Factors Driving Resistance to Clinical Decision Support: Finding Inspiration in Radiology 3.0.

PURPOSE: The effectiveness of evidence-based guidelines (EBGs) and clinical decision support (CDS) is significantly hampered by widespread clinician resistance to it. Our study was designed to better understand the reasons for this resistance to CDS and explore the factors that drive it. METHODS: We used a mixed-methods approach to explore and identify the drivers of resistance for CDS among clinicians, including a web-based multispecialty survey exploring clinicians' impressions of the strengths and weaknesses of CDS, two clinician focus groups, and several one-on-one focused clinician interviews in which individual participants were asked to comment on their rationale for choosing imaging utilization that might not be supported by EBGs. Additionally, a unique electronic learning and assessment module known as Amplifire was used to probe clinician knowledge gaps regarding EBGs and CDS. RESULTS: In both the quantitative and qualitative portions of the study, the primary factor driving resistance to CDS was a desire to order studies not supported by EBGs, primarily for the purpose of reducing the clinician's diagnostic uncertainty. CONCLUSIONS: Our results suggest that to enhance the effectiveness of CDS, we must first address the issue of clinician discomfort with diagnostic uncertainty and the role of imaging via educational outreach and ongoing radiologist consultation.

Purposeful Remote Radiology Education: Strategies and Recommendations.

The COVID-19 global pandemic has presented new challenges to radiology educators and their learners. As a specialty that is accustomed to adapting to continual technologic innovation, as well as one with the capacity for remote work, radiology is uniquely positioned to meet these challenges by taking advantage of online remote educational strategies. This represents an opportunity to not only leverage new methods and technologies but also reexamine the most effective way to implement established ones. The authors review the benefits of taking a purposeful goal-oriented approach to these challenges, provide a corresponding qreview of the general categories of resources that are currently available, and explore educational strategies by using broad categories of software solutions. An invited commentary by Awan is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Review of Artificial Intelligence Training Tools and Courses for Radiologists.

Artificial intelligence (AI) systems play an increasingly important role in all parts of the imaging chain, from image creation to image interpretation to report generation. In order to responsibly manage radiology AI systems and make informed purchase decisions about them, radiologists must understand the underlying principles of AI. Our task force was formed by the Radiology Research Alliance (RRA) of the Association of University Radiologists to identify and summarize a curated list of current educational materials available for radiologists.

Incidental CT Findings Suspicious for COVID-19-Associated Pneumonia on Nuclear Medicine Examinations: Recognition and Management Plan.

Some patients undergoing routine SPECT/CT and PET/CT examinations during the COVID-19 pandemic may incidentally reveal findings of COVID-19-associated pneumonia (C-19AP) on localizing CT. It is critical for nuclear medicine physicians to develop diagnostic skills for timely recognition of typical findings of C-19AP on a localizing CT. Furthermore, it is our responsibility to know the optimal practices for safely isolating and managing such patients while protecting the staff, other patients at the facility, family and/or friend accompanying the patients, and the public in general from risky exposure to COVID-19 sources. We offer several steps following an encounter suspicious of C-19AP.

Everything Every Radiologist Always Wanted (and Needs) to Know About Clinical Decision Support.

As of January 2020, clinical decision support needs to be implemented across US health systems for advanced diagnostic imaging services. This article reviews the history, importance, and hurdles of clinical decision support and discusses a few pearls and pitfalls regarding its implementation.

Multisite Implementation of Radiology-TEACHES (Technology-Enhanced Appropriateness Criteria Home for Education Simulation).

PURPOSE: After encouraging results from a single-institution pilot, a novel case-based education portal using integrated clinical decision support at the simulated point of order entry was implemented at multiple institutions to evaluate whether the program is scalable and results transferable. The program was designed to fill key health systems' science gaps in traditional medical education curricula, ultimately aiding the transition from volume to value in health care. The module described uses commonly encountered medical vignettes to provide learners with a low-stakes educational environment to improve their awareness and apply curricular content regarding appropriate resource utilization, patient safety, and cost. METHODS: In 2016 and 2017, the team implemented the modules at eight US medical schools. A total of 199 learners participated in this institutional review board-approved study; 108 completed the module, and 91 were in the control group. RESULTS: The module group had higher posttest scores than their control group peers, after controlling for pretest scores (ß = 4.05, P < .001). The greatest knowledge gains were on questions related to chest radiography (22% improvement) and adnexal cysts (20.33% improvement) and the least on items related to pulmonary embolism (0.33% improvement). The majority of learners expressed satisfaction with the educational content provided (70.4%) and an increased perception to appropriately select imaging studies (65.2%). CONCLUSIONS: This program is promising as a standardized educational resource for widespread implementation in developing health systems science curricula. Learners at multiple institutions judged this educational resource as valuable and, through this initiative, synthesized practice behaviors by applying evidence-based guidelines in a cost-effective, safe, and prudent manner.

Downregulation of CD73 associates with T cell exhaustion in AML patients.

BACKGROUND: Successful treatment for acute myeloid leukemia (AML) remains challenging. Inhibiting immune checkpoint to enhance anti-tumor response is an attractive strategy for effective leukemia therapeutics. CD73 is a recently recognized immune checkpoint mediator that is highly expressed on tumor cells and stromal cells in tumor microenvironment. The ectonucleotidase activity of CD73 catalyzes AMP to adenosine, which subsequently inhibits anti-tumor immune responses. In this study, we aim to explore the effect of CD73 in AML. METHODS: Peripheral blood samples collected from patients with newly diagnosed AML (n = 27) were used in this study. CD73 expression on each immune cell component was examined by flow cytometry. Phenotypic study of CD73-expressing T cells and analysis of the correlation between CD73 and other immune checkpoints were performed using flow cytometry-based assays. Functional status of CD73+ vs. CD73- T cells was assessed in an in vitro cytokine release assay upon CD3/CD28 antibody stimulation. RESULTS: In contrast to the long recognized immune suppressive effect of CD73-adenosine signaling in tumor tissue, we made a striking observation that in AML, CD73 expression on CD8 T cells associates with an increased immune response. CD73+ CD8 T cells are more functional, whereas CD73- CD8 T cells exhibit features of exhaustion manifested by high expression of inhibitory receptors such as PD-1 and TIGIT, increased intracellular expression of Eomes, reduced capacity of cytokine production, and high susceptibility to apoptosis. CONCLUSIONS: Our data highlight the potential of CD73 as a double-edged sword in anti-leukemia immunity and argue strongly for the combinational treatment by adding immune checkpoint inhibitors to the CD73-targeting approaches.

Making Learning Fun: Gaming in Radiology Education.

With continued technologic advances, it is not surprising that gaming techniques are increasingly being used in radiology residency programs. This comprehensive review on gaming in radiology education offers insight into the importance of gaming, types of games and principles utilized in gaming, as well as applications that are inherent in artificial intelligence and continued medical education. The advantages and disadvantages of gaming will be considered, as well as barriers to successful adoption of gaming.

Applications of Ventilation-Perfusion Scintigraphy in Surgical Management of Chronic Obstructive Lung Disease and Cancer.

Ventilation-perfusion scintigraphy (VPS) depicts the two main physiological processes that are fundamental to oxygen-dependent life. The test has affirmed its critical place in the evaluation of patients with lung cancer preparing for lung resection. The results of the study can differentiate patients who are very likely to survive surgery and the subsequent pulmonary function loss from those who are not. This review presents validated and evolving testing techniques for this critical indication. VPS has long been an integral part of the preoperative evaluation of lung transplant candidates, guiding the single lung grafts to the side with the worst function. New applications are emerging in the rapidly developing surgical and interventional management of severe chronic obstructive lung diseases. Enhanced by the advancements in hybrid imaging and computer processing, the VPS examination continues to be reinvented and updated to keep pace with the needs of modern medicine.

Evaluation of Three-Dimensional Printed Materials for Simulation by Computed Tomography and Ultrasound Imaging.

INTRODUCTION: The use of three-dimensional (3D) printing allows for creation of custom models for clinical care, education, and simulation. Medical imaging, given the significant role it plays in both clinical diagnostics and procedures, remains an important area for such education and simulation. Unfortunately, the materials appropriate for use in simulation involving radiographic or ultrasound imaging remains poorly understood. Therefore, our study was intended to explore the characteristics of readily available 3D printing materials when visualized by computed tomography (CT) and ultrasound. METHODS: Seven 3D printing materials were examined in standard shapes (cube, cylinder, triangular prism) with a selection of printing methods ("open," "whole," and "solid" forms). For CT imaging, these objects were suspended in a gelatin matrix molded to match a standard human CT phantom. For ultrasound imaging, the objects were placed in acrylic forms filled with a gelatin matrix. All images were examined using OsiriX software. RESULTS: Computed tomography imaging revealed marked variation in materials' Hounsfield units as well as patterning and artifact. The Hounsfield unit variations revealed a number of materials suitable for simulation various human tissues. Ultrasound imaging showed echogenicity in all materials, with some variability in shadowing and posterior wall visualization. CONCLUSIONS: We were able to demonstrate the potential utility for 3D printing in the creation of CT and ultrasound simulation models. The similar appearance of materials via ultrasound supports their broad utility for select tissue types, whereas the more variable appearance via CT suggests greater potential for simulating differing tissues but requiring multiple printer technologies to do so.

Quality metrics currently used in academic radiology departments: results of the QUALMET survey.

OBJECTIVE: We present the results of the 2015 quality metrics (QUALMET) survey, which was designed to assess the commonalities and variability of selected quality and productivity metrics currently employed by a large sample of academic radiology departments representing all regions in the USA. METHODS: The survey of key radiology metrics was distributed in March-April of 2015 via personal e-mail to 112 academic radiology departments. RESULTS: There was a 34.8% institutional response rate. We found that most academic departments of radiology commonly utilize metrics of hand hygiene, report turn around time (RTAT), relative value unit (RVU) productivity, patient satisfaction and participation in peer review. RTAT targets were found to vary widely. The implementation of radiology peer review and the variety of ways in which peer review results are used within academic radiology departments, the use of clinical decision support tools and requirements for radiologist participation in Maintenance of Certification also varied. Policies for hand hygiene and critical results communication were very similar across all institutions reporting, and most departments utilized some form of missed case/difficult case conference as part of their quality and safety programme, as well as some form of periodic radiologist performance reviews. CONCLUSION: Results of the QUALMET survey suggest many similarities in tracking and utilization of the selected quality and productivity metrics included in our survey. Use of quality indicators is not a fully standardized process among academic radiology departments. Advances in knowledge: This article examines the current quality and productivity metrics in academic radiology.

Oral Cholecystagogue Cholescintigraphy: A Systematic Review of Fatty Meal Options.

OBJECTIVES: Intermittent unavailability of sincalide for determination of gallbladder ejection fraction (GBEF) prompted increased usage of fatty meal cholecystagogues (FMCs). The aim of this systematic review was to identify the state of current FMC options in cholescintigraphy, focusing on the quality of corresponding normal GBEF values. METHODS: We performed an extensive literature search of the MEDLINE, Cochrane, and CINAHL databases without date or language restrictions with a broad spectrum of search terms. Selection criteria required both that the study use a FMC as part of a stimulated GBEF examination to gather data on normal volunteers or patients without evidence of gastrointestinal disease and that the meal used be described sufficiently for emulation. A cumulative point system was used to grade the quality of normal GBEF values: 1 point for screening ultrasound, 1 point for detailed screening questionnaire, 1 point for 20 or greater number of participants in a study, 1 additional point for 60 or greater number of participants in a study, 0.5 points for cursory screening questions, and 0 points when no screening process was mentioned. The meal was expressed in grams of fat per volume, when available. RESULTS: Twelve studies met inclusion criteria out of 15 studies claiming to report normal values. Two studies (17%) achieved a score of 3, 5 studies (42%) at 2 to 2.5, 3 studies (25%) at 1 to 1.5, and the remaining 2 studies (17%) at 0 to 0.5. Total number of participants examined ranged from 6 to 100. Meal composition varied widely. In 1 study, sham feeding was used. Most meals had components that could present problems to patients with relatively common dietary restrictions (ie, lactose intolerance, egg protein allergy, etc). Results for proposed normal values varied widely (from 16.3% to 85.6%). The commercial fatty meal products of Humana Infant Formula 1 and Ensure Plus offered the highest-quality normal values. CONCLUSIONS: There is a need to establish high-quality normal GBEF range for a ubiquitous fatty meal (ie, a meal that would be widely available, easy to prepare, inexpensive, and free of sensitivity-provoking ingredients). A corn oil emulsion, has immense potential as an ideal FMC, limited currently only by its lack of established normal values. Currently, the highest-quality normal GBEF values available for FMC exist for 2 commercial products, Humana Infant Formula 1 and Ensure Plus. However, these products may not be readily available at some institutions, and neither one is free from dietary restrictions.

Bacillus Calmette-Guerin injections for melanoma immunotherapy: potential for a false-positive PET/CT.

An 82-year-old woman presented for routine follow-up PET/CT after undergoing local melanoma resection in the left lower leg, isolated limb infusion chemotherapy, and immunomodulation therapy with Bacillus Calmette-Guérin (BCG) vaccine. Symmetric, bilateral, moderately intense FDG avid axillary and inguinal cutaneous nodules were observed that were new from the prior PET-CT. The patient had developed skin lesions at the BCG injection sites several months before the study. The case raises awareness to PET/CT appearance of local inflammatory response to BCG injection, which could be mistaken by an unaware reader for recurrent melanoma.

Standing prone positioning in establishing causality between matched ventilation-perfusion defects and pleural effusion.

Ventilation-perfusion scintigraphy is routinely performed in patients with suspected pulmonary thromboembolism. Pleural effusions in such patients are common and can cause matched ventilation-perfusion defects. This is especially true of the posterior projections in the supine patient. Prone positioning has been described as a useful technique to redistribute pleural fluid anteriorly, exposing perfusion in posterior lung fields; however, some patients have a concurrent condition that renders prone positioning difficult. This report discusses a modified technique that allows patients to be imaged in a standing prone position with excellent results.

False-positive PET/CT for lymphoma recurrence secondary to Langerhans cell histiocytosis.

A 28-year-old man with a history of Hodgkin lymphoma that was intensely [F-18]fluoro-2-deoxy-D-glucose-avid at diagnosis had achieved complete remission following appropriate therapy. On surveillance positron emission tomography/computed tomography (CT), new, intensely [F-18]fluoro-2-deoxy-D-glucose-avid lesions (lytic on CT) were seen within the vertebral body of C7, left scapula, and right glenoid. The findings of a biopsy revealed these lesions to be Langerhans cell histiocytosis. Langerhans cell histiocytosis arising in the context of lymphoma is a well-documented phenomenon, and its appearance on positron emission tomography/CT cannot be conclusively distinguished from lymphoma recurrence. This manuscript emphasizes the necessity of biopsy to ensure correct diagnosis and subsequent correct therapy.

Testicular ascent as a mechanism for intra-abdominal torsion.

Testicular ascent, while uncommon, can occur. A testicle that has ascended out of the scrotum can torse and may present as an acute inguinal mass or acute abdomen. Testicle ascent can occur even if previous intra-scrotal location has been documented.

Lysophosphatidic acid induces chemotaxis in MC3T3-E1 osteoblastic cells.

Lysophosphatidic acid (LPA) is a bioactive lipid that has pleiotropic effects on a variety of cell types and enhances the migration of endothelial and cancer cells, but it is not known if this lipid can alter osteoblast motility. We performed transwell migration assays using MC3T3-E1 osteoblastic cells and found LPA to be a potent chemotactic agent. Quantitative time-lapse video analysis of osteoblast migration after wounds were introduced into cell monolayers indicated that LPA stimulated both migration velocity and the average migration distance per cell. LPA also elicited substantial changes in cell shape and actin cytoskeletal structure; lipid-treated cells contained fewer stress fibers and displayed long membrane processes that were enriched in F-actin. Quantitative RT-PCR analysis showed that MC3T3-E1 cells express all four known LPA-specific G-protein-coupled receptors (LPA1-LPA4) with a relative mRNA abundance of LPA1>LPA4>LPA2>>LPA3. LPA-induced changes in osteoblast motility and morphology were antagonized by both pertussis toxin and Ki16425, a subtype-specific blocker of LPA1 and LPA3 receptor function. Cell migration in many cell types is linked to changes in intracellular Ca2+. Ki16425 also inhibited LPA-induced Ca2+ signaling in a dose-dependent manner, suggesting a link between LPA-induced Ca2+ transients and osteoblast chemotaxis. Our data show that LPA stimulates MC3T3-E1 osteoblast motility via a mechanism that is linked primarily to the G-protein-coupled receptor LPA1.