length and post-procedure complications. METHODS: In this HIPAA-compliant, IRB-approved retrospective study, the data from 771 ultrasound-guided adult parenchymal liver biopsies were analyzed. Post-procedure complications were assigned a 3-point rating scale. Associations between specimen length and post-procedure complications with lobe laterality, needle gauge, and number of passes were analyzed. Multivariate logistic regression models were used to analyze the likelihood for achieving a specimen length of at least 2 cm. RESULTS: Post-procedure complications were not associated with lobe laterality, needle gauge, and number of passes (p > 0.3). Specimen length was associated with the number of passes dichotomized at the study mean (p = 0.007), but not with lobe laterality or needle gauge (p > 0.2). After adjusting for lobe laterality and needle gauge, procedures with 1 or 2 passes were associated with a higher likelihood of obtaining a 2 cm or longer specimen (OR 2.469; CI 1.08-5.63, p = 0.0315) than procedures with 3 or more passes, possibly due to poorer sample quality. After adjusting for lobe laterality, an 18-gauge needle was associated with higher odds of a biopsy procedure with 1 or 2 passes (OR 3.665; CI 1.93-6.95, p < 0.0001) than a 20-gauge needle. CONCLUSIONS: Lobe laterality was not associated with specimen length or post-procedure complications. An 18-gauge needle compared to a 20-gauge needle could reduce the need for a procedure with more than 2 passes. There was no difference in post-procedure complications between the two needle sizes.

Dedicated breast CT: geometric design considerations to maximize posterior breast coverage.

An Institutional Review Board-approved protocol was used to quantify breast tissue inclusion in 52 women, under conditions simulating both craniocaudal (CC) and mediolateral oblique (MLO) views in mammography, dedicated breast CT in the upright subject position, and dedicated breast CT in the prone subject position. Using skin as a surrogate for the underlying breast tissue, the posterior aspect of the breast that is aligned with the chest-wall edge of the breast support in a screen-film mammography system was marked with the study participants positioned for CC and MLO views. The union of skin marks with the study participants positioned for CC and MLO views was considered to represent chest-wall tissue available for imaging with mammography and served as the reference standard. For breast CT, a prone stereotactic breast biopsy unit and a custom-fabricated barrier were used to simulate conditions during prone and upright breast CT, respectively. For the same breast marked on the mammography system, skin marks were made along the breast periphery that was just anterior to the apertures of the prone biopsy unit and the upright barrier. The differences in skin marks between subject positioning simulating breast CT (prone, upright) and mammography were quantified at six anatomic locations. For each location, at least one study participant had a skin mark from breast CT (prone, upright) posterior to mammography. However for all study participants, there was at least one anatomic location where the skin mark from mammography was posterior to that from breast CT (prone, upright) positioning. The maximum amount by which the skin mark from mammography was posterior to breast CT (prone and upright) over all six locations was quantified for each study participant and pair-wise comparison did not exhibit statistically significant difference between prone and upright breast CT (paired t- test, p = 0.4). Quantitatively, for 95% of the study participants the skin mark from mammography was posterior to breast CT (prone or upright) by at the most 9 mm over all six locations. Based on the study observations, geometric design considerations targeting chest-wall coverage with breast CT equivalent to mammography, wherein part of the x-ray beam images through the swale during breast CT are provided. Assuming subjects can extend their chest in to a swale, the optimal swale-depth required to achieve equivalent coverage with breast CT images as mammograms for 95% of the subjects varies in the range of ~30-50 mm for clinical prototypes and was dependent on the system geometry.

Renal biopsy: comparative yield of cranial versus caudal needle trajectory. An ex vivo analysis.

AIM: To compare the diagnostic quality of tissue cores obtained using cranial and caudal angulation of the renal biopsy needle. Comparison was made in terms of the number of glomeruli and proportion of renal cortex with medulla on pathological analysis. METHODS: A total of 40 desktop, renal biopsies were performed on 10 ex vivo porcine kidneys using two different targeting angles. Biopsies were obtained from the 'lower pole' of each kidney using both cephalad and caudad angulations of the biopsy needle. Ten 18-gauge semi-automated cutting needles were used during twenty biopsies obtained per each angle; two biopsies were made using each needle. The resulting samples were collected in 40 separate and labelled formalin containers according to the used targeting angle. Two pathologists blinded to the corresponding biopsy angles reviewed the samples in consensus. RESULTS: Samples with a cephalad targeting angle had a mean length of 14.5 mm with mean number of 9.6 glomeruli and average 82% cortex and 18% medulla. Samples obtained using a caudad needle angulation had a mean length of 14.1 mm with mean number of 11.6 glomeruli and on the average 99% cortex. The P-values comparing the two samples were as follows: 0.63 comparing the mean length of cores, 0.08 for number of glomeruli and 0.002 comparing the proportion of cortex. CONCLUSION: The proportion of cortical tissue in the core biopsy specimen using the caudad angle approach was statistically significantly higher, compared with the cephalad needle trajectory.

Focused peer review: the end game of peer review.

PURPOSE: The aim of this report is to describe the authors' experience with expanding the routine peer-review process to include misdiagnoses from all sources and the use of focused peer review (FPR) in faculty accountability and management. METHODS: A department-wide routine peer review was conducted. Each radiologist was assigned 12 cases per month. In addition, clinically reported errors, missed diagnoses discovered outside the routine peer-review process, were identified. Cases were scored from 1 to 5. The department quality office evaluated cases with scores of 3 and 4 from both sources for further processing with FPR, a multistep continuation of the peer-review process using a tracking document. Once initiated, FPR was processed by seeking comments from the division director and the interpreting radiologist. In some cases, FPR was discontinued before completion. Completed FPR documents were submitted to the department chair for administrative action, ranging from no action to termination. All FPR cases are presented at monthly departmental morbidity and mortality conferences. RESULTS: Routine peer review was done on 1,646 cases from a total of about 300,000 studies by 31 radiologists. Thirty-five cases from the two sources with scores of 3 and 4 were analyzed, 21 from the routine peer review and 14 clinically reported errors. The quality officer initiated 25 FPRs, rejecting 10 because errors were not considered significant. Further scrutiny lead to dropping 7 of the 12 routine and 2 of the 13 cases with clinically reported error. Sixteen FPRs were completed, 5 (31%) from routine peer review and 11 (69%) from clinically reported errors. For these 16 completed FPRs, management decisions were made by the department chair. CONCLUSIONS: Processing of routine peer-review data together with cases of clinically reported error strengthens the peer-review process. Focused peer review can effectively contribute to the surveillance and management of faculty performance for improved patient care.

Unusual complication after left-lobe liver biopsy for diffuse liver disease: severe bleeding from the superior epigastric artery.

OBJECTIVE: Imaging-guided parenchymal liver biopsy for diffuse liver disease is increasingly performed via an epigastric route from the left lobe, as opposed to the more traditional intercostal right-sided approach. MATERIALS AND METHODS: We conducted a retrospective analysis of all liver biopsies performed at our department for 3 years (July 2007 through June 2010). A total of 1028 liver biopsies were performed during this period. Of these, 776 biopsies were performed for diffuse medical liver disease. Electronic medical records were reviewed for any documented complications. RESULTS: We identified six cases (0.8%) of documented significant bleeding after 776 biopsies. All bleeding complications were associated with the left-sided epigastric approach. No documented case of major bleeding from the right-sided approach was recorded during the same period. We describe four patients with severe bleeding complications in which classic imaging features were noted on CT, pointing to injury of the superior epigastric artery as the possible cause of the bleeding. CONCLUSION: It is important to recognize the subtle CT signs of superior epigastric artery bleeding because the traditional femoral approach with angiography of the hepatic and portal vessels may not reveal active bleeding. The superior epigastric artery, rather than the hepatic arteries, should be evaluated. A brachial approach for the angiogram may be the more optimal technique.

Addenda to the radiology report: what are we trying to convey?

PURPOSE: The aims of this paper are to describe addenda to radiology reports and to discuss the communication gaps in radiology addenda reaching referring physicians. The authors examine impediments to compliance with an addendum policy and suggest possible solutions. METHODS: A total of 62,500 radiology reports were reviewed to analyze the occurrence of report addenda. Addenda types were separated into clinical, generated by radiologists, and administrative (for billing or regulatory reasons). Two radiologists reviewed all clinical addenda and classified them as significant or not significant. Significant addenda were further analyzed for various aspects. An e-mail survey was also conducted to assess prevailing practices in academic departments of radiology. RESULTS: There were 1,069 reports with addenda (1.7%). Of these, 575 were generated by radiologists. Forty-nine (8.5%) were for clinically significant errors and 526 (91.5%) were not. Of the 49 significant addenda, 9 (18%) were fully compliant with departmental addendum policies, 27 (55%) were noncompliant, and 13 (27%) were partially compliant. Of the 49 clinically significant addenda, 17 (55%) were dictated within 1 hour and 40 (82%) within 24 hours of the finalized original reports. CONCLUSIONS: Poor compliance with an addendum policy was found. The reasons for noncompliance and possible remedies are discussed, with the hope of beginning a dialogue in the radiology literature on the risks of poor communication processes and the benefits of full implementation of well thought-out addendum policies.

Alcohol sclerosis of a giant liver cyst following failed deroofings.

Percutaneous alcohol sclerotherapy for simple liver cysts is an established and safe procedure. We report alcohol ablation of a very large (5.5 liters) liver cyst that had failed laparoscopic deroofing procedures twice. The cyst responded to multisession alcohol sclerotherapy.

Umbilical concretion.

Umbilical concretion is a rarely encountered benign entity. Concretions typically form within an umbilical cleft which is unusually deep and consist of keratinaceous and sebaceous material. Lack of attention to umbilical hygiene usually plays a role in their formation. Concretions are generally asymptomatic and may only present clinically when complicated by inflammation or infection. Their appearance on imaging studies may be problematic for the radiologist given their rarity, particularly in the setting of a known or suspected intra-abdominal malignancy.

Focal nodular hyperplasia: central scar enhancement pattern using Gadoxetate Disodium.

PURPOSE: To illustrate the unusual enhancement pattern of the focal nodular hyperplasia central scar using Gadoxetate Disodium. MATERIALS AND METHODS: Over a 10-month period, six patients, with a total of seven focal nodular hyperplasia lesions with typical central scar, had MRI of the liver using Gadoxetate Disodium (Eovist, Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ). Four of the six patients had a prior Gadobenate Dimeglumine (Multihance, Bracco Diagnostics Inc., Princeton, NJ) -enhanced MRI of the liver performed within the previous year. The dynamic enhancement pattern of the central scar on the 10 liver MRIs was independently analyzed by two abdominal imaging radiologists who were blinded to the contrast agent used. RESULTS: On the Gadoxetate Disodium-enhanced MRIs and during the arterial phase, 1-min, 2-min, and 3-min delay, none of the central scars demonstrated enhancement. However, all four of the lesions that were previously scanned using Gadobenate Dimeglumine demonstrated typical enhancement after a 3-min delay. CONCLUSION: On Gadoxetate Disodium-enhanced MRIs of the liver, the central scar of focal nodular hyperplasia lesions does not typically demonstrate delayed enhancement.