Jay Pahade

Quality Initiatives Imaging Pregnant Patients with Suspected Pulmonary Embolism: What the Radiologist Needs to Know

Pregnancy is associated with a fivefold increase in the prevalence of venous thromboembolism, and pulmonary embolism is a leading cause of maternal death. However, the diagnosis of pulmonary embolism during pregnancy is challenging because classic clinical symptoms are often absent and physiologic changes during pregnancy can mimic pulmonary embolism. Concerns about exposure of the fetus to ionizing radiation and intravenously administered contrast material, as well as potential medicolegal issues, further complicate the diagnosis. Although diagnostic imaging plays an important role in this setting, there are currently no widely accepted guidelines for radiologists and clinicians to follow. Thus, radiologists should be familiar with the advantages and disadvantages of available imaging modalities, methods for dose reduction, radiation risks, and medicolegal risk management guidelines.

Reviewing Imaging Examination Results With a Radiologist Immediately After Study Completion: Patient Preferences and Assessment of Feasibility in an Academic Department

OBJECTIVE The purpose of this study was to assess patient preferences about receiving radiology results and reviewing the images and findings directly with a radiologist after completion of an examination. SUBJECTS AND METHODS A prospective survey of English-speaking outpatients undergoing either nononcologic CT of the chest, abdomen, and pelvis or nonobstetric ultrasound examinations was completed between December 2010 and June 2011. Responses to survey items such as preferences regarding communication of results, knowledge of a radiologist, and anxiety level before and after radiologist-patient consultation were recorded. The average wait time between the end of the imaging examination and the consultation and the duration of consultation were documented. RESULTS Eighty-six patients (43 men, 43 women; mean age, 52 years) underwent 37 CT and 49 ultrasound examinations). Forty-eight patients (56%) identified a radiologist as a physician who interprets images. Before imaging, 70 patients (81%) preferred hearing results from both the ordering provider and the radiologist. This percentage increased to 78 (91%) after consultation (p=0.03). Before consultation, 84 of the 86 patients (98%) indicated they would be comfortable hearing normal results or abnormal results from the person interpreting the examination; the number increased to 85 (99%) after consultation. Eighty-five patients (99%) agreed or strongly agreed that reviewing their examination findings with a radiologist was helpful. Eighty-four patients (98%) indicated they wanted the option of reviewing or always wanted to review future examination findings with a radiologist. After consultation, anxiety decreased in 41 patients (48%), increased in 13 (15%), and was unchanged in 32 (37%) (p=0.0001). The average wait for consultation and the duration of consultation were 9.9 and 10.4 minutes for CT and 1.2 and 7.1 minutes for ultrasound. CONCLUSION Patients prefer hearing examination results from both their ordering provider and the interpreting radiologist. Most patients find radiologist consultation beneficial. Patients are comfortable hearing results from the radiologist, with most displaying decreased anxiety after consultation.

Incidence of Contrast-Induced Nephropathy in Patients With Multiple Myeloma Undergoing Contrast-Enhanced CT

OBJECTIVE The purpose of this article is to evaluate the incidence of contrast-induced nephropathy (CIN) and the effects of associated risk factors in patients with multiple myeloma undergoing contrast-enhanced CT (CECT) with IV administration of nonionic iodinated contrast agent. MATERIALS AND METHODS This retrospective review of medical records identified patients with a diagnosis of myeloma who underwent a CECT examination of the chest, abdomen, or pelvis between January 1, 2005, and December 1, 2008. Analysis for CIN, as defined by an increase in creatinine level after the CECT examination of 25% or more, or of 0.5 mg/dL, compared with the level before the CECT examination, both within 48 hours and within 7 days, was performed. Statistical correlations between the development of CIN and creatinine level before CECT examination, patient location, type and amount of contrast agent, blood urea nitrogen-creatinine ratio, history of diabetes, hypercalcemia, Bence Jones proteinuria, β(2)-microglobulin level, albumin level, International Myeloma Staging System stage, and history of myeloma provided at the time the CT examination was ordered were calculated. RESULTS Forty-six patients who completed 80 unique examinations were included; their average creatinine level before CECT examination was 0.97 mg/dL. There was no significant difference in the average creatinine levels before CT examination between patients without and those with CIN. Four (5%) and 12 (15%) patients developed CIN within 48 hours and 7 days, respectively. Only serum β(2)-microglobulin level showed a statistically significant (p = 0.03) correlation with the development of CIN. CONCLUSION The incidence of CIN in patients with multiple myeloma with a normal creatinine level is low and correlates with β(2)-microglobulin levels. The administration of contrast agent in this patient population is safe but should be based on the potential benefit of the examination and the expected low risk of developing CIN.

Delayed Growth in Incidental Pancreatic Cysts: Are the Current American College of Radiology Recommendations for Follow-up Appropriate?

PURPOSE To evaluate growth kinetics of asymptomatic small (<2 cm) incidental pancreatic cysts and to assess potential implications of these in the context of current American College of Radiology recommendations. MATERIALS AND METHODS This institutional review board-approved HIPAA-compliant retrospective study with waiver of informed consent included patients with asymptomatic small incidental pancreatic cysts (diameter, 5-20 mm) with two or more magnetic resonance (MR) examinations performed at least 6 months apart at a tertiary institution. The largest cyst dimension was measured on T2-weighted single-shot fast spin-echo images by one of six radiologists (1-3 years of experience) who were trained to measure pancreatic cysts in a similar manner. All analysis was conducted at the patient level by choosing the cyst that exhibited the greatest growth over the follow-up period in each patient. Fisher exact, χ(2), and Kruskal-Wallis tests and analysis of variance were used to test correlation between cyst characteristics and growth. RESULTS A total of 259 patients (mean age, 65 years ± 11 [standard deviation], male-to-female ratio, 42:58) with 370 asymptomatic small incidental pancreatic cysts were included. At presentation, median cyst size was 9.4 mm (interquartile range [IQR], 7.0-12.2 mm), and 64 patients (25%; 95% confidence interval [CI]: 20, 30) had septations. The median imaging follow-up period was 2.2 years (IQR, 1.2-3.9 years; range, 0.5-11.0 years), with a median of three MR examinations (IQR, two to four examinations) per patient. In 171 (66%; 95% CI: 60, 72) of the 259 patients, cysts remained stable; in 18 (7%; 95% CI: 4, 11), cysts shrank; and in 70 (27%; 95% CI: 22, 33), cysts grew (median total growth and median annual growth of 4.8 mm and 2.3 mm/y, respectively). Age, cyst size, and cyst septation at presentation were not predictive of growth. Overall, 29 (11%), 16 (6%), and four (1.5%) of the cysts increased in size after 1, 2, and 3 years of initial stability, respectively. Of the 18 patients who underwent pancreatic surgery, only one patient with an intraductal papillary mucinous neoplasm had high-grade dysplasia. One patient developed pancreatic adenocarcinoma remotely at the location of the pancreatic cyst diagnosed 11 months prior. CONCLUSION In the majority of patients, asymptomatic small incidental pancreatic cysts remained stable during a median follow-up period of 2.2 years; however, in 27% of patients, cysts increased in size over time, with 11% growing after an initial 1-year period of stability. Current American College of Radiology recommendations to discontinue imaging follow-up after 1 year of stability may need to be reevaluated.

Magnetic Resonance Imaging and Sonography in the Diagnosis of Placental Invasion.

To compare older and newer magnetic resonance imaging (MRI) criteria for placental invasion and to compare the sensitivity, specificity, and accuracy of MRI and sonography in determining the depth of placental invasion.

CT angiography in potential living kidney donors: 80 kVp versus 120 kVp.

OBJECTIVE The purpose of this article is to retrospectively investigate the diagnostic accuracy, image quality, and radiation dose of renal artery CT angiography (CTA), at 80 kVp compared with 120 kVp, in adult kidney donors. MATERIALS AND METHODS CTA examinations of 258 consecutive potential kidney donors were retrospectively evaluated; 189 patients were scanned using 64-MDCT scanners (higher maximal tube current), and 69 patients were scanned using 16-MDCT scanners (lower maximal tube current). On the basis of the tube potential and scanners, the study population was divided into four groups. Qualitative and quantitative analysis include vascular attenuation measurements, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). Volume CT dose index (CTDIvol) was recorded, and size-specific dose estimate was also estimated. RESULTS Using 80 kVp for the 16-MDCT scanner, there was a 64.9% reduction in size-specific dose estimate (66.1% reduction in CTDIvol), increased noise, and tube current saturation in all cases. Axial image quality was significantly lower compared with that obtained at 120 kVp (p = 0.02), but image quality and visibility of renal artery branch order were comparable. Using 80 kVp for the 64-MDCT scanner, there was a 40.5% reduction in size-specific dose estimate (43.6% reduction in CTDIvol) and increased SNR and CNR (p < 0.001). No significant differences in 3D image quality and branch order visibility were observed. Tube current saturation was reached in 31% of cases. One hundred fifty-one patients (86 imaged at 80 kVp and 65 imaged at 120 kVp) underwent donor nephrectomy; CTA diagnostic accuracy was 100%. CONCLUSION Renal artery CTA using 80 kVp combined with limiting the tube current results in a significant reduction in radiation dose and improved SNR and CNR, without deterioration of image quality.

Direct Communication of Results to Patients

AJR 2014; 202:W121 0361–803X/14/2021–W121

What Patients Want to Know about Imaging Examinations: A Multiinstitutional U.S. Survey in Adult and Pediatric Teaching Hospitals on Patient Preferences for Receiving Information before Radiologic Examinations

Purpose To identify what information patients and parents or caregivers found useful before an imaging examination, from whom they preferred to receive information, and how those preferences related to patient-specific variables including demographics and prior radiologic examinations. Materials and Methods A 24-item survey was distributed at three pediatric and three adult hospitals between January and May 2015. The χ2 or Fisher exact test (categorical variables) and one-way analysis of variance or two-sample t test (continuous variables) were used for comparisons. Multivariate logistic regression was used to determine associations between responses and demographics. Results Of 1742 surveys, 1542 (89%) were returned (381 partial, 1161 completed). Mean respondent age was 46.2 years ± 16.8 (standard deviation), with respondents more frequently female (1025 of 1506, 68%) and Caucasian (1132 of 1504, 75%). Overall, 78% (1117 of 1438) reported receiving information about their examination most commonly from the ordering provider (824 of 1292, 64%), who was also the most preferred source (1005 of 1388, 72%). Scheduled magnetic resonance (MR) imaging or nuclear medicine examinations (P < .001 vs other examination types) and increasing education (P = .008) were associated with higher rates of receiving information. Half of respondents (757 of 1452, 52%) sought information themselves. The highest importance scores for pre-examination information (Likert scale ≥4) was most frequently assigned to information on examination preparation and least frequently assigned to whether an alternative radiation-free examination could be used (74% vs 54%; P < .001). Conclusion Delivery of pre-examination information for radiologic examinations is suboptimal, with half of all patients and caregivers seeking information on their own. Ordering providers are the predominant and preferred source of examination-related information, with respondents placing highest importance on information related to examination preparation.

MRI-Ultrasound Fusion Targeted Biopsy of Prostate Imaging Reporting and Data System Version 2 Category 5 Lesions Found False-Positive at Multiparametric Prostate MRI

OBJECTIVE The purpose of this study was to determine imaging and clinical features associated with Prostate Imaging Reporting and Data System (PI-RADS) category 5 lesions identified prospectively at multiparametric MRI (mpMRI) that were found benign at MRI-ultrasound fusion targeted biopsy. MATERIALS AND METHODS Between January 2015 and July 2016, 325 men underwent prostate mpMRI followed by MRI-ultrasound fusion targeted biopsy of 420 lesions prospectively identified and assessed with PI-RADS version 2. The frequency of clinically significant prostate cancer (defined as Gleason score ≥ 7) among PI-RADS 5 lesions was determined. Lesions with benign pathologic results were retrospectively reassessed by three abdominal radiologists and categorized as concordant or discordant between mpMRI and biopsy results. Multivariate logistic regression was used to identify factors associated with benign disease. Bonferroni correction was used. RESULTS Of the 98 PI-RADS 5 lesions identified in 89 patients, 18% (18/98) were benign, 10% (10/98) were Gleason 6 disease, and 71% (70/98) were clinically significant prostate cancer. Factors associated with benign disease at multivariate analysis were lower prostate-specific antigen density (odds ratio [OR], 0.88; p < 0.001) and apex (OR, 3.54; p = 0.001) or base (OR, 7.11; p = 0.012) location. On secondary review of the 18 lesions with benign pathologic results, 39% (7/18) were scored as benign prostatic hyperplasia nodules, 28% (5/18) as inflammatory changes, 5% (1/18) as normal anatomic structures, and 28% (5/18) as discordant with imaging findings. CONCLUSION PI-RADS 5 lesions identified during routine clinical interpretation are associated with a high risk of clinically significant prostate cancer. A benign pathologic result was significantly correlated with lower prostate-specific antigen density and apex or base location and most commonly attributed to a benign prostatic hyperplasia nodule. Integration of these clinical features may improve the interpretation of high-risk lesions identified with mpMRI.

Benefit of a Visual Aid in the Management of Moderate-Severity Contrast Media Reactions

OBJECTIVE The purpose of this study was to compare management of moderate-severity reactions with and without a visual aid or flowchart in contrast medium reaction simulations. SUBJECTS AND METHODS All attending radiologists and trainees were requested to participate in a contrast medium reaction simulation program, including a moderate-severity reaction scenario, and were randomized to groups having or not having a visual aid. The time to administer intramuscular (IM) epinephrine via automated injector and errors in administration were recorded. After the simulation, all participants completed a survey assessing their comfort in treating reactions to contrast media with and without a visual aid. RESULTS A total of 138 participants were divided into 21 sessions in the program, with 68 participants in the moderate-severity reaction scenario. Eleven groups were provided a visual aid; 10 groups were not. Errors in management occurred in 18.2% (2 of 11) of groups with visual aids versus 40% (4 of 10) in groups without (p = 0.35), with epinephrine self-administration reflecting the most common error. Excluding the groups with errors, the mean time to administration of IM epinephrine was 97 seconds with versus 152 seconds without the visual aid (p = 0.04). Of the 138 participants, 97.8% agreed that the poster would aid in medication administration, and 87% agreed that it would help decrease time to administer medications. CONCLUSION A visual aid increased the subjective confidence of radiologists in the dose and route of medication administration in the contrast medium reaction simulation and led to faster administration of epinephrine. Self-administration IM epinephrine errors were common and seen in both groups.