Introduction of a Maternal-Fetal Medicine Tele-Ultrasound Program in Rural Alberta.

OBJECTIVES: We established a program of Maternal-Fetal Medicine (MFM) telemedicine that is safe and acceptable. Since December 2019, a multi-disciplinary team has been planning this quality improvement project. METHODS: We performed a pilot study to investigate the feasibility of using telemedicine and tele-ultrasound to enable prompt MFM consultations for patients in remote locations. We began with the training of sonographers followed by implementation in a small pilot. Interim analysis of the acceptability and feasibility of the program was done through patient surveys, images audit, and review of neonatal outcomes. RESULTS: Our background epidemiologic data showed that in Alberta, between 2017 and 2022, 460 patients travelled >6 hours, and 5038 travelled >2 hours from home to reach their site of birth. Patients were appropriately triaged to delivery/consultation at the tertiary level center based on diagnosis/suspicion of anomalies, such as abnormally invasive placenta, intrauterine growth restriction, hydrops, and partial agenesis of the corpus callosum, all of which were confirmed postdelivery. There was no neonatal mortality, and the single stillbirth was related to an unpreventable peri-viable co-twin demise. The patient survey demonstrated that for >85% of respondents the program reduced costs and stress. Ultrasound image audit found improvement and consistency in image quality after 3 months of training combined with supervision. CONCLUSION: MFM telemedicine is feasible and can be safe with adequate supervision. Additional support and resources are needed to scale and spread this quality improvement initiative.

Is Ultrasound Useful for Further Evaluation of Homogeneously Hyperattenuating Renal Lesions Detected on CT?

OBJECTIVE: The purpose of this study was to evaluate the ability of ultrasound (US) to characterize hyperattenuating cysts detected as indeterminate hyperattenuating renal lesions on unenhanced and single phase enhanced CT. MATERIALS AND METHODS: A total of 107 consecutive homogeneously hyperattenuating renal lesions underwent gray-scale and Doppler US at our institution between 2010 and 2013. Two radiologists who were unaware of the final diagnosis retrospectively evaluated US images for visibility and diagnosis (simple cyst, intermediate complexity cyst, cystic or solid mass showing internal flow on Doppler US, or indeterminate). A third radiologist assessed lesion size, location, and distance to skin on CT and US. US visibility was compared using chi-square and independent t tests. Consensus US interpretation was compared with reference standard diagnoses, and accuracy for diagnosis of hyperattenuating cysts was tabulated. RESULTS: Mean lesion size ± SD was 20 ± 16 mm (range, 6-96 mm) and mean distance to skin on CT was 62 ± 25 mm (range, 18-125 mm). In all, 89.7% (96/107) of the lesions were visible on US, including all lesions that were 15 mm or larger. Nonvisible lesions were smaller than visible ones (10.0 ± 3.6 mm vs 20.7 ± 16.3 mm, p = 0.03) regardless of location (p > 0.05). CT overestimated lesion distance to skin compared with US (46.6 ± 18.6 mm, p < 0.001). Final diagnoses for US visible lesions (n = 96) were hyperattenuating cyst (n = 66), Bosniak IIF cyst (n = 13), and cystic or solid neoplasm (n = 15); two patients were lost to follow-up. Of the 66 hyperattenuating cysts, 54 (81.8%) appeared as simple cysts on US with sensitivity and specificity for diagnosis of hyperattenuating cyst of 81.8% (95% CI, 75.6-84.3%) and 92.9% (95% CI, 78.1-98.7%), respectively. The other 12 (18.2%) hyperattenuating cysts appeared complex. Two of the 13 Bosniak IIF lesions were incorrectly classified as simple cysts with US. Including the 11 (10%) nonvisible lesions reduced sensitivity and specificity for diagnosis of hyperattenuating cyst to 73.0% (95% CI, 66.9-75.9%) and 89.7% (95% CI, 74.2-97.2%), respectively. CONCLUSION: US can further characterize hyperattenuating cysts presenting as indeterminate hyperattenuating renal lesions on CT in the majority of cases.

Disinfection of the Radiologist Workstation and Radiologist Hand Hygiene: A Single Institution Practice Quality Improvement Project.

PURPOSE: The purpose of this study was to evaluate the workstation disinfection rates and hand hygiene of radiologists and trainees at shared departmental workstations and assess the impact of education and reminder placards on daily habits. METHODS: A 10-question survey was administered to all staff radiologists, fellows, and residents at our institution. The questions pertained to workstation disinfection, hand hygiene habits, and accessibility to disinfectant wipes and hand sanitizer stations. Subsequently, a short educational PowerPoint presentation was emailed to the department and small reminder placards were placed at each workstation. A follow-up survey was administered. Chi-square and Wilcoxon signed-rank tests were used to analyse the results. RESULTS: The percentage of participants who disinfect their workstations 1-2 times/week, 3-4 times/week or everyday increased from 53.4% (45 of 84 participants) to 74.3% (55 of 74 participants; P = .01), while the number who disinfect their workstation <1 time/week or never decreased from 46.4% (39 of 84 participants) to 25.7% (19 of 74 participants; P = .01). Hand washing before working at the workstation increased from 41.6% (35 of 84 participants) to 48.7% (36 of 74 participants; P = .76) and hand washing after working at the workstation increased from 50.0% (42 of 84 participants) to 56.8% (42 of 74 participants; P = .49). CONCLUSIONS: At our institution, the implementation of daily reminder placards at each workstation and the administration of an educational PowerPoint presentation improved the rate of radiologist workstation disinfection.

Evaluation of apparent diffusion coefficient and MR volumetry as independent associative factors for extra-prostatic extension (EPE) in prostatic carcinoma.

BACKGROUND: To assess mean apparent diffusion coefficient (ADC) and MR-derived tumor volume (Vt) as associative factors for extra-prostatic extension (EPE) in prostate cancer (PCa). METHODS: With institutional review board approval, 73 consecutive patients diagnosed with PCa at trans-rectal ultrasound biopsy underwent preoperative multi-parametric (T2W+DWI+DCE) 3 Tesla MRI before radical prostatectomy between 2012 and 2014; 52% (38/73) patients had EPE. Clinical parameters including: age, prostate serum antigen (PSA), digital rectal examination (DRE) and percentage positive cores (PPC) were recorded. Two blinded radiologists subjectively evaluated for EPE using PI-RADS with T2W-MRI. A third blinded radiologist recorded: mean ADC (mm(2) /s) of tumor and tumor volume on ADC and T2W (derived from planar volumetry). VtMAX (the largest volume on ADC or T2W) was documented. Multivariate and receiver operator characteristic analyses were performed. RESULTS: There were no significant differences in age, DRE, or Gleason score between groups (P = 0.52, 0.06, 0.61, 0.36). PSA approached significance being higher with EPE (12.9 ± 12.6 versus 8.2 ± 7.4; P = 0.06). PPC was higher with EPE (60.9 ± 21.9% versus 38.3 ± 21.6%; P < 0.01) with an area under the curve (AUC) of 0.78 and sensitivity/specificity = 75.7/75% when PPC ≥ 45%. AUC for T2W-MRI was 0.46-0.51 with sensitivity/specificity = 40.0-42.9/48.6-57.1% (R1, R2). Inter-observer agreement was fair, k = 0.39. There was no difference in mean ADC between groups (0.89 ± 0.25 versus 0.88 ± 0.19 [EPE] mm(2) /s), P = 0.70. T2W-Vt, ADC-Vt, and VtMAX were larger with EPE (5.1 ± 7.4, 5.8 ± 6.5, 6.3 ± 7.4 cm(3) versus 1.6 ± 1.8, 1.8 ± 1.3, 2.1 ± 1.8), P < 0.01. VtMAX AUC was 0.77 with sensitivity/specificity = 78.4/73.5% when VtMAX ≥ 2.1 cm(3) which outperformed all other parameters (P > 0.05) except PPC (P = 0.6) for the diagnosis EPE. CONCLUSION: MR volumetry and percentage of positive core biopsies are associated with EPE; whereas, in this study, other clinical and MR parameters including mean ADC and subjective T2W-MR analysis were not useful for assessment of EPE.

Evaluation of the European Society of Urogenital Radiology (ESUR) PI-RADS scoring system for assessment of extra-prostatic extension in prostatic carcinoma.

INTRODUCTION: To evaluate extra-prostatic extension (EPE) comparing PI-RADS to non-standardized reporting. MATERIALS AND METHODS: With IRB approval, 145 consecutive patients underwent radical prostatectomy (RP) and multi-parametric (T2W+DWI+DCE) MRI between 2012 and 2013. Eighty patients (66.3% with EPE) were staged without PI-RADS and 65 patients (64.6% with EPE) were staged using a 5-point PI-RADS scoring system. Studies were reported by fellowship-trained radiologists in routine clinical practice. Individual PIRADS scores were assessed using ROC to determine the score which optimized sensitivity/specificity. Diagnostic accuracy for EPE was compared with/without PI-RADS using the McNemar test. Subgroup analysis by radiologist experience was performed using Spearman correlation and chi-square. RESULTS: Area under ROC curve for EPE using PI-RADS was 0.62 and optimal sensitivity/specificity was achieved with PI-RADS score ≥ 3. Compared to non-standardized reporting, sensitivity for EPE improved with PI-RADS (59.5% [49.1-68.2] vs. 24.5% [16.7-31.2]), p=0.01; with no difference in specificity (68.0% [50.5-82.6]) vs. (75.0% [60.1-87.6]), p=0.06. Overall accuracy improved with PI-RADS (62.7% [49.6-73.6] vs. 42.0% [31.7-50.7%]), p=0.006. Diagnostic accuracy was better among experienced radiologists without PI-RADS (p=0.005); however, there was no difference in accuracy by reader experience using PI-RADS (p=0.24). CONCLUSION: The PI-RADS criteria for EPE improves sensitivity without reducing specificity. PI-RADS may reduce differences in accuracy by reader experience.

False positive and false negative diagnoses of prostate cancer at multi-parametric prostate MRI in active surveillance.

MP-MRI is a critical component in active surveillance (AS) of prostate cancer (PCa) because of a high negative predictive value for clinically significant tumours. This review illustrates pitfalls of MP-MRI and how to recognise and avoid them. The anterior fibromuscular stroma and central zone are low signal on T2W-MRI/apparent diffusion coefficient (ADC), resembling PCa. Location, progressive enhancement and low signal on b ≥1000 mm²/s echo-planar images (EPI) are differentiating features. BPH can mimic PCa. Glandular BPH shows increased T2W/ADC signal, cystic change and progressive enhancement; however, stromal BPH resembles transition zone (TZ) PCa. A rounded morphology, low T2 signal capsule and posterior/superior location favour stromal BPH. Acute/chronic prostatitis mimics PCa at MP-MRI, with differentiation mainly on clinical grounds. Visual analysis of diffusion-weighted MRI must include EPI and appropriate windowing of ADC. Quantitative ADC analysis is limited by lack of standardization; the ADC ratio and ADC histogram analysis are alternatives to mean values. DCE lacks standardisation and has limited utility in the TZ, where T2W/DWI are favoured. Targeted TRUS-guided biopsies of MR-detected lesions are challenging. Lesions detected on MP-MRI may not be perfectly targeted with TRUS and this must be considered when faced with a suspicious lesion on MP-MRI and a negative targeted TRUS biopsy histopathological result. KEYPOINTS: • Multi-parametric MRI plays a critical role in prostate cancer active surveillance. • Low T2W signal intensity structures appear dark on ADC, potentially simulating cancer. • Stromal BPH mimics cancer at DWI and DCE. • Long b value trace EPI should be reviewed • Targeted biopsy of MR-detected lesions using TRUS guidance may be challenging.

Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis.

The purpose of this study was twofold: (1) to determine the incidence of positive computed tomography (CT) findings in patients presenting to the emergency department (ED) with non-traumatic headache at our institution and (2) to examine follow-up exams, including lumbar puncture, non-enhanced CT, CT angiogram, CT venogram, and magnetic resonance imaging (MRI), to see how often the use of further testing changes the diagnosis. With IRB approval, 865 patients were identified through ED requisitions for CT head with the indication of headache during the calendar year 2011. Exclusion criteria included head trauma, prior intracranial surgery, focal neurologic symptoms, and known intracranial mass. CT results were divided into three categories: P0, P1, and P2. Negative studies were graded as P0. Positive studies were subdivided into clinically insignificant or P1 and clinically significant or P2. Clinically significant was defined as requiring medical treatment. Subsequently, the electronic medical records and picture archiving and communication system (PACS) were reviewed to determine the incidence of follow-up exams, including lumbar puncture or imaging. The secondary tests were divided into the same P0, P1, and P2 categories. There were 254 positive studies: P1 clinically insignificant (27.1 %, 235/865) and P2 clinically significant (2.2 %, 19/865). Of 257 follow-up exams performed, the majority were lumbar punctures (36.0 %) or CT angiograms (29.5 %). In 19/257 exams or 7.4 %, the additional testing changed the clinically insignificant (P0/P1) diagnosis to a significant (P2) result. At our institution, there was a 2.2 % incidence of significant positive CT findings in patients presenting to the ED with non-traumatic headache. Follow-up testing was variable and resulted in a 7.4 % increase in the severity of diagnosis compared to the initial negative CT scan.

Magnetic resonance enterography in post-operative inflammatory bowel disease.

OBJECTIVE: To describe the role of magnetic resonance enterography (MRE) in patients with inflammatory bowel disease (IBD), and to review the expected post-operative appearance, as well as, potential surgical complications in this unique patient population. CONCLUSION: MRE compares favorably to CT Enterography (CTE) in terms of overall diagnostic accuracy and may provide better functional assessment of the small bowel through cine-MRI, diffusion-weighted imaging and dynamic contrast-enhancement. In the post-operative population, MRE provides critical information including: normal post-surgical anatomy, chronic strictures vs. active inflammation and disease/treatment-related complications. The post-operative IBD patient undergoes frequent repeated imaging and MRE may significantly reduce cumulative radiation dose while providing similar or improved diagnostic accuracy compared to CTE. MRE should be considered as an alternative imaging modality in this population.

Case study: chronic recurrent multifocal osteomyelitis in the femoral diaphysis of a young female.

Chronic recurrent multifocal osteomyelitis (CRMO) is relatively uncommon. Even though the name suggests it is the result of infection, this is not likely the case. Instead it is more likely the result of genetic, autoimmune, or autoinflammatory causes. Although CRMO has a benign course and responds well to anti-inflammatory medications, it can have a very aggressive clinical and imaging presentation overlapping with infectious osteomyelitis and malignancy. Therefore, radiologists and clinicians need to be aware of its clinical and imaging presentation to avoid morbidity associated with more aggressive treatment. We present the case of a ten-year-old female with CRMO as a solitary expansile-mixed lytic and sclerotic lesion in the distal femoral diaphysis. The diaphyseal location and mixed lytic and sclerotic appearance are less common and have an aggressive imaging appearance. We also review the pathophysiology, imaging findings, and therapeutic approach to this uncommon but clinically important condition.