Annette J. Johnson

Cohort Study of Structured Reporting Compared with Conventional Dictation

PURPOSE To determine if radiology residents who used a structured reporting system (SRS) produced higher quality reports than residents who used conventional free-text dictation to report cranial magnetic resonance (MR) imaging in patients suspected of having a stroke. MATERIALS AND METHODS The study was approved by an institutional review board and was HIPAA compliant; informed consent was obtained. This study included residents, with 16 in the control group and 18 in the intervention group. For phase 1, each subject reviewed the same set of 25 brain MR imaging cases and dictated the cases by using free-text conventional dictation. For phase 2, 4 months later, the control group repeated the same process, whereas the intervention group reread the same MR imaging cases by using SRS to create reports. Resident-generated reports were graded for accuracy and completeness by a neuroradiologist on the basis of consensus interpretations and criterion standard diagnoses as established with at least 6 months of clinical follow-up, imaging follow-up, and/or histologic examination where appropriate. Accuracy and completeness scores were analyzed by using a Wilcoxon signed rank test for paired data and a Mann-Whitney U test for nonpaired data. Intervention group residents were surveyed regarding their opinions of SRS. RESULTS For phase 1 reports, no significant difference in accuracy or completeness scores between control and intervention groups was found. Decreases in accuracy (91.5 to 88.7) and completeness (68.7 to 54.3) scores for phase 2 compared with phase 1 for the intervention group were found; increases in accuracy (91.4 to 92.4) and completeness (67.8 to 71.7) scores for phase 2 compared with phase 1 for the control group were found (all P values < .001). The most common complaints were that the SRS was overly constraining with regard to report content and was time-consuming to use. CONCLUSION While there are many potential benefits of structuring radiology reports, such changes cannot be assumed to improve report accuracy or completeness. Any SRS should be tested for effect on intrinsic report quality.

Access to Radiologic Reports via a Patient Portal: Clinical Simulations to Investigate Patient Preferences

PURPOSE The aim of this study was to determine (1) the patient-preferred timing characteristics of a system for online patient access to radiologic reports and (2) patient resource needs and preferences after exposure to reports. METHODS Adult outpatients from a single imaging center completed researcher-administered electronic questionnaires. Participants were exposed to 3 simulated clinical scenarios and asked to answer questions on the basis of what they thought they would do in each. Scenarios included symptomatology and written radiology reports that were nearly normal, seriously abnormal, and indeterminate, with reports containing typical medical terminology. Participants were asked about preferred timing for online access to reports, communication methods, educational resources, and alternative formats. McNemars test correlated proportions and generalized estimating equations were used to evaluate responses. RESULTS Participants (n = 53) most often preferred immediate access to reports: 32 (60.2%) for the nearly normal scenario, 25 (47.2%) for the seriously abnormal scenario, and 24 (45.3%) for the indeterminate scenario. Three-day delayed access was next most commonly preferred: 15 (28.3%), 19 (35.8%), and 19 (35.8%), respectively. Forty-two participants (79.2%) preferred the portal method of notification over ways they have historically gotten results, with an increased proportion being satisfied with it overall (P < .04). Most would use a variety of educational resources and found alternative lay language conclusions and hyperlinks helpful. CONCLUSIONS Some outpatients want immediate online access to complete, written radiologic reports and would use multiple resources to understand report contents. Effects of immediate access on provider workflow and on anxiety and autonomy among a diverse population of patients still need to be studied.

Limited Margins Using Modern Radiotherapy Techniques Does Not Increase Marginal Failure Rate of Glioblastoma.

Objective:We investigate the patterns of failure in the treatment of glioblastoma (GBM) based on clinical target volume (CTV) margin size, dose delivered to the site of initial failure, and the use of temozolomide and intensity-modulated radiotherapy (IMRT). Methods:Between August 2000 and May 2010, 161 patients with GBM were treated with radiotherapy with or without concurrent temozolomide. Patients were treated with CTV expansions that ranged from 5 to 20 mm using a shrinking field technique. Patterns of failure and time to progression and overall survival were compared based on CTV margin, use of temozolomide, and use of IMRT. Kaplan Meier analysis was used to estimate survival times, and &khgr;2 test was used for comparison of cohorts. Results:For patients treated with 5-, 10-, and 15- to 20-mm CTV, 79%, 77%, and 86% experienced failures in the 60 Gy volume, respectively. Forty-eight percent, 55%, and 66% of patients with 5-, 10-, and 15- to 20-mm CTV experienced failures in the 46 Gy volume, respectively. There was no statistical difference between patients treated with 5-, 10-, 15- to 20-mm margins with regard to 60 Gy failure (P=0.76), 46 Gy failure (P=0.51), or marginal failure (P=0.73). Eighty percent of patients receiving temozolomide experienced failures in the 60 Gy volume. There was no increased likelihood of marginal failures in patients receiving IMRT (P=0.97). Conclusions:Modern treatment techniques including use of concurrent temozolmide, limited CTV margin size, and IMRT have not greatly changed the patterns of failure of GBM.

7.0-T magnetic resonance imaging characterization of acute blood-brain-barrier disruption achieved with intracranial irreversible electroporation.

The blood-brain-barrier (BBB) presents a significant obstacle to the delivery of systemically administered chemotherapeutics for the treatment of brain cancer. Irreversible electroporation (IRE) is an emerging technology that uses pulsed electric fields for the non-thermal ablation of tumors. We hypothesized that there is a minimal electric field at which BBB disruption occurs surrounding an IRE-induced zone of ablation and that this transient response can be measured using gadolinium (Gd) uptake as a surrogate marker for BBB disruption. The study was performed in a Good Laboratory Practices (GLP) compliant facility and had Institutional Animal Care and Use Committee (IACUC) approval. IRE ablations were performed in vivo in normal rat brain (n = 21) with 1-mm electrodes (0.45 mm diameter) separated by an edge-to-edge distance of 4 mm. We used an ECM830 pulse generator to deliver ninety 50-μs pulse treatments (0, 200, 400, 600, 800, and 1000 V/cm) at 1 Hz. The effects of applied electric fields and timing of Gd administration (−5, +5, +15, and +30 min) was assessed by systematically characterizing IRE-induced regions of cell death and BBB disruption with 7.0-T magnetic resonance imaging (MRI) and histopathologic evaluations. Statistical analysis on the effect of applied electric field and Gd timing was conducted via Fit of Least Squares with α = 0.05 and linear regression analysis. The focal nature of IRE treatment was confirmed with 3D MRI reconstructions with linear correlations between volume of ablation and electric field. Our results also demonstrated that IRE is an ablation technique that kills brain tissue in a focal manner depicted by MRI (n = 16) and transiently disrupts the BBB adjacent to the ablated area in a voltage-dependent manner as seen with Evans Blue (n = 5) and Gd administration.

From traditional reading rooms to a soft copy environment: radiologist satisfaction survey.

Academic radiologists are experiencing increased clinical workloads. New technology such as picture archiving and communication systems (PACS) are often justified on the premise of increased efficiency. The authors believe that efficiency can be influenced by the image interpretation environment, and thus they set out to establish baseline satisfaction levels with this environment. The authors surveyed 90 Indiana University (IU) faculty radiologists, fellows, and residents. Their survey was implemented with a questionnaire sent via e-mail. Questions focused on satisfaction with the current soft-copy reading environments and preferences regarding improvements. Of the 90 radiologists surveyed, 55 (61%) responded. Several key findings emerged: (1) Overall satisfaction with the soft-copy environment is low, with nearly half (46%) of respondents rating themselves as “very dissatisfied” or “dissatisfied.” (2) Faculty are least satisfied regarding work space ergonomics, room layout, and amount of work space. Appropriate lighting also emerged as an area with low satisfaction and high importance. (3) Ninety-eight percent of respondents indicated that an “ideal” soft-copy environment would have a positive effect on their efficiency. The dissatisfaction with the current soft-copy interpretation environments used by the IU radiologists indicates that this is an area that requires attention. Furthermore, there may be a direct relationship between radiologist efficiency and satisfaction with the image interpretation environment. Attention should be focused on this environment during a soft-copy technology implementation to ensure that planned efficiency gains are realized.

Use of 3.0-T MRI for Stereotactic Radiosurgery Planning for Treatment of Brain Metastases: A Single-Institution Retrospective Review

PURPOSE To investigate the efficacy of 3.0-T magnetic resonance imaging (MRI) for detecting brain metastases for stereotactic radiosurgery (SRS) planning. METHODS AND MATERIALS All adult patients scheduled for SRS treatment for brain metastases at our institution between October 2005 and January 2008 were eligible for analysis. All patients underwent radiosurgery treatment planning 3.0-T MRI on the day of scheduled radiosurgery and a diagnostic 1.5-T MRI in the days or weeks prior to radiosurgery for comparison. Both scans were interpreted by neuroradiologists who reported their findings in the radiology reports. We performed a retrospective review of the radiology reports to determine the number of brain metastases identified using each MRI system. RESULTS Of 254 patients scheduled for treatment from October 2005 to January 2008, 138 patients had radiology reports that explicitly described the number of metastases identified on both scans. With a median interval of 17 days (range, 1-82) between scans, the number of metastases detected using 1.5-T MRI system ranged from 1 to 5 and from 1 to 8 using the 3.0 T-MRI system. Twenty-two percent of patients were found to have a greater number of metastases with the 3.0 T-MRI system. The difference in number of metastases detected between the two scans for the entire cohort ranged from 0 to 6. Neither histology (p = 0.52 by chi-sq test) nor time between scans (p = 0.62 by linear regression) were significantly associated with the difference in number of metastases between scans. CONCLUSIONS The 3.0-T MRI system appears to be superior to a 1.5-T MRI system for detecting brain metastases, which may have significant implications in determining the appropriate treatment modality. Our findings suggest the need for a prospectively designed study to further evaluate the use of a 3.0 T-MRI system for stereotactic radiosurgery planning in the treatment of brain metastases.

Trigeminal Trophic Syndrome from Stroke

Trigeminal trophic syndrome (TTS) is the historic name for neuropathic self-induced facial ulceration from abnormal sensory symptoms leading to uncontrolled scratching. Anatomic co-localization of sensory loss (numbness) plus neuropathic itch and pain permits painless scratching. If the itch is severe, some patients will scratch to the point of causing self-injury. Patients may be unaware or may conceal the fact that their lesions are self-induced and thus the diagnosis presents a clinical challenge. Many cases remain undiagnosed, leading to unnecessary and ineffective tests, procedures, and prescribing. We document a patient with a central cause of TTS — multiple cerebral vascular accidents — and summarize the presentation, pathogenesis, and treatment options.

Tumor resection with carmustine wafer placement as salvage therapy after local failure of radiosurgery for brain metastasis

Prolonged survival in brain metastasis patients increases recurrence rates and places added importance on salvage therapies. Research examining carmustine polymer wafers as an adjuvant therapy for brain metastasis is limited. We present a single institution retrospective series documenting the use of BCNU wafers placed in the cavity of resected recurrent brain metastases that had failed prior stereotactic radiosurgery (SRS). Between February 2002 and April 2013, a total of 31 patients with brain metastases failed SRS and underwent resection with intracavitary placement of carmustine wafers. Clinical outcomes including local control, survival, cause of death, and toxicity were determined from electronic medical records. Kaplan-Meier analysis was performed to assess local control and survival. Imaging features were reviewed and described for patients with serial post-operative follow-up imaging examinations over time. Overall survival at 6 months and 12 months was 63% and 36%, respectively. Fourteen of 31 patients (45%) died from neurologic causes. Local control within the resection cavity was 87% and 70% at 6 and 12 months, respectively. Five patients (16%) underwent further salvage therapy following carmustine wafer placement after local failure. Resection cavities of all six patients with follow-up imaging showed linear peripheral enhancement. Pericavity and wafer enhancement was present as early as the same day as surgery and persisted in all cases to 6 months or longer. Carmustine polymer wafers are an effective salvage treatment following resection of a brain metastasis that has failed prior SRS. For patients with successful local control after wafer implantation, linear enhancement at the cavity is common.

Clinical outcomes of brain metastases treated with Gamma Knife radiosurgery with 3.0 T versus 1.5 T MRI-based treatment planning: Have we finally optimised detection of occult brain metastases?

The goal of this study was to determine if clinically relevant endpoints were changed by improved MRI resolution during radiosurgical treatment planning.

Decreasing pediatric patient anxiety about radiology imaging tests: prospective evaluation of an educational intervention

This trial investigated anxiety levels and effect of an educational coloring book (CB) among pediatric patients about to undergo radiology imaging tests. Control group (N = 101) and intervention group (N = 175) children ages 3—10 years and their parents were surveyed to determine anxiety levels before the imaging test, with the intervention group being surveyed after patient and parental review of the CB. Anxiety was low for all subjects overall compared with findings from previously published literature, perhaps related to systemic measures to make children’s hospitals more child friendly in recent years. Review of the CB was not associated with decreased anxiety among patients or parents. However, among a subgroup with higher baseline parental anxiety, there was a trend toward lower patient anxiety in the intervention group. Most parents indicated that the CB was informative and helped them and their child be less worried, and that they were pleased to have received the CB.