Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review.

OBJECTIVES: The objective of this systematic review was to offer a comprehensive overview and explore the associated outcomes from imaging referral guidelines on various key stakeholders, such as patients and radiologists. MATERIALS AND METHODS: An electronic database search was conducted in Medline, Embase and Web of Science to retrieve citations published between 2013 and 2023. The search was constructed using medical subject headings and keywords. Only full-text articles and reviews written in English were included. The quality of the included papers was assessed using the mixed methods appraisal tool. A narrative synthesis was undertaken for the selected articles. RESULTS: The search yielded 4384 records. Following the abstract, full-text screening, and removal of duplication, 31 studies of varying levels of quality were included in the final analysis. Imaging referral guidelines from the American College of Radiology were most commonly used. Clinical decision support systems were the most evaluated mode of intervention, either integrated or standalone. Interventions showed reduced patient radiation doses and waiting times for imaging. There was a general reduction in radiology workload and utilisation of diagnostic imaging. Low-value imaging utilisation decreased with an increase in the appropriateness of imaging referrals and ratings and cost savings. Clinical effectiveness was maintained during the intervention period without notable adverse consequences. CONCLUSION: Using evidence-based imaging referral guidelines improves the quality of healthcare and outcomes while reducing healthcare costs. Imaging referral guidelines are one essential component of improving the value of radiology in the healthcare system. CLINICAL RELEVANCE STATEMENT: There is a need for broader dissemination of imaging referral guidelines to healthcare providers globally in tandem with the harmonisation of the application of these guidelines to improve the overall value of radiology within the healthcare system. KEY POINTS: The application of imaging referral guidelines has an impact and effect on patients, radiologists, and health policymakers. The adoption of imaging referral guidelines in clinical practice can impact healthcare costs and improve healthcare quality and outcomes. Implementing imaging referral guidelines contributes to the attainment of value-based radiology.

Appropriateness of lumbar spine radiography and factors influencing imaging ordering patterns: paving the path toward value-driven health care.

The demand for diagnostic imaging continues to rise. Against the backdrop of rising health care costs and finite resources, this has prompted a paradigm shift toward value-driven patient care. Inappropriate imaging is a barrier toward achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral Emergency Department (ED) and assess whether physicians' specialization and years of experience influence appropriateness. A total of 1030 lumbar spine radiographs performed in the ED of an academic medical center over a consecutive 3-month period were reviewed retrospectively. Referral indications were reviewed for adherence to 2021 American College of Radiology appropriateness guidelines for lower back pain, and referral patterns were evaluated among physician groups based on specialists' training and years in practice. 63.8% of lumbar spine radiographs were appropriate, with trauma being the most common indication. 36.2% of orders were inappropriate, with lower back pain of <6 weeks duration being the most common indication. Significant differences in inappropriate orders were found (P < .001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in training (27.8%), and non-specialists with ≥3 (60.0%) and <3 (36.9%) years in practice, respectively. Approximately one-third of lumbar spine radiographs performed in the ED were inappropriately ordered by American College of Radiology guidelines; specialists training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce health care costs.

Adapting to a new normal? 5 key operational principles for a radiology service facing the COVID-19 pandemic.

KEY POINTS: • Radiology services encountering the coronavirus disease-19 pandemic will need to modify their daily operational practices.• Leadership, patient risk stratification, adequate manpower, operational workflow clarity, and workplace/social responsibility will help Radiology services safely and sustainably deal with the current disease outbreak.

Déjà Vu or Jamais Vu? How the Severe Acute Respiratory Syndrome Experience Influenced a Singapore Radiology Department's Response to the Coronavirus Disease (COVID-19) Epidemic.

OBJECTIVE. This article shares the ground operational perspective of how a tertiary hospital radiology department in Singapore is responding to the coronavirus disease (COVID-19) epidemic. This same department was also deeply impacted by the severe acute respiratory syndrome (SARS) outbreak in 2003. CONCLUSION. Though similar to SARS, the COVID-19 outbreak has several differences. We share how lessons from 2003 are applied and modified in our ongoing operational response to this evolving novel pathogen.

Lymphomatosis Cerebri: A diagnostic dilemma.

Background: Lymphomatosis cerebri (LC) is a rare manifestation of primary central nervous system lymphoma (PCNSL) with only a few cases reported in the literature, appearing as diffuse infiltrating process rather than a solitary mass. It is a non-Hodgkin's type of lymphoma and is usually of the B-cell type origin. Purpose: We intend to report this unique case of LC which came across as a diagnostic challenge. Methods: A 53-year-old gentleman presented with complaints of two episodes of seizures 24 h apart followed by postictal confusion for 10-15 min. He underwent multiple MRI scans and underwent a biopsy of the lesion which reported infection, but he did not benefit from the treatment. Result: The imaging was reviewed, suspicion of LC was raised and a review of histopathology was requested which later confirmed primary CNS lymphoma. Conclusion: LC is a rare but established manifestation of PCNSL which mimics multiple other conditions. Understanding of the imaging pattern is important in making the diagnosis and differentiating it from other mimic conditions.

Evaluation of Compressed SENSE on Image Quality and Reduction of MRI Acquisition Time: A Clinical Validation Study.

RATIONALE AND OBJECTIVES: To evaluate the effect of compressed SENSE (CS) in clinical settings on scan time reduction and image quality. MATERIALS AND METHODS: Ninety-five magnetic resonance imaging (MRI) scans from different anatomical regions were acquired, consisting of a standard protocol sequence (SS) and sequence accelerated with CS. Anonymized paired sequences were randomly displayed and rated by six blinded subspecialty radiologists. Side-by-side evaluation on perceived sharpness, perceived signal-to-noise-ratio (SNR), lesion conspicuity, and artifacts were compared and scored on a five-point Likert scale, and individual image quality was evaluated on a four-point Likert scale. RESULTS: CS reduced overall scan time by 32% while maintaining acceptable MRI quality for all regions. The largest time savings were seen in the spine (mean = 68 seconds, 44% reduction) followed by the brain (mean = 86 seconds, 37% reduction). The sequence with maximum time savings was intracranial 3D-time-of-flight magnetic resonance angiography (202 seconds, 56% reduction). CS was mildly inferior to SS on perceived sharpness, perceived SNR, and lesion conspicuity (mean scores = 2.32-2.96, P < .001 [1: SS superior; 3: equivalent; 5: CS superior]). CS was equivalent to SS for joint and body scans on overall image quality (CS = 3.02-3.37, SS = 3.04-3.68, P > .05, [1: lowest quality and 4: highest quality]). The overall image quality of CS was slightly less for brain and spine scans (mean CS = 2.79-3.05, mean SS = 3.13-3.43, P = .021) but still diagnostic. Good overall clinical acceptance for CS (88%) was noted with full clinical acceptance for body scans (100%) and high acceptance for other regions (68%-95%). CONCLUSION: CS significantly reduced MR acquisition time while maintaining acceptable image quality. The implementation of CS may improve departmental workflows and enhance patient care.

Quantitative iron-neuromelanin MRI associates with motor severity in Parkinson's disease and matches radiological disease classification.

Background: Neuromelanin- and iron-sensitive MRI studies in Parkinson's disease (PD) are limited by small sample sizes and lack detailed clinical correlation. In a large case-control PD cohort, we evaluated the diagnostic accuracy of quantitative iron-neuromelanin MRI parameters from the substantia nigra (SN), their radiological utility, and clinical association. Methods: PD patients and age-matched controls were prospectively recruited for motor assessment and midbrain neuromelanin- and iron-sensitive [quantitative susceptibility mapping (QSM) and susceptibility map-weighted imaging (SMWI)] MRI. Quantitative neuromelanin-iron parameters from the SN were assessed for their discriminatory performance in PD classification using ROC analysis compared to those of qualitative visual classification by radiological readers of differential experience and used to predict motor severity. Results: In total, 191 subjects (80 PD, mean age 65.0 years; 111 controls, 65.6) were included. SN masks showed (a) higher mean susceptibility (p < 0.0001) and smaller sizes after thresholding for low susceptibility (p < 0.0001) on QSM and (b) lower contrast range (p < 0.0001) and smaller sizes after thresholding for high-signal voxels (p < 0.0001) on neuromelanin-sensitive MRI in patients than in controls. Quantitative iron and neuromelanin parameters showed a moderate correlation with motor dysfunction (87.5%: 0.4< | r | <0.6, p < 0.0001), respectively. A composite quantitative neuromelanin-iron marker differentiated the groups with excellent performance (AUC 0.94), matching the diagnostic accuracy of the best-performing reader (accuracy 97%) using SMWI. Conclusion: Quantitative neuromelanin-iron MRI is associated with PD motor severity and matched best-performing radiological PD classification using SMWI, with the potential to improve diagnostic confidence in the clinics and track disease progression and response to neuroprotective therapies.

A Tale of Two Organ Systems: Imaging Review of Diseases Affecting the Thoracic and Neurological Systems. Part 2.

In an era of rapidly expanding knowledge and sub-specialization, it is becoming increasingly common to focus on one organ system. However, the human body is intimately linked, and disease processes affecting one region of the body not uncommonly affect the other organ systems as well. Understanding diseases from a macroscopic perspective, rather than a narrow vantage point, enables efficient and accurate diagnosis. This tenet holds true for diseases affecting both the thoracic and neurologic systems; in isolation, the radiologic appearance of disease in one organ system may be nonspecific, but viewing the pathophysiologic process in both organ systems may markedly narrow the differential considerations, and potentially lead to a definitive diagnosis. In this article, we discuss a variety of disease entities known to affect both the thoracic and neurological systems, either manifesting simultaneously or at different periods of time. Some of these conditions may show neither thoracic nor neurological manifestations. These diseases have been systematically classified into infectious, immune-mediated/ inflammatory, vascular, syndromic/ hereditary and neoplastic disorders. The underlying pathophysiological mechanisms linking both regions and radiologic appearances in both organ systems are discussed. When appropriate, brief clinical and diagnostic information is provided. Ultimately, accurate diagnosis will lead to expedited triage and prompt institution of potentially life-saving treatment for these groups of complex disorders.

A Tale of Two Organ Systems: Imaging review of diseases affecting the thoracic and neurological systems. Part 1.

In an era of rapidly expanding knowledge and sub-specialization, it is becoming increasingly common to focus on one organ system. However, the human body is intimately linked, and disease processes affecting one region of the body not uncommonly affect the other organ systems as well. Understanding diseases from a macroscopic perspective, rather than a narrow vantage point, enables efficient and accurate diagnosis. This tenet holds true for diseases affecting both the thoracic and neurological systems; in isolation, the radiologic appearance of disease in one organ system may be nonspecific, but viewing the pathophysiologic process in both organ systems may markedly narrow the differential considerations, and potentially lead to a definitive diagnosis. In this article, we discuss a variety of disease entities known to affect both the thoracic and neurological systems, either manifesting simultaneously or at different periods of time. Some of these conditions may show neither thoracic nor neurological manifestations. These diseases have been systematically classified into infectious, immune-mediated / inflammatory, vascular, syndromic / hereditary and neoplastic disorders. The underlying pathophysiological mechanisms linking both regions and radiologic appearances in both organ systems are discussed. When appropriate, brief clinical and diagnostic information is provided. Ultimately, accurate diagnosis will lead to expedited triage and prompt institution of potentially life-saving treatment for these groups of complex disorders.

Cardiovascular Hoarseness (Ortner's Syndrome): A Pictorial Review.

Ortner's syndrome, also known as cardiovocal syndrome, encompasses any cardiac or vascular process that affects the recurrent laryngeal nerve(s), subsequently leading to vocal cord palsy. Various causes of Ortner's syndrome have been described in the literature, which include but are not limited to aortic aneurysms, pulmonary hypertension, left atrial enlargement, and congenital cardiac disorders. We hereby present a pictorial review of the more commonly reported entities, which have been implicated in this syndrome. Ultimately, understanding the pathophysiology underlying Ortner's syndrome will help in diagnosis and institution of potentially life-saving treatment.

A survey of anxiety and burnout in the radiology workforce of a tertiary hospital during the COVID-19 pandemic.

INTRODUCTION: We aimed to study anxiety and burnout among Division of Radiological Sciences (RADSC) staff during the COVID-19 pandemic and identify potential risk and protective factors. These outcomes were compared with non-RADSC staff. METHODS: A cross-sectional online study was conducted between 12 March and 20 July 2020 in the largest public tertiary hospital receiving COVID-19 cases. Burnout and anxiety were assessed with the Physician Work-Life Scale and the Generalized Anxiety Disorder-7 Scale, respectively. Workplace factors were examined as potential risk and protective factors using multivariable ordinary least squares regression analyses, adjusting for pertinent demographic characteristics. RESULTS: RADSC staff (n = 180) and non-RADSC staff (n = 1458) demonstrated moderate-to-severe anxiety rates of 6.7 and 13.2 % and burnout rates of 17.8 and 23.9 %, respectively. RADSC staff reported significantly lower anxiety (mean ± SD: 4.0 ± 3.7 vs 4.9 ± 4.5; P-value < 0.05), burnout (mean ± SD: 1.9 ± 0.7 vs 2.1 ± 0.8; P-value < 0.01), increased teamwork (82.2% vs 74.1%; P-value < 0.05) and fewer night shifts (36.7% vs 41.1%; P-value < 0.01). Among RADSC staff, higher job dedication was associated with lower anxiety (b (95% CI) = -0.28 (-0.45, -0.11)) and burnout (b (95% CI) = -0.07 (-0.11,-0.04)), while longer than usual working hours was associated with increased anxiety (b (95% CI) = 1.42 (0.36, 2.45)) and burnout (b (95% CI) = 0.28 (0.09, 0.48)). CONCLUSIONS: A proportion of RADSC staff reported significant burnout and anxiety, although less compared to the larger hospital cohort. Measures to prevent longer than usual work hours and increase feelings of enthusiasm and pride in one's job may further reduce the prevalence of anxiety problems and burnout in radiology departments.

Healthcare worker stress, anxiety and burnout during the COVID-19 pandemic in Singapore: A 6-month multi-centre prospective study.

AIM: The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout. METHOD: A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale). RESULTS: The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout. CONCLUSIONS: Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

Extensive systemic metastases from primary central nervous system haemangiopericytoma.

Primary intracranial tumours rarely metastasise outside of the central nervous system (CNS). This report describes a rare case of recurrent meningeal haemangiopericytoma with extensive systemic metastases, which eventually resulted in a fatal outcome. We discuss some prevailing theories as to the rarity of extracranial metastases from primary CNS haemangiopericytoma, and elucidate the epidemiology, imaging features, differential diagnosis, treatment, and prognosis of this unusual but surprisingly aggressive meningeal tumour. Besides aggressive treatment for local tumour control, patients with primary CNS haemangiopericytoma require long-term post-treatment surveillance to detect systemic metastases.

The Wandering Charm Needle.

Charm needles, otherwise known as susuk, are small pin like objects worn subcutaneously, thought to bring magic powers, bringing health, wealth, beauty, and other benefits to the wearer. These talismans are fairly common in South-East Asia, and are generally thought to be benign entities with few clinical sequela. In fact, no known complications have ever been reported in the literature, as susuk are typically composed of biologically inert precious metals and rarely migrate from their origin. Herein, we detail the first ever reported case of a complication from a charm needle, involving a middle aged Chinese female who had a charm needle subcutaneously inserted into the occipital scalp, which eventually migrated through the skull and into her left cerebellar hemisphere. Our aim is to familiarize readers to this peculiar phenomenon not widely practiced in the western world, and to highlight that charm needles are not as benign as initially conceived. To the best of our knowledge, this case demonstrates the first reported complication of a charm needle in the English medical literature.

Chest Radiographs and CTs in the Era of COVID-19: Indications, Operational Safety Considerations and Alternative Imaging Practices.

Coronavirus disease-19 (COVID-19) is a pathogen that has shown an ability for sustained community transmission. To ensure utmost safety, radiology services will need to adapt to this disease in the coming months and possibly years ahead. This will include learning how to perform radiographs and CT in a safe and sustainable manner. Due to the risk of nosocomial spread of disease, the judicious use and implementation of strict infection protocols is paramount to limit healthcare worker and patient transmission. Between 28 January 2020 and 8 June 2020, our institution performed 12,034 radiographs and 178 CT scans for suspected or confirmed COVID-19 patients. As of 8 June 2020, there have been no documented instances of healthcare staff acquiring COVID-19 during the course of work. In this article, we present the indications and operational considerations used by our institution to safely image patients with suspected or confirmed COVID-19. Alternative practices for imaging radiographs are also discussed.

Extramedullary multiple myeloma with central nervous system and multiorgan involvement: Case report and literature review.

Multiple myeloma is a hematologic malignancy due to monoclonal plasma cell proliferation. It is usually confined to the bone marrow, although extramedullary involvement is known to occur in almost any organ system; myelomatous spread to the central nervous system is a rare manifestation of myeloma. Extramedullary disease is thought to be related to hematogenous spread when myeloma cells show decreased cell surface receptor expression, allowing cells to escape from the bone marrow. Disease outside of the bone marrow generally indicates a poor prognosis; central nervous system involvement is associated with a median prognosis of less than 6 months, thereby requiring more aggressive treatment paradigms. We herein describe an unusual case of a patient with extramedullary multiple myeloma with central nervous system and multiorgan involvement. Despite an aggressive treatment strategy, the patient died a few months later after the initial diagnosis. The etiology, diagnostic criteria, clinical presentation, radiological features and differential diagnosis of this patient with extramedullary multiple myeloma are discussed here. The current treatment strategies are also briefly discussed.

Clinics in diagnostic imaging (190). Subacute combined degeneration of the spinal cord (SCD).

A 54-year-old man presented with progressive onset of lower limb paraesthesias, sensory ataxia, gait instability and lower limb weakness. Laboratory findings revealed low serum B12 levels. Magnetic resonance imaging showed long-segment symmetrically increased T2 signal within the dorsal columns of the spinal cord in the lower thoracic spine. The conglomeration of findings was consistent with a diagnosis of subacute combined degeneration of the spinal cord (SCD). Aside from mild residual paraesthesias, the patient's symptoms largely resolved after treatment with intramuscular injections of vitamin B12. The clinical presentation, pathophysiology, clinical and radiologic differential diagnosis, and management of SCD were described.

Clinics in diagnostic imaging (191). Multiple system atrophy-cerebellar type (MSA-C).

A 49-year-old Chinese man was evaluated for progressive uncoordinated movements, dysphagia and urinary symptoms. Magnetic resonance imaging demonstrated a cruciform pattern of T2-weighted hyperintensity within the pons and selective atrophy of the cerebellar hemispheres and pons. The clinical history and radiological findings were consistent with a diagnosis of multiple system atrophy-cerebellar type. This article discussed the background, proposed mechanisms, diagnosis, radiological characteristics, prognosis and management of multiple system atrophy-cerebellar type.

Clinics in diagnostic imaging (188). Transient global amnesia (TGA).

A 60-year-old woman was travelling on a plane with her spouse when she suddenly developed acute-onset disorientation to time and space. According to her husband, she repetitively questioned her whereabouts and complained of a minor headache. Upon landing, she was immediately brought to the emergency room and subsequent magnetic resonance imaging was performed, which showed multiple punctate 2-3 mm regions of diffusion-weighted imaging hyperintensity in the medial aspects of both temporal lobes. The conglomeration of clinical history and radiological findings was most suggestive of transient global amnesia. This article discussed the background, proposed mechanisms, diagnosis, radiological characteristics and management of transient global amnesia.