An International Survey of Quality and Safety Programs in Radiology.

PURPOSE: The aim of this study was to determine the status of radiology quality improvement programs in a variety of selected nations worldwide. METHODS: A survey was developed by select members of the International Economics Committee of the American College of Radiology on quality programs and was distributed to committee members. Members responded on behalf of their country. The 51-question survey asked about 12 different quality initiatives which were grouped into 4 themes: departments, users, equipment, and outcomes. Respondents reported whether a designated type of quality initiative was used in their country and answered subsequent questions further characterizing it. RESULTS: The response rate was 100% and represented Australia, Canada, China, England, France, Germany, India, Israel, Japan, the Netherlands, Russia, and the United States. The most frequently reported quality initiatives were imaging appropriateness (91.7%) and disease registries (91.7%), followed by key performance indicators (83.3%) and morbidity and mortality rounds (83.3%). Peer review, equipment accreditation, radiation dose monitoring, and structured reporting were reported by 75.0% of respondents, followed by 58.3% of respondents for quality audits and critical incident reporting. The least frequently reported initiatives included Lean/Kaizen exercises and physician performance assessments, implemented by 25.0% of respondents. CONCLUSION: There is considerable diversity in the quality programs used throughout the world, despite some influence by national and international organizations, from whom further guidance could increase uniformity and optimize patient care in radiology.

Synovial Fat Deposition of the Knee Is Associated with Degenerative Joint Disorder.

Synovial fat deposition, also known as lipoma arborescens, is a rare articular disorder with villous synovial proliferation, commonly seen in the knee. We explored the relationship between the degree of synovial fat deposition on the magnetic resonance imaging (MRI) and the severity of degenerative joint disorder, also called osteoarthritis, on plain radiography. The enrolled patients underwent MRI with a 0.4T permanent magnetic unit in a single institution over a 9-month period. The indications of MRI were chronic knee disorder of non-specific cause. Patients with minor trauma were also included. Consecutive 1,091 knees of 1,075 patients were assessed for the degree of synovial fat deposition on MRI and the severity of degenerative joint disorder on plain radiography. The degenerative joint disorder was graded by radiographic features obtained within one month from MRI using Kellgrene-Lawrence (K-L) scores. MRI features of synovial fat deposition were classified as none, mild and severe. Synovial fat deposition was identified in 30 knees of 29 patients (2.7%) (11 men and 18 women; aged from 25 to 86 years, one patient with bilateral lesions): one female patient with osteoarthritis secondary to rheumatoid arthritis and 28 patients with degenerative joint disorder. The K-L grade was 4 in the case of rheumatoid arthritis. There was a moderate positive correlation between the K-L grade and fat deposition grade (correlation coefficient: 0.59, p < 0.001). Thus, synovial fat deposition was noted in the advanced degenerative joint disorder. We propose that fat deposition represents a nonspecific secondary phenomenon of degenerative joint disorder.

The impact of portal vein thrombosis on the prognosis and liver function of nonmalignant cirrhotic patients.

OBJECTIVES: The clinical impact of portal vein thrombosis (PVT) in cirrhotic patients remains unclear. The aim of the study is whether recanalization of acute PVT in nonmalignant cirrhotic patients is associated with their prognosis. MATERIALS AND METHODS: We identified subject with PVT in cirrhotic patients from institutional database. Patients with ≥50% reduction in thrombus size were classified into the improved group and those with ≤49% reduction in thrombus size, or thrombus development in other branches were classified into the deteriorated group. We compared the cumulative survival rate, event-free survival rate (EFS), and liver function (albumin-to-bilirubin (ALBI) and model for end-stage liver disease XI (MELD-XI) between the two groups. RESULTS: Twenty-seven patients were enrolled in this retrospective study. Sixteen patients were classified into the improved group, and 11 were classified into the deteriorated group. In the improved group, the ALBI grade and MELD-XI measured before the onset of PVT and at one year after the onset of PVT were not significantly different. In contrast, MELD-XI was significantly aggravated in deteriorated group (MELD-XI [p = .02]). The cumulative survival of the two groups did not differ significantly; however, the EFS of the deteriorated group was significantly lower (p = .049). CONCLUSIONS: Residual thrombosis of PVT in cirrhotic patients increased the incidence of liver-related events and was associated with the deterioration of the liver function.

Nationwide surveillance of bacterial respiratory pathogens conducted by the surveillance committee of Japanese Society of Chemotherapy, the Japanese Association for Infectious Diseases, and the Japanese Society for Clinical Microbiology in 2012: General view of the pathogens' antibacterial susceptibility.

The nationwide surveillance on antimicrobial susceptibility of bacterial respiratory pathogens from the patients in Japan was conducted by Japanese Society of Chemotherapy, Japanese association for infectious diseases and Japanese society for Clinical Microbiology in 2012. The isolates were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections during the period between January and December in 2012 by three societies. Antimicrobial susceptibility testing was conducted at the central reference laboratory according to the method recommended by Clinical Laboratory Standard Institutes. Susceptibility testing was evaluated in 1236 strains (232 Staphylococcus aureus, 225 Streptococcus pneumoniae, 16 Streptococcus pyogenes, 231 Haemophilus influenzae, 147 Moraxella catarrhalis, 167 Klebsiella pneumoniae and 218 Pseudomonas aeruginosa). Ratio of methicillin-resistant S. aureus was 51.3%, and those of penicillin-intermediate S. pneumoniae was 0.4%. Among H. influenzae, 5.6% of them were found to be ß-lactamase-producing ampicillin-resistant strains, and 37.2% to be ß-lactamase-non-producing ampicillin-resistant strains. Extended spectrum ß-lactamase-producing K. pneumoniae and multi-drug resistant P. aeruginosa with metallo ß-lactamase were 4.2% and 3.2%, respectively. Continuous national surveillance is important to determine the actual situation of the resistance shown by bacterial respiratory pathogens to antimicrobial agents.

Hand osteolysis in patients with adult T-cell leukemia-lymphoma: radiographic characteristics.

Adult T-cell leukemia-lymphoma (ATLL) is caused by human T-cell lymphotrophic virus I (HTLV-I) infection. Among ATLL cases, 70% of patients present with leukemia and the remaining patients present with lymphoma. Hand osteolysis in the patients with ATLL is considered as paraneoplastic syndrome and caused by parathyroid hormone-related peptide (PTHrP) released from tumor cells. Radiographic features are similar to hyperparathyroidism, but the distribution of osteolysis in hands appears to be slightly different with the authors' experiences. The objective of this study was to identify radiographic characteristics of hand osteolysis associated with ATLL. We included six ATLL patients (5 men and 1 woman; age range, 45-71 years). All the patients presented with acute leukemia, and three were associated with hypercalcemia and pain in various locations including hands. Patterns of osteolysis on hand radiographs were evaluated and recorded independently by three musculoskeletal radiologists. We analyzed the distribution of the bone resorption in the ray distribution of the hand, finger predilection, and the difference between the ulnar and radial sides. The bone resorption was characterized by frequent involvement of the distal and proximal phalanges, predilection of ring fingers and prominent involvement on the ulnar side, compared with frequent involvement of proximal and middle phalanges, index and middle fingers, and on the radial side in the bone resorption of typical hyperparathyroidism. Such distribution may be a characteristic feature of hand osteolysis in patients with ATLL. The present findings are helpful for physicians to differentiate PTHrP-mediated osteolysis in ATLL from parathyroid hormone-mediated hyperparathyroidism.

Core Needle Percutaneous Transpedicular Vertebral Body Biopsy: A Study of 128 Cases.

STUDY DESIGN: We report an accurate technique for percutaneous transpedicular core needle biopsy of vertebral body lesions, and evaluate its effectiveness for histologic diagnosis retrospectively. OBJECTIVE: The purpose of this study is to evaluate the effectiveness and accuracy of this method retrospectively. SUMMARY OF BACKGROUND DATA: Better knowledge of vertebral pedicle morphometry has led to the development of transpedicular fixation techniques in spinal surgery. After experience with these techniques, we have been performing percutaneous transpedicular vertebral body core needle biopsies (transpedicular biopsy) for histologic diagnosis since 1993. METHODS: A total of 128 patients who had undergone transpedicular biopsy for T1-L5 vertebral body lesions were evaluated. The biopsies were carried out under local anesthesia, except in children, for whom general anesthesia was used. Biopsy specimens were obtained by passing 8 or 11 G needle biopsy instruments percutaneously through the pedicle into the site of the lesion under C-arm fluoroscopy guidance. Histologic analyses were performed, and the accuracy and effectiveness of this technique were evaluated. RESULTS: The pathologic evaluations were definitive in 120 patients (93.8%) and not diagnostic in 8. The accuracy of the results differed among the diagnostic categories. Diagnostic accuracy was 78.6% for primary neoplasms and 97.0% for metastatic neoplasms. There was a significant difference in the diagnostic criteria and spinal segment. True positive rate was higher in the thoracic spine (92.2%) than that of lumbar spine (76.6%). CONCLUSIONS: Transpedicular biopsy is a useful procedure for evaluation of thoracic and lumbar vertebral body lesions.

[Failure to Remove Long-Term Indwelling Central Venous Catheters in Two Patients].

The use ofa central venous(CV)port system has become common for the treatment of patients with tumors. We report on the failure to remove CV catheters in 2 patients. The first patient was a 50 years woman with acute myeloid leukemia. She underwent CV port implantation via the left brachial approach 11 years previously. The second patient was an 80 years man with a lower gingival carcinoma. He underwent CV port implantation via the left brachial approach 6 years previously. CV catheter removal was attempted in both patients, but was unsuccessful because of strong adhesion to the vessel wall. Based on our experience, if catheter removal is impossible, its retention is more suitable.

Minor ossicular anomalies in the middle ear: role of submillimeter multislice computed tomography.

OBJECTIVE: The objective was to elucidate clinical effectiveness of submillimeter multislice 2- and 3-dimensional computed tomography (CT) for diagnosis of congenital middle ear anomaly. MATERIALS AND METHODS: Preoperative CT and operative findings were retrospectively analyzed in 36 ears of 33 patients. The distance between the malleal handle (MH) and the incus long process (ILP) was measured in 28 normal ears. RESULTS: Mean ± SD MH-ILP distance in normal ears was 1.8 ± 0.3 mm. In patients with middle ear anomaly, overall specificity, accuracy, and positive and negative predictive values were 99.7%, 98.7%, 91.7%, and 99.1%, respectively. Overall sensitivity was 82.1%, with relatively low sensitivities for detecting fused incudomalleolar joint, lenticular process defect, stapedial footplate defect, and oval window atresia and high sensitivities (80%-100%) for stapedial crural anomaly and certain fibrous connections. CONCLUSIONS: Submillimeter CT improved detectability of anomalies of the stapedial superstructure; however, it is still difficult to identify abnormalities of the footplate.

Spontaneous temporomandibular joint herniation into the external auditory canal through a persistent foramen tympanicum (Huschke): radiographic features.

Persistent foramen tympanicum (Huschke) is an anatomical variation located in the anteroinferior portion of the external auditory canal. We present a case of symptomatic temporomandibular joint (TMJ) herniation into the external auditory canal though an enlarged osseous defect. The herniated retrodiscal TMJ tissue moved backward when the patient's mouth was closed, and forward, when opened. Magnetic resonance imaging findings were useful for differentiating TMJ herniation from salivary fistula caused by an ectopic salivary gland.

Patterns of soft-tissue tumor extension in and out of the pelvis.

OBJECTIVE: The purpose of this article is to present the route of extension in nine soft-tissue tumors and tumorlike lesions of the pelvic wall. CONCLUSION: Soft-tissue tumors of the pelvis, particularly malignant ones, extend into other compartments through specific pathways that are bordered by bones, ligaments, and fasciae. Such pathways include the greater sciatic foramen, the obturator foramen, the femoral canal, the muscular lacuna, the pelvic outlet, and the inguinal canal.

Diagnostic value of cardiac CT in the evaluation of bicuspid aortic stenosis: comparison with echocardiography and operative findings.

OBJECTIVE: This study was conducted to assess the diagnostic value of cardiac CT for the evaluation of patients with bicuspid aortic valve disease. MATERIALS AND METHODS: Fifty consecutive patients with aortic stenosis who underwent surgical valve repair between September 2005 and November 2006 were examined by ECG-gated CT and echocardiography. A 64-MDCT scanner was used. The image findings regarding the number of leaflets (bicuspid or tricuspid) were compared against the intraoperative findings and were statistically analyzed by one-way univariate analysis of variance. The aortic valve area (AVA) was also measured by CT and echocardiography, and the measured values were statistically compared by use of the paired Student's t test. RESULTS: Seventeen patients had a bicuspid aortic valve, and 33 had a tricuspid aortic valve. In 10 of the 50 patients, echocardiography was unable to depict the type of aortic valve because of extensive calcification. The sensitivity, specificity, positive predictive value, and negative predictive value for the detection of a bicuspid aortic valve were 76.5%, 60.6%, 68.4%, and 95.2%, respectively, for echocardiography and 94.1%, 100%, 100%, and 97.1%, respectively, for CT. The CT findings were not significantly different from the intraoperative findings (p = 0.99), but the echocardiographic findings were (p < 0.05). The AVA measurements obtained by CT and echocardiography were 0.940 ± 0.44 cm(2) and 0.659 ± 0.234 cm(2), respectively, showing a significant difference (p < 0.05). CONCLUSION: ECG-gated cardiac CT is useful for the accurate morphologic assessment of bicuspid aortic stenosis, especially in patients with severe valve calcification.

Hand and wrist arthritis of Behçet disease: imaging features.

BACKGROUND: Reports on arthritis in Behçet disease are relatively scarce, and imaging features vary. PURPOSE: To document the various imaging features of articular disorders of the hand and wrist in Behçet disease. MATERIAL AND METHODS: Four patients, four women aged 26 to 65 years, fulfilling the diagnostic criteria of Behçet disease, with imaging findings of hand and wrist arthritis, were seen in two institutions. Radiography and magnetic resonance (MR) imaging were studied to elucidate the pattern and distribution. RESULTS: Both non-erosive arthritis and erosive arthritis of different features were noted: one with non-erosive synovitis of the wrist, one with wrist synovitis with minimal erosion, and two with erosive arthritis of the distal interphalangeal joint. CONCLUSION: Imaging manifestations of arthritis of Behçet disease vary, and may be similar to other seronegative arthritides.

Delivery and Effectiveness of Carboplatin via Targeted Delivery Compared to Passive Accumulation of Intravenously Injected Particles Releasing Carboplatin upon Irradiation.

In this study, nanoparticles that release anticancer drugs upon irradiation were developed. Here, MM46 and MM48 tumors in C3He/N mice were irradiated. Furthermore, the intravenously (i.v.) injected nanoparticles were tested for their ability to deliver the anticancer drug, increase the antitumor effect via a synergistic effect of combining targeted anticancer drugs with radiation and decrease adverse effects by localizing the anticancer drug. The nanoparticles were prepared by spraying a mixture of hyaluronic acid and alginate, supplemented with carboplatin, into a solution of CaCl2 and FeCl2 through a 0.8-lm-pore stainless mesh filter. Nanoparticles (1 × 1010) were i.v. injected and irradiated (100-KeV soft X rays, 10-40 Gy) when the accumulation of particles peaked. The nanoparticles were 547 ± 43 nm in diameter. The i.v.-injected nanoparticles accumulated around tumors. Maximum accumulations were observed 9 h post-injection. Subsequently, 10-40 Gy of radiation was administered. The accumulated nanoparticles released the carboplatin and gelatinized their outer shells, which prolonged the intra-tumor concentration of carboplatin and increased the radiation-induced synergistic antitumor effect. The localization of carboplatin by nanoparticles significantly reduced the adverse effects of the anticancer drug.

Difference in tracer delay-induced effect among deconvolution algorithms in CT perfusion analysis: quantitative evaluation with digital phantoms.

Institutional review board approval and informed consent were obtained. The purpose was to evaluate the differences in tracer delay-induced effects of various deconvolution algorithms for computed tomographic (CT) perfusion imaging by using digital phantoms created from actual source data. Three methods of singular value decomposition (SVD) were evaluated. For standard SVD (sSVD), the delays induced significant errors in cerebral blood flow and mean transit time. In contrast, for block-circulant SVD (bSVD), these values remained virtually unchanged, whereas for delay-corrected SVD (dSVD), mild changes were observed. bSVD was superior to sSVD and dSVD for avoiding the tracer delay-induced effects in CT perfusion imaging.

Clinical findings of hibernoma of the buttock and thigh: rare involvements and extremely high uptake of FDG-PET.

BACKGROUND: Hibernoma is a rare adipose tissue tumor of the soft tissue and the term is derived from the histological similarities to the brown fat found in hibernating animals. It usually occurs in the interscapular area, back, and neck and a few cases have been reported in the buttock or thigh. CASE REPORT: Two cases are presented, one of which had a lesion in the buttock and the other a lesion in the thigh. The lesion in the buttock extended into the pelvis. CT and MR findings suggested liposarcoma in both cases, but the uptake was extremely intense on 18F-FDG-PET in one case. This was not typical of liposarcoma and suggestive of hibernoma. Biopsy specimens revealed a proliferation of adipose cells with vacuolated granular eosinophilic cytoplasm. No cellular atypia or mitotic figures were observed in either case. A marginal excision was performed in one case and an intralesional excision in the other. There were no signs of local recurrence at the final follow-up. CONCLUSIONS: While occurrences in the buttock or thigh are exceedingly rare, hibernoma should be included in the differential diagnosis of an adipose tissue tumor in the thigh, even though the imaging findings mimic liposarcoma. 18F-FDG-PET may be a very meaningful technique to differentiate hibernoma from liposarcoma. A correct diagnosis should be established to prevent over-surgery.

Detectability of minute temporal bone structures with ultra-high resolution CT.

OBJECTIVE: Computed tomography (CT) is the imaging tool of choice in the diagnosis of temporal bone lesions. With the recent progress in imaging technology, CT with higher spatial resolution (Ultra-high resolution CT) has become available in the clinical setting. The purpose of this study is to evaluate the visibility of small temporal bone structures using ultra-high resolution CT. MATERIAL AND METHODS: The visibility of 27 minute temporal bone structures on ultra-high resolution CT images was evaluated. Non-helical axial scans were performed in 18 normal hearing ears without previous otologic diseases. Visibility was scored by an experienced radiologist and otologist. RESULTS: Minute temporal bone structures including the ossicular chain, the crus of the stapes, the greater superficial petrosal nerve, and the anterior malleolar ligament were clearly visualized on ultra-high resolution CT. The stapedius muscle tendon and the chorda tympani exiting the posterior canaliculus and coursing medial to the malleus could be visualized. CONCLUSION: Ultra-high resolution CT provides good visualization of small temporal bone structures in normal subjects.

Effective, same-day preoperative embolization and surgical resection of carotid body tumors.

BACKGROUND: The aim of this study was to evaluate the efficacy of the procedure by analyzing the blood loss and duration of carotid body tumor (CBT) surgery following same-day preoperative embolization. METHODS: We reviewed the medical records of subjects retrospectively. Fifteen patients with 16 CBTs were enrolled in this study. Our same-day procedure comprises preoperative embolization of the feeding arteries in the morning followed by surgery within 3 hours after the embolization is completed. RESULTS: The mean operative time and the mean amount of blood loss were 138 minutes and 29.3 mL, respectively. The tumor volume after embolization was markedly reduced and the mean reduction rate was 50%. We found that 13 CBTs had more than three feeding arteries. Almost all the postoperative complications, mainly cranial nerve paralyzes, resolved within months after surgery. CONCLUSION: Our same-day procedure is a safer and superior alternative to traditional CBT surgery, having good outcomes.

Cerebral air embolism treated with hyperbaric oxygen therapy following percutaneous transthoracic computed tomography-guided needle biopsy of the lung.

A 71-year-old man presented with cough and sputum for 12 months. Chest radiography showed a homogeneous opacity in the right lower lobe. Computed tomography (CT) showed a nodular opacity, 2 cm in diameter, in the posterior segment of the right lower lobe. Mild emphysematous changes were also seen. With the patient in a prone position, a 19-gauge 7.8-cm introducer was placed in the lesion during a single inspiratory breath-hold. A coaxial 20-gauge automated needle was inserted through the introducer using a biopsy gun. Although the patient did not complain of any symptoms, postbiopsy CT showed air in the left ventricle and ascending aorta. After 5 h of bed rest, we found weakness in his left lower extremity. He was transferred to a hyperbaric oxygen chamber and recovered the next day. Air embolism is a rare, potentially fatal complication of percutaneous lung biopsy. Although the true effect of hyperbaric oxygen therapy is controversial, knowledge regarding the prompt management of such cases may help radiologists who perform this procedure.

[Arterial infusion chemotherapy for advanced gallbladder cancer and liver metastasis].

Ten patients with advanced gallbladder cancer were treated by arterial infusion chemotherapy. Seven patients had unresected tumors, and three had liver metastasis after resection of primary tumor. The infusion catheter-port system was implanted via the femoral artery. 5-fluorouracil, mitomycin C and epirubicin were administered using implantable port. The response rate was 50% and the median survival time was 192 days. In one patient with good PR, a primary tumor was resected, and he survived for 2 years 7 months without recurrence. No severe side effect was found. Systemic chemotherapy using gemcitabine is well accepted, however arterial infusion chemotherapy will be one of the options when systemic chemotherapy is fails.

The influence of a peritoneovenous shunt for cirrhotic and malignant intractable ascites on renal function.

BACKGROUND: Peritoneovenous shunts (PVS) are widely used for palliation of intractable ascites caused by peritoneal carcinomatosis (PC) or liver cirrhosis (LC). Some patients who need PVS have renal dysfunction. However, renal dysfunction is considered a relative contraindication. Therefore, it is important to assess renal function before PVS placement. PURPOSE: To evaluate the relationship between PVS and renal function. MATERIAL AND METHODS: Between October 2007 and July 2015, 60 patients (PC = 47; LC = 10; others = 3) underwent PVS placement for intractable ascites. Changes in estimated glomerular filtration rate (eGFR) and other adverse events (AEs) were retrospectively analyzed. RESULTS: Changes in eGFR before, one day after, and one week after PVS placement could be evaluated in 46 patients. The median eGFR before, one day after, and one week after was 56.5, 59.1, and 64.7 mL/min/1.73 m2, respectively (P < 0.05). These values were 61.6, 72, and 67.1 mL/min/1.73 m2, respectively, in PC patients (n = 34; P < 0.05) and 28.5, 27, and 37.2 mL/min/1.73 m2, respectively, in LC patients (n = 10; P < 0.05). In 17 patients with moderate to severe renal dysfunction (eGFR < 45), these values were 23.4, 23.7, and 30.5 mL/min/1.73 m2, respectively. The most frequent AE was PVS catheter obstruction, which occurred in 12 patients (20.7%). Clinical disseminated intravascular coagulation occurred in six patients (10.3%) and caused death in three patients (5.2%). CONCLUSION: PVS placement for intractable ascites is associated with various AEs. However, PVS appeared to promote renal function, especially in patients with renal impairment.