Retrospective Evaluation of Artificial Intelligence Leveraging Free-Text Imaging Order Entry to Facilitate Federally Required Clinical Decision Support.

OBJECTIVE: The Protecting Access to Medicare Act mandates clinical decision support (CDS) at imaging order entry, necessitating the use of structured indications to map CDS scores. We evaluated the performance of a commercially available artificial intelligence (AI) tool leveraging free-text order entry to facilitate provider selection of the necessary structured indications. METHODS: Our institution implemented an AI tool offering predicted structured indications based upon the ordering provider's entry of a free-text reason for examination. Providers remained able to order via the traditional direct search for structured indications. Alternatively, they could take the new free-text-AI approach allowing them to select from AI-predicted indications, perform additional direct searches, indicate no matching indication, or exit CDS workflow. We hypothesized the free-text-AI approach would be elected more often and the AI tool would be successful in facilitating selection of structured indications. We reviewed advanced imaging orders (n = 40,053) for the first 3 months (February to May 2020) since implementation. RESULTS: Providers were more likely (P < .001) to choose the free-text-AI approach (23,580; 58.9%) to order entry over direct search for structured indications (16,473; 41.1%). The AI tool yielded alerts with predicted indications in 91.7% (n = 21,631) of orders with free text. Ultimately, providers chose AI-predicted indications in 57.7% (n = 12,490) of cases in which they were offered by the tool. DISCUSSION: Providers significantly more often elected the new free-text-AI approach to order entry for CDS, suggesting provider preference over the traditional approach. The AI tool commonly predicted indications acceptable to ordering providers.

Preprocedural Imaging Evaluation of Pulmonary Valve Replacement After Repair of Tetralogy of Fallot: What the Radiologist Needs to Know.

Tetrallogy of Fallot (TOF) is the most frequent form of cyanotic congenital heart disease. Despite advances in surgical and medical treatment, mortality remains high. Residual dysfunction of the pulmonary valve (PV) after correction of right ventricular outflow tract obstruction is an important cause of morbidity, leading to irreversible right ventricular dysfunction, arrhythmias, heart failure and occasionally, death. The strategies for PVR have evolved over the last decades, and the timing of the intervention remains the foundation of the decision-making process. Symptoms of heart failure are unreliable indicators for optimal timing of repair. Imaging plays an essential role in the assessment of PV integrity and dysfunction. The identification of the best timing for PVR requires a multimodality approach. Transthoracic echocardiography is the most commonly used imaging modality for the initial assessment and follow-up of TOF patients, although its utility has technical limitations, especially in adults. Cardiac computed tomography and magnetic resonance imaging are now routinely used for preoperative and postoperative evaluation of these patients, and provide highly valuable information about the anatomy and pathophysiology. Imaging evidence of disease progression is now part of the major guidelines to define the best timing for reintervention. The purpose of this article is to review the pathophysiology after TOF repair, identify the main imaging anatomic and physiologic features, describe the indications for PVR and recognize the role of imaging in the assessment of these patients to define the appropriate timing of PVR.

Neoplastic Cerebral Aneurysm from Metastatic Lung Adenocarcinoma with Neuroendocrine Features.

BACKGROUND: Neoplastic cerebral aneurysms are exceedingly rare. We describe a case of a ruptured, distal middle cerebral artery aneurysm as the presenting symptom leading to the identification of metastatic lung cancer. CASE DESCRIPTION: The patient underwent an uncomplicated surgical trapping and ligation of the aneurysm. Histopathologic examination of the aneurysm confirmed the neoplastic cerebral aneurysm was due to a metastatic lung adenocarcinoma with neuroendocrine features. The patient subsequently underwent stereotactic radiosurgery to the resection cavity. CONCLUSIONS: Neoplastic cerebral aneurysms are rare, and there are insufficient data to support specific guidelines for management. This case is novel as the patient received adjuvant stereotactic radiosurgery to the operative bed, as well as systemic chemotherapy, and has maintained good functional status as of last follow-up at 6 months.

Duodenal diverticulum: incidental finding with potentially dangerous outcomes.

We present the case of an 83-year-old woman with a past medical history significant for schizoaffective disorder, presenting to our emergency department with the complaint of 'pain'. Given the non-specific complaint and the limited history obtained, CT imaging was performed on her chest and abdomen which incidentally found a large duodenal diverticulum. This manuscript discusses the incidence of duodenal diverticula and the potential associated complications.

Green fingernail.

The patient hadn't injured her thumb and it didn't hurt. So why had her nail turned green?

Impending aortic aneurysm rupture - a case report and review of the warning signs.

Abdominal aortic aneurysm (AAA) may present with subtle clinical findings. Recognition of the imaging features of an impending rupture is key for timely diagnosis. This report reviews the classic computed tomography findings of impending AAA rupture and presents a recent case which illustrates the key features.

Hemifacial spasm in a patient with basilar artery dolichoectasia caused by uncontrolled hypertension.

A 47-year-old male presented with a 2-year history of hemifacial spasm. Magnetic resonance imaging performed showed his tortuous basilar artery with nerve compression, and the patient was treated conservatively with botulinum toxin injections with complete resolution of symptoms. This rare disease was caused by his long history of hypertension, which led to his major basilar artery dolichoectasia.

Hypertriglyceridemic pancreatitis associated with confounding laboratory abnormalities.

We present the case of a 36-year-old woman who presented to our hospital with epigastric abdominal pain and tenderness. Laboratory evaluation identified high lipase, normal amylase, pseudohyponatremia, and relatively falsely low triglyceride levels (initial value of 2,329 mg/dl which on repeat was found to have corrected value of >10,000 mg/dl). The overall clinical picture was consistent with acute pancreatitis due to hypertriglyceridemia. The patient was commenced on IV insulin and eventually required plasmapheresis with good clinical outcome. This case highlights the importance of being cognizant of falsely low amylase and TG levels that can be present in patients with hypertriglycereidemic pancreatitis.