State of Academic Radiology: Current Challenges, Future Adaptations.

There are approximately 200 academic radiology departments in the United States. While academic medical centers vary widely depending on their size, complexity, medical school affiliation, research portfolio, and geographic location, they are united by their 3 core missions: patient care, education and training, and scholarship. Despite inherent differences, the current challenges faced by all academic radiology departments have common threads; potential solutions and future adaptations will need to be tailored and individualized-one size will not fit all. In this article, we provide an overview based on our experiences at 4 academic centers across the United States, from relatively small to very large size, and discuss creative and innovative ways to adapt, including community expansion, hybrid models of faculty in-person vs teleradiology (traditional vs non-traditional schedule), work-life integration, recruitment and retention, mentorship, among others.

Improved radiologic diagnosis of delayed gastric conduit emptying (DGCE) after esophagectomy using a functional upper gastrointestinal contrast study.

BACKGROUND: With increasing incidence of esophageal cancer, a growing number of patients are at risk of developing delayed gastric conduit emptying (DGCE) in the early postoperative phase after esophagectomy. This condition is of great postoperative concern due to its association with adverse outcomes. PURPOSE: To give a narrative review of the literature concerning radiological diagnosis of DGCE after esophagectomy and a proposal for an improved, functional protocol with objective measurements. MATERIAL AND METHODS: The protocol was designed at Virginia Mason Medical Center in Seattle and is based on the Timed Barium Esophagogram (TBE) concept, which has been adapted to assess the passage of contrast from the gastric conduit into the duodenum. RESULTS: The literature review showed a general lack of standardization and scientific evidence behind the use of radiology to assess DGCE. We found that our proposed standardized upper gastrointestinal (UGI) contrast study considers both the time aspect in DGCE and provides morphologic information of the gastric conduit. This radiological protocol was tested on 112 patients in a trial performed at two high-volume centers for esophageal surgery and included an UGI contrast study 2-3 days postoperatively. The study demonstrated that this UGI contrast study can be included in the standardized clinical pathway after esophagectomy. CONCLUSION: This new, proposed UGI contrast study has the potential to diagnose early postoperative DGCE in a standardized manner and to improve overall patient outcomes after esophagectomy.

Opportunistic Screening of Patients for Hepatic Steatosis: Clinical Follow-Up and Diagnostic Yield.

PURPOSE: Hepatic steatosis is a common incidental finding on abdominal imaging that is not always reported or recognized as having clinical significance. Because of its association with liver disease, cirrhosis, and diabetes, the aim of this study was to bring attention to this finding and provide clinical guidance to referring clinicians by inserting standardized text into radiology reports of patients with incidentally detected hepatic steatosis. METHODS: Patients with incidentally discovered hepatic steatosis on abdominal ultrasound or CT had standard text inserted into the impression sections of their diagnostic imaging reports. A total of 1,256 patients whose reports were tagged between April 2016 and September 2017 were retrospectively identified and their electronic medical records reviewed to determine subsequent acknowledgment in the medical record or clinical action in response to the tagged report. Information regarding patient demographics, the type of provider who ordered the examination, and the acuity of the examination results was also recorded. RESULTS: Acknowledgment and subsequent clinical action were more likely in patients whose examinations was ordered by primary care providers, whose examination results were not urgent, and who were in the ultrasound group. The overall diagnostic yield in patients who underwent clinical evaluation was nonalcoholic fatty liver disease in 70%, nonalcoholic steatohepatitis in 6%, and alcoholic hepatitis in 17%. CONCLUSIONS: Opportunistic screening for incidental hepatic steatosis on abdominal CT and ultrasound is feasible, with substantial yield for patients with clinically important entities including nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

Contrast-enhanced paravertebrogram to confirm paravertebral catheter position in elective thoracic surgery: a proof of concept study.

BACKGROUND: Paravertebral pain catheters have been shown to be equally effective as epidural pain catheters for postoperative analgesia after thoracic surgery with the possible additional benefit of less hemodynamic effect. However, a methodology for verifying correct paravertebral catheter placement has not been tested or objectively confirmed in previous studies. The aim of the current study was to describe a technique to confirm the correct position of a paravertebral pain catheter using a contrast-enhanced paravertebrogram. METHODS: A retrospective cohort proof of concept study was performed including 10 consecutive patients undergoing elective thoracic surgery with radiographic contrast-enhanced confirmation of intraoperative paravertebral catheter placement (paravertebrogram). RESULTS: The results of the paravertebrograms, which were done in the operating room at the end of the procedure, verified correct paravertebral catheter placement in 10 of 10 patients. The radiographs documented dissemination of local anesthetic within the paravertebral space. CONCLUSION: This proof of concept study demonstrated that a contrast-enhanced paravertebrogram could be used in conjunction with standard postoperative chest radiography to add valuable information for the assessment of paravertebral catheter placement. This technique has the potential to increase the accuracy and efficiency of postoperative analgesia, and to set a quality standard for future studies of paravertebral pain catheters.

Erosion of Mesh Mid-urethral Sling Into a Complex Urethral Diverticulum: Diagnosis, Evaluation, and Surgical Management.

We present a case of an eroded mesh mid-urethral sling into a urethral diverticulum. Preoperative MRI and 3-dimensional translabial ultrasound aided in the identification and surgical approach. Vaginal excision of sling with urethral diverticulectomy and complex urethral reconstruction was performed. To the author's knowledge, this is the first case documented in the literature describing an eroded mesh mid-urethral sling into a urethral diverticulum.

Osteochondroma of the Pubic Symphysis Involved With Aberrantly Placed Minisling: A Case Report.

Osteochondromas are benign bone tumors that rarely involve the pubic symphysis. This case report describes a 41-year-old woman with a pubic symphyseal osteochondroma associated with an aberrantly placed single incision sling. After an outside surgeon placed a single incision midurethral sling for stress urinary incontinence, she developed pelvic pain, dyspareunia and vaginal mesh sling exposure. Imaging demonstrated a 2.6 centimeter calcified mass posterior to the pubic symphysis. The patient underwent excision of the mass and the eroded mesh sling via vaginal and abdominal approaches. Pathology demonstrated osteochondroma aggregated around mesh. This is a rare case of a single incision sling placed aberrantly into a pubic symphyseal osteochondroma that required excision.

Significance of radiographic splenic vessel involvement in the pancreatic ductal adenocarcinoma of the body and tail of the gland.

BACKGROUND AND OBJECTIVES: Unlike pancreatic head tumors, little is known about the biological significance of radiographic vessel involvement with pancreatic body/tail adenocarcinoma. We hypothesized radiographic splenic vessel involvement may be an adverse prognostic factor. METHODS: All distal pancreatectomies performed for resectable pancreatic adenocarcinoma between 2000 and 2016 were reviewed and clinicopatholgic data were collected, retrospectively. Preoperative computed tomography imaging was re-reviewed and splenic vessel involvement was graded as none, abutment, encasement, or occlusion. RESULTS: Among a total of 71 patients, splenic artery or vein encasement/occlusion was present in 41% (29 of 71) of patients, each. There were no significant differences in tumor size or grade, margin positivity, and perineural or lymphovascular invasion. However, splenic artery encasement/occlusion (P = 0.001) and splenic vein encasement/occlusion (P = 0.038) both correlated with lymph node positivity. Splenic artery encasement was associated with a reduced median overall survival (20 vs 30 months, P = 0.033). Multivariate analysis also showed that splenic artery encasement was an independent risk factor of worse survival (hazard ratio, 2.246; 95% confidence interval, 1.118-4.513; P = 0.023). CONCLUSION: Patients with cancer of the body or tail of the pancreas presenting with radiographic encasement of the splenic artery, but not the splenic vein, have a poorer prognosis and perhaps should be considered for neoadjuvant therapy before an attempt at curative resection.

New guidelines for use of endoscopic ultrasound for evaluation and risk stratification of pancreatic cystic lesions may be too conservative.

BACKGROUND: The role of EUS in managing asymptomatic pancreatic cystic lesions (PCLs) remains unresolved. We retrospectively evaluated EUS in risk stratification of PCLs when adhering to the most recent AGA guidelines. METHODS: Asymptomatic PCLs that were evaluated by EUS from January 2014 to December 2014 were retrospectively reviewed including associated cytology, fluid analysis, and relevant surgical pathology. Cross-sectional imaging reports were reviewed blindly by an expert radiologist using AGA risk stratification terminology. Accepted imaging high-risk features (HRF) included cyst diameter > 3 cm, dilated upstream pancreatic ducts, and a solid component in the cyst. RESULTS: We reviewed 125 patients who underwent EUS. Expert review of cross-sectional imaging resulted in a different interpretation 25% of the time including 1 malignant cyst. Ninety-three patients (75%) had no HRFs on cross-sectional imaging; 28 patients (22%) were diagnosed with 1 HRF and 4 patients (3%) had 2 HRFs. Adhering to AGA guidelines using 2 HRF as threshold for use of EUS, the diagnosis of malignant and high-risk premalignant lesions (including pancreatic adenocarcinoma, mucinous cystadenoma, neuroendocrine tumors, and IPMN with dysplasia) had a 40% sensitivity and 100% specificity. Had EUS been utilized based on a threshold of 1 HRF on imaging, malignant and high-risk premalignant lesions would have been identified with 80% sensitivity and 95% specificity. By adding EUS to radiographic imaging, the specificity for detecting carcinomas (p = 0.0009) and detection of all premalignant lesions (p = 0.003) statistically improved. Furthermore, EUS allowed 14 patients (11%) to avoid further surveillance by lowering their risk stratification. CONCLUSION: EUS remains an essential risk stratification modality for incidental PCLs. Current guideline suggestions of its utility may be too stringent. Our study justifies expert radiology review when managing PCLs. Further studies are required to identify the optimal approach to PCL management.

Changes in Physician Decision Making after CT: A Prospective Multicenter Study in Primary Care Settings.

Purpose To determine the effect of computed tomography (CT) results on physician decision making in three common clinical scenarios in primary care. Materials and Methods This research was approved by the institutional review board (IRB) and was HIPAA compliant. All physicians consented to participate with an opt-in or opt-out mechanism; patient consent was waived with IRB approval. In this prospective multicenter observational study, outpatients referred by primary care providers (PCPs) for CT evaluation of abdominal pain, hematuria, or weight loss were identified. Prior to CT, PCPs were surveyed to elicit their leading diagnosis, confidence in that diagnosis (confidence range, 0%-100%), a rule-out diagnosis, and a management plan if CT were not available. Surveys were repeated after CT. Study measures were the proportion of patients in whom leading diagnoses and management changed (PCP management vs specialist referral vs emergency department transfer), median changes in diagnostic confidence, and the proportion of patients in whom CT addressed rule-out diagnoses. Regression analyses were used to identify associations between study measures and site and participant characteristics. Specifically, logistic regression analysis was used for binary study measures (change in leading diagnosis, change in management), and linear regression analysis was used for the continuous study measure (change in diagnostic confidence). Accrual began on September 5, 2012, and ended on June 28, 2014. Results In total, 91 PCPs completed pre- and post-CT surveys in 373 patients. In patients with abdominal pain, hematuria, or weight loss, leading diagnoses changed after CT in 53% (131 of 246), 49% (36 of 73), and 57% (27 of 47) of patients, respectively. Management changed in 35% (86 of 248), 27% (20 of 74), and 54% (26 of 48) of patients, respectively. Median absolute changes in diagnostic confidence were substantial and significant (+20%, +20%, and +19%, respectively; P ≤ .001 for all); median confidence after CT was high (90%, 88%, and 80%, respectively). PCPs reported CT was helpful in confirming or excluding rule-out diagnoses in 98% (184 of 187), 97% (59 of 61), and 97% (33 of 34) of patients, respectively. Significant associations between primary measures and site and participant characteristics were not identified. Conclusion Changes in PCP leading diagnoses and management after CT were common, and diagnostic confidence increased substantially. © RSNA, 2016 Online supplemental material is available for this article.

Preoperative computed tomography scan to predict pancreatic fistula after distal pancreatectomy using gland and tumor characteristics.

BACKGROUND: Preoperative risk stratification for postoperative pancreatic fistula in patients undergoing distal pancreatectomy is needed. METHODS: Risk factors for postoperative pancreatic fistula in 220 consecutive patients undergoing distal pancreatectomy at 2 major institutions were recorded retrospectively. Gland density was measured on noncontrast computed tomography scans (n = 101), and histologic scoring of fat infiltration and fibrosis was performed by a pathologist (n = 120). RESULTS: Forty-two patients (21%) developed a clinically significant pancreatic fistula within 90 days of surgery. Fat infiltration was significantly associated with gland density (P = .0013), but density did not predict pancreatic fistula (P = .5). Recursive partitioning resulted in a decision tree that predicted fistula in this cohort with a misclassification rate less than 15% using gland fibrosis (histology), density (HU), margin thickness (cm), and pathologic diagnosis. CONCLUSIONS: This multicenter study shows that no single perioperative factor reliably predicts postoperative pancreatic fistula after distal pancreatectomy. A decision tree was constructed for risk stratification.

A quality improvement initiative to reduce unnecessary follow-up imaging for adnexal lesions.

Our objective was to improve the quality of pelvic ultrasound reports and decrease the number of physiologic and benign adnexal lesions unnecessarily referred for follow-up. We performed a prospective cohort study of 2 quality improvement interventions: academic detailing with education for the ultrasound radiologists and sonographers, and implementation of a national consensus guideline on adnexal cysts. Our primary quality outcome measure was the proportion of pelvic ultrasound exams in which follow-up was recommended for an adnexal lesion. Baseline data collection in January 2006 identified 252 pelvic ultrasound exams, of which 58 (23%) reported an adnexal lesion and 31 (12%) recommended follow-up. Retrospective review revealed that 17 of 31 (55%) reported adnexal lesions with follow-up recommended were physiologic or benign. After intervention 1, 59 of 214 (28%) pelvic ultrasound exams from January 2008 reported an adnexal lesion, with 18 (8%) recommending follow-up. After intervention 2, 64 of 296 (22%) pelvic ultrasound exams from January 2011 reported an adnexal lesion, with 16 (5%) recommending follow-up. Follow-up recommendations decreased 58% (12% versus 5%, P = .004), with significant increase in the proportion characterized as physiologic or benign (P = .001). Through a quality initiative aimed at appropriate description and follow-up recommendations for adnexal cystic lesions identified at ultrasound, we effectively reduced unnecessary imaging referrals. We conclude that: (1) acceptance of an expert consensus guideline was important to add credibility, (2) accessible image-rich charts are invaluable tools at point of use, and (3) elimination of some unnecessary imaging is under the control of the radiologist.

Reversible cytotoxic edema in a cirrhotic patient following TIPS.

The authors report the magnetic resonance imaging (MRI) findings in a 52-year-old man with cirrhosis from chronic hepatitis C who developed episodic acute hepatic encephalopathy Type C following placement of transjugular intrahepatic portosystemic shunt (TIPS). Brain MRI revealed hyperintense T2 signal and restricted diffusion distributed through the cerebral cortex. The patient's mentation improved with treatment of his hyperammonemia. Brain MRI performed 5 months later revealed diffuse cerebral atrophy and new areas of hyperintense T2 signal in the cerebral white matter. The cortical signal abnormalities and low apparent diffusion coefficient values on the initial MRI resolved with exception of a mild amount of hyperintense FLAIR signal in the cingulate cortex. Acute hepatic encephalopathy following portosystemic shunting -- either from placement of TIPS or from development of spontaneous shunts -- is a widely recognized complication of portal hypertension and cirrhosis. We report MRI findings of reversible cytotoxic edema in a patient with acute hepatic encephalopathy following placement of TIPS.

Imaging evaluation of pulmonary and abdominal complications following hematopoietic stem cell transplantation.

Hematopoietic stem cell transplantation is used to treat hematologic disorders and as an adjunct treatment for solid organ malignancies. After undergoing transplantation, patients are at risk for opportunistic infections and other complications caused by dysfunction of the immune system. Pulmonary complications include cryptogenic organizing pneumonia, opportunistic pneumonias caused by Aspergillus and Zygomycetes species and cytomegalovirus, alveolar hemorrhage, and constrictive bronchiolitis. Abdominal complications include hepatic veno-occlusive disease, graft-versus-host disease (GVHD), colitis, and hemorrhagic cystitis. Allogeneic transplant recipients are at risk for developing GVHD. Autologous and syngeneic transplant recipients are less likely to have chronic or late posttransplantation complications. Nonmyeloablative transplant recipients are less likely to develop opportunistic infections and other complications in the period immediately following transplantation, but are at risk for developing chronic GVHD and other chronic complications. Radiologic evaluation serves as the cornerstone for timely diagnosis of these complications, which is essential to reduce patient morbidity and mortality. Combining clinical factors-including the type of transplant and the point of time during the posttransplantation course-with characteristic imaging features yields the most specific and accurate differential diagnosis for radiologic findings in stem cell transplant recipients.

The kinesin-related protein MCAK is a microtubule depolymerase that forms an ATP-hydrolyzing complex at microtubule ends.

MCAK belongs to the Kin I subfamily of kinesin-related proteins, a unique group of motor proteins that are not motile but instead destabilize microtubules. We show that MCAK is an ATPase that catalytically depolymerizes microtubules by accelerating, 100-fold, the rate of dissociation of tubulin from microtubule ends. MCAK has one high-affinity binding site per protofilament end, which, when occupied, has both the depolymerase and ATPase activities. MCAK targets protofilament ends very rapidly (on-rate 54 micro M(-1).s(-1)), perhaps by diffusion along the microtubule lattice, and, once there, removes approximately 20 tubulin dimers at a rate of 1 s(-1). We propose that up to 14 MCAK dimers assemble at the end of a microtubule to form an ATP-hydrolyzing complex that processively depolymerizes the microtubule.