Incidental findings in imaging diagnostic tests: a systematic review

Incidental findings are frequent in shoulder CT and MRI scans and increase with age

Objectives

CT and MRI scans of the shoulder can lead to the identification of incidental findings (IF), which can have a major impact on the further treatment of the patient. The aim of this retrospective study was to record the prevalence of IF, incidentalomas (IT) and malignant IT for CT and MRI examinations of the shoulder and to investigate the effect of patient characteristics on the statistical occurrence of IF, IT and malignant IT.

Materials and methods

A total of 903 shoulder examinations (415 CT, 488 MRI) were retrospectively analyzed for the presence of IF, subsequently categorized (harmless IF, IT requiring clarification, malignant IT) and analyzed regarding patient characteristics. The statistical analysis was carried out using independent t- and chi-square tests. A significance level of p < 0.05 was set.

Results

Among the 903 patients evaluated (436 female, 467 male), 153 (16.9%) patients experienced IF (harmless IF: 101 (11.2%) patients, IT: 94 (10.4%), malignant IT: 4 (0.4%). The average age of the patients without IF and IT was significantly lower compared to the patients with IF and IT (p < 0.001). While IF occurred in 31.1% of the CT, IF was only detected in 4.9% of the MRI (p < 0.001).

Conclusion

IF have a high prevalence (16.9%), especially in CT examinations of the shoulder, which increases with age. The exact detection and initiation of appropriate therapy is of great clinical importance, as early detection of life-threatening diseases enables more effective treatment and a potential gain in health and lifespan.

Sustainability in healthcare by reducing low-value imaging - A narrative review

OBJECTIVES

This narrative review aims to present the concept of value in imaging and explore why we conduct low-value procedures, how to reduce this wasteful use, and what we could gain from reducing low-value imaging.

KEY FINDINGS

Imaging of low value to the patient contributes to thousands of metric tons of CO2 emissions, costing several billion US dollars annually. With a 20% reduction in low-value imaging, we would reduce the waste of resources related to 7.2 million procedures and, at the same time, reduce the risk of incidentalomas, overdiagnosis, and overtreatment and reduce wait times for patients in need of imaging services of high value. Multi-component initiatives targeting barriers in all levels of society and healthcare are needed to reduce low-value imaging. Radiographers are key actors in medical imaging and can make substantial contributions to this effort by, together with the radiologists, referrers, and managers, ensuring that all imaging procedures conducted are sustainable along four dimensions of sustainability: value, cost, risk, and environment.

CONCLUSION

Efforts to secure sustainable imaging considering the four crucial dimensions (value, cost, radiation, and environment) should be made at all levels of society and healthcare, from governmental management to the individual healthcare worker. Radiographers are vital in obtaining sustainability to ensure only sustainable imaging procedures are conducted.

IMPLICATIONS FOR PRACTICE

When assessing the appropriateness of imaging procedures, we need to consider the environment, safety, effectiveness, and efficiency. To obtain this, we need a collective and coordinated effort locally, nationally, and internationally to deliver sustainable imaging services.

Audit and feedback to change diagnostic image ordering practices: A systematic review and meta-analysis

BACKGROUND

Up to 30% of diagnostic imaging (DI) tests may be unnecessary, leading to increased healthcare costs and the possibility of patient harm. The primary objective of this systematic review was to assess the effect of audit and feedback (AF) interventions directed at healthcare providers on reducing image ordering. The secondary objective was to examine the effect of AF on the appropriateness of DI ordering.

METHODS

Studies were identified using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registry on December 22nd, 2022. Studies were included if they were randomized control trials (RCTs), targeted healthcare professionals, and studied AF as the sole intervention or as the core component of a multi-faceted intervention. Risk of bias for each study was evaluated using the Cochrane risk of bias tool. Meta-analyses were completed using RevMan software and results were displayed in forest plots.

RESULTS

Eleven RCTs enrolling 4311 clinicians or practices were included. AF interventions resulted in 1.5 fewer image test orders per 1000 patients seen than control interventions (95% confidence interval (CI) for the difference -2.6 to -0.4, p-value = 0.009). The effect of AF on appropriateness was not statistically significant, with a 3.2% (95% CI -1.5 to 7.7%, p-value = 0.18) greater likelihood of test orders being considered appropriate with AF vs control interventions. The strength of evidence was rated as moderate for the primary objective but was very low for the appropriateness outcome because of risk of bias, inconsistency in findings, indirectness, and imprecision.

CONCLUSION

AF interventions are associated with a modest reduction in total DI ordering with moderate certainty, suggesting some benefit of AF. Individual studies document effects of AF on image order appropriateness ranging from a non-significant trend toward worsening to a highly significant improvement, but the weighted average effect size from the meta-analysis is not statistically significant with very low certainty.

Off the wall: incidental paraspinal and pelvic muscle pathology on abdominopelvic imaging

As the use of cross-sectional abdominal and pelvic imaging has increased exponentially in the past several decades, incidental musculoskeletal findings have become commonplace. These are often unrelated to the indication for the examination and are frequently referred to as the "radiologist's blind spot" on these studies. The differential diagnosis for abnormalities of the paraspinal and pelvic musculature is, in many cases, quite different from the anterior abdominal wall muscles. Furthermore, due to their relatively deep location, pathology involving the former muscle groups is more likely to be clinically occult, often presenting only incidentally when the patient undergoes cross-sectional imaging. Effective treatment of diseases of these muscles is dependent on adherence to a diverse set of diagnostic and treatment algorithms. The purpose of this review article is to familiarize the radiologist with the unique pathology of these often-overlooked muscles of the abdomen and pelvis.

Evaluation of GPT-4 ability to identify and generate patient instructions for actionable incidental radiology findings

OBJECTIVES

To evaluate the proficiency of a HIPAA-compliant version of GPT-4 in identifying actionable, incidental findings from unstructured radiology reports of Emergency Department patients. To assess appropriateness of artificial intelligence (AI)-generated, patient-facing summaries of these findings.

MATERIALS AND METHODS

Radiology reports extracted from the electronic health record of a large academic medical center were manually reviewed to identify non-emergent, incidental findings with high likelihood of requiring follow-up, further sub-stratified as "definitely actionable" (DA) or "possibly actionable-clinical correlation" (PA-CC). Instruction prompts to GPT-4 were developed and iteratively optimized using a validation set of 50 reports. The optimized prompt was then applied to a test set of 430 unseen reports. GPT-4 performance was primarily graded on accuracy identifying either DA or PA-CC findings, then secondarily for DA findings alone. Outputs were reviewed for hallucinations. AI-generated patient-facing summaries were assessed for appropriateness via Likert scale.

RESULTS

For the primary outcome (DA or PA-CC), GPT-4 achieved 99.3% recall, 73.6% precision, and 84.5% F-1. For the secondary outcome (DA only), GPT-4 demonstrated 95.2% recall, 77.3% precision, and 85.3% F-1. No findings were "hallucinated" outright. However, 2.8% of cases included generated text about recommendations that were inferred without specific reference. The majority of True Positive AI-generated summaries required no or minor revision.

CONCLUSION

GPT-4 demonstrates proficiency in detecting actionable, incidental findings after refined instruction prompting. AI-generated patient instructions were most often appropriate, but rarely included inferred recommendations. While this technology shows promise to augment diagnostics, active clinician oversight via "human-in-the-loop" workflows remains critical for clinical implementation.

Lung cancer statistics, 2023

Despite decades of declining mortality rates, lung cancer remains the leading cause of cancer death in the United States. This article examines lung cancer incidence, stage at diagnosis, survival, and mortality using population-based data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries. Over the past 5 years, declines in lung cancer mortality became considerably greater than declines in incidence among men (5.0% vs. 2.6% annually) and women (4.3% vs. 1.1% annually), reflecting absolute gains in 2-year relative survival of 1.4% annually. Improved outcomes likely reflect advances in treatment, increased access to care through the Patient Protection and Affordable Care Act, and earlier stage diagnosis; for example, compared with a 4.6% annual decrease for distant-stage disease incidence during 2013-2019, the rate for localized-stage disease rose by 3.6% annually. Localized disease incidence increased more steeply in states with the highest lung cancer screening prevalence (by 3%-5% annually) than in those with the lowest (by 1%-2% annually). Despite progress, disparities remain. For example, Native Americans have the highest incidence and the slowest decline (less than 1% annually among men and stagnant rates among women) of any group. In addition, mortality rates in Mississippi and Kentucky are two to three times higher than in most western states, largely because of elevated historic smoking prevalence that remains. Racial and geographic inequalities highlight longstanding opportunities for more concerted tobacco-control efforts targeted at high-risk populations, including improved access to smoking-cessation treatments and lung cancer screening, as well as state-of-the-art treatment.

The influence of the initial clinical presentation of upper tract urothelial carcinoma on histopathological tumor features

PURPOSE

To investigate the influence of the initial clinical presentation (symptomatic vs. asymptomatic) on histopathological tumor features in patients with upper tract urothelial carcinoma (UTUC).

METHODS

We conducted a single-center, cross-sectional, and retrospective study that enrolled 72 adults with primary UTUC who underwent radical nephroureterectomy at our institution over a period of 4 years (April 2019-April 2023).

RESULTS

Symptomatic patients exhibited significantly higher frequencies of high-grade UTUC (73.6% vs. 36.8%, p = 0.006), ≥ T2 stage UTUC (60.4% vs. 26.3%, p = 0.007), and larger tumor sizes (median 5 vs. 4 cm, p = 0.015) compared to asymptomatic patients. Multiple regression analyses demonstrated significant associations between symptomatic presentation and the presence of high-grade UTUC (OR 6.35, 95% CI 1.81-22.27, p = 0.004), ≥ T2 stage UTUC (OR 5.98, 95% CI 1.62-22.08, p = 0.007), and larger tumor size (B 3.14, 95% CI 0.62-5.66, p = 0.015). A subset of patients with hematuria was separately analyzed to assess the influence of hematuria severity (gross vs. microscopic) on UTUC characteristics. Patients with gross hematuria exhibited significantly higher frequencies of high-grade UTUC (72.9% vs. 33.3%, p = 0.048) and ≥ T2 stage UTUC (58.3% vs. 22.2%, p = 0.001). Multiple regression analyses showed significant associations between gross hematuria and the presence of high-grade UTUC (OR 6.34, 95% CI 1.15-34.95, p = 0.034) and ≥ T2 stage UTUC (OR 6.54, 95% CI 1.11-38.93, p = 0.039).

CONCLUSION

Initial symptomatic presentation was independently associated with adverse histopathological UTUC characteristics, potentially attributed to earlier detection of UTUC in asymptomatic patients, before the onset of symptoms.

Impact of disclosure of radiographic test results on quality of life among patients with hernias: a randomized controlled trial

PURPOSE

Hernias noted on radiographic imaging are common. We aimed to determine if informing patients of the presence of a clinically apparent or occult hernia on imaging would change their abdominal wall quality of life (AW-QOL).

METHODS

This study was registered on clinicaltrials.gov (NCT04355819) in April 2020. Patients with a ventral hernia on elective CT abdomen/pelvis were enrolled. Patients underwent standardized abdominal examination by surgeons, and completed the modified Activities Assessment Scale, a validated, hernia-specific AW-QOL survey. On this scale, 1 is poor AW-QOL, 100 is perfect, and the minimally clinically important difference is five for a minor change. Patients were randomized to complete the one-year follow-up survey before or after being informed of the presence of a hernia on their imaging results. Primary outcome was follow-up AW-QOL adjusted for baseline AW-QOL.

RESULTS

Of 169 patients randomized, 126 (75%) completed follow up at one-year. Among patients with occult hernias, those who completed the follow-up survey after being informed of having a hernia had a lower follow-up AW-QOL (mean difference - 7.6, 95% CI =  - 20.8 to 5.7, p = 0.261) compared to those who completed the survey before being informed. Conversely, for patients with clinical hernias, those who completed the survey after being informed had higher adjusted follow-up AW-QOL (mean difference 10.3, 95% CI =  - 3.0 to 23.6, p = 0.126) than those that completed it after.

CONCLUSION

Conveying findings of hernias found on CT imaging can influence patients' AW-QOL. Future research should focus on identifying and addressing patients' concerns after disclosure of CT results.

Impact of Early Direct Patient Notification on Follow-Up Completion for Nonurgent Actionable Incidental Radiologic Findings

PURPOSE

The aim of this study was to evaluate whether early direct patient notification in addition to an existing multistage recommendation-tracking system (Backstop) increases follow-up completion rates for actionable incidental findings (AIFs). Patient attitudes toward early notification were also assessed.

METHODS

This prospective, randomized controlled trial recruited patients with AIFs requiring follow-up being enrolled into the Backstop system. Patients were randomized into four groups: those receiving additional early direct notification in a mailed letter (group 1, similar to Pennsylvania Act 112), by phone (group 2), or in an electronic portal message (group 3) and a control group (group 4) without additional notifications added to the existing Backstop system. Differences in follow-up completion rates among these groups were determined using χ2 tests. Patients were surveyed on binary yes/no and Likert-type scale questions, and descriptive statistics are reported.

RESULTS

Data from 2,548 randomized patients were analyzed for the study, including 593 patients notified by letter, 637 notified by phone, 701 notified by portal, and 617 control patients. Group 3 demonstrated the lowest rate of follow-up completion within 1 month of the follow-up due date at 36.4%, compared with 58.7% for group 1, 60.4% for group 2, and 53.2% for group 4 (P < .0001 for all). Group 2 was the only group to have a significantly higher completion rate than group 4 (P = .014). Patients responded positively regarding early notification and preferred electronic portal communication.

CONCLUSIONS

Early direct notification had a mixed impact on follow-up completion rates on the basis of communication modality but was positively received by patients and may have health care benefits when implemented within a recommendation-tracking system.

Errors in visual search: Are they stochastic or deterministic?

In any visual search task in the lab or in the world, observers will make errors. Those errors can be categorized as "deterministic": If you miss this target in this display once, you will definitely miss it again. Alternatively, errors can be "stochastic", occurring randomly with some probability from trial to trial. Researchers and practitioners have sought to reduce errors in visual search, but different types of errors might require different techniques for mitigation. To empirically categorize errors in a simple search task, our observers searched for the letter "T" among "L" distractors, with each display presented twice. When the letters were clearly visible (white letters on a gray background), the errors were almost completely stochastic (Exp 1). An error made on the first appearance of a display did not predict that an error would be made on the second appearance. When the visibility of the letters was manipulated (letters of different gray levels on a noisy background), the errors became a mix of stochastic and deterministic. Unsurprisingly, lower contrast targets produced more deterministic errors. (Exp 2). Using the stimuli of Exp 2, we tested whether errors could be reduced using cues that guided attention around the display but knew nothing about the content of that display (Exp3a, b). This had no effect, but cueing all item locations did succeed in reducing deterministic errors (Exp3c).

Communication of Incidental Imaging Findings on Inpatient Discharge Summaries After Implementation of Electronic Health Record Notification System

OBJECTIVES

Inadequate follow-up of incidental imaging findings (IIFs) can result in poor patient outcomes, patient dissatisfaction, and provider malpractice. At our institution, radiologists flag IIFs during report dictation to trigger electronic health record (EHR) notifications to providers and patients. Nurse coordinators directly contact patients or their primary care physicians (PCPs) regarding IIFs if follow-up is not completed within the recommended time frame. Despite these interventions, many patients and their PCPs remain unaware of IIFs. In an effort to improve awareness of IIFs, we aim to investigate communication of IIFs on inpatient discharge summaries after implementation of our EHR notification system.

METHODS

Inpatient records with IIFs from 2018 to 2021 were retrospectively reviewed to determine type of IIFs, follow-up recommendations, and mention of IIFs on discharge summaries. Nurse coordinators spoke to patients and providers to determine their awareness of IIFs.

RESULTS

Incidental imaging findings were reported in 51% of discharge summaries (711/1383). When nurse coordinators called patients and PCPs regarding IIFs at the time follow-up was due, the patients and PCPs were aware of 79% of IIFs (1096/1383).

CONCLUSIONS

With implementation of EHR notifications to providers regarding IIFs, IIFs were included in 51% of discharge summaries. Lack of inclusion of IIFs on discharge summaries could be related to transitions of care within hospitalization, provider alert fatigue, and many diagnostic testing results to distill. These findings demonstrate the need to improve communication of IIFs, possibly via automating mention of IIFs on discharge summaries, and the need for care coordinators to follow up on IIFs.

Enhancing Radiology Education With a Case-Based Intro to Radiology on the UF WIDI e-Learning Platform

RATIONALE AND OBJECTIVES

This study explores the implementation and efficacy of an online, interactive, case-based radiology education tool, Wisdom in Diagnostic Imaging (WIDI) Case-Based Intro to Radiology (CBIR). We hypothesize that the WIDI CBIR platform would enhance radiology teaching, foster critical thinking, and provide a comprehensive curriculum in imaging interpretation and utilization.

MATERIALS AND METHODS

A focus group consisting of 1 undergraduate, 7 medical students, 9 physician assistant students, and 3 PhD students participated in this study. We tested 3 different teaching methods: a didactic approach without WIDI, a proctored didactic approach using WIDI, and a flipped classroom approach using WIDI. An online survey was conducted to assess student preference and feedback on these methods and the use of WIDI in their curriculum.

RESULTS

Most students preferred the proctored didactic approach with WIDI. They reported that the platform complemented their curriculum and encouraged critical thinking. The modules covered adequate clinical and imaging details and enhanced their skills in imaging interpretation. Despite the limitations of a small sample size and reliance on self-reported outcomes, this study indicates that the WIDI platform could be integrated into PA and medical school curricula throughout the US, offering a standardized radiology curriculum.

CONCLUSION

The UF WIDI appears to be a promising tool for modernizing radiology education, improving imaging interpretation skills, and enhancing appropriate imaging selection among nonradiologist medical learners. WIDI offers case-based education in imaging use, workflow, search-pattern selection, and interpretation of common radiological findings, potentially bridging the gap in radiology education. Further research and larger studies are required to assess the long-term impact on performance and clinical practice.

Frequency and Clinical Significance of Incidental Findings on CBCT Imaging: a Retrospective Analysis of Full-Volume Scans

Objectives

This retrospective study aims to identify incidental findings in cone-beam computed tomography scans of patients irradiated for preoperative evaluation for implant placement and obtained using the same imaging unit as well as the same field of view. The incidence of each incidental finding, as well as the overall incidence, were calculated and the findings were ranked according to their clinical significance.

Material and Methods

A total of 741 cone-beam computed tomography (CBCT) examinations with extended field of view (15 x 15 cm) were retrospectively evaluated for incidental findings (IFs). These were identified, recorded, classified as to their location, and ranked according to their clinical significance.

Results

The vast majority of CBCT examinations presented at least one IF, resulting in a surprisingly high prevalence in total. If extreme anatomical variants are considered (nasal septum deviation, sinus septations etc.), the cumulative prevalence exceeds 99%. IFs of major significance, that may require immediate attention, are beyond 10% in frequency.

Conclusions

We found high prevalence of incidental findings on cone-beam computed tomography examinations performed for preoperative evaluation for implant placement (99.5% if anatomical variants included). Most incidental findings were of minor significance. Although the number of incidental findings that require immediate attention is relatively low, there is a considerable number of cases that need periodic evaluation and/or referral.

Quantification and significance of extraprostatic findings on prostate MRI: a retrospective analysis and three-tier classification

OBJECTIVES

To quantify extraprostatic findings (EPFs) on prostate MRI, estimate the proportion of reported and unreported EPFs, assess their clinical importance, and propose standardized reporting of EPFs.

MATERIALS AND METHODS

Prostate 3-T MRI studies, reports, and clinical data from 623 patients (age 67.9 ± 8.2 years) were retrospectively analyzed and re-evaluated for the presence of EPFs and their clinical significance: E1-no finding or findings that have no clinical significance; E2-potentially significant findings; and E3-significant findings.

RESULTS

Secondary reading identified 1236 EPFs in 593 patients (1.98 ± 1.13 EPFs per patient, no EPFs in 30 patients), from which 468 (37.8%) were mentioned in the original report. The most common findings included diverticulosis (44% of patients), hydrocele (34%), inguinal fat hernia (16%), and bladder wall trabecular hypertrophy (15%). There were 80 (6.5%) E2 EPFs and 30 (2.4%) E3 EPFs. From E3 EPFs, 10 (33%) were not originally reported. A workup was suggested in 35 (52%) of the 67 originally reported E2 and E3 findings with follow-up and performed in 20 (30%). Fourteen (21%) EPFs in 11 patients influenced their management. Four experienced radiologists originally reported 1.8 to 2.5 findings per patient (p < 0.0001).

CONCLUSIONS

EPFs on prostate MRI are frequent, but only 2.4% are clinically significant (E3), and 33% of these are not reported. Only 30% of E2 and E3 findings are further explored, and 21% influence patient management. We suggest that an "E" category should be attached to the PI-RADS system to identify the presence of EPFs that require further workup.

CRITICAL RELEVANCE STATEMENT

Extraprostatic findings on prostate MRI are frequent, but only 2.4% are clinically significant (E3), and 33% of these are not reported. We advocate standardized reporting of extraprostatic findings indicating their clinical significance.

KEY POINTS

• Extraprostatic findings on prostate MRI are frequent with an average of two findings per patient. • 2.4% of extraprostatic findings are significant, and 33% of these are not reported. • There is a significant variability among experienced radiologists in reporting extraprostatic findings.

[Geriatric ultrasound : Prospective evaluation of ultrasound as extended screening in acute geriatric patients]

BACKGROUND

The aim of this study was to evaluate ultrasound as a routinely used procedure and extended physical examination in geriatric patients in acute care.

METHODS

Prospective study of 86 patients using ultrasound as a screening examination (abdomen, basal sections of the thorax, thyroid glands) under comparative use of a hand-held ultrasound device (HHUSD) and a high-end ultrasound (HEUS = gold standard).

RESULTS

In 20/86 (23.2%) clinically relevant findings with therapeutic consequences were found (pleural effusion, urinary retention, choledocholithiasis metatases, colon tumor). In 22/86 (25.6%) patients, additional questions existed besides the screening indication: tumor search (9.3%), anemia (5.8%), liver value elevation (5.8%), dyspnea (5.8%), splenic pathologies (2.3%), weight loss (1.2%), infectious focus (1.2%), diarrhea (1.2%), intra-abdominal hematoma (1.1%), abdominal aortic aneurysm (1.2%). The most common sonographic findings included: cholecystolithiasis (32.6%); right pleural effusion (31.4%), thyroid nodules (30.2%), renal cysts (27.9%), and fatty liver (26.7%). There were significant differences in sizing between HHUSD and HEUS (kidneys, pancreatic corpus and pancreatic caudal diameters, portal vein, left hepatic vein) without diagnostic relevance.

CONCLUSION

The extended screening by ultrasound provided important answers to classical questions in geriatrics (e.g. urinary retention, volume deficiency/pleural effusion) in many cases. The new findings had therapeutic consequences in one fifth of the patients. The HHUSD can be used in screening.

Can we revolutionize diagnostic imaging by keeping Pandora's box closed?

Incidental imaging findings are a considerable health problem, because they generally result in low-value and potentially harmful care. Healthcare professionals struggle how to deal with them, because once detected they can usually not be ignored. In this opinion article, we first reflect on current practice, and then propose and discuss a new potential strategy to pre-emptively tackle incidental findings. The core principle of this concept is to keep the proverbial Pandora's box closed, i.e. to not visualize incidental findings, which can be achieved using deep learning algorithms. This concept may have profound implications for diagnostic imaging.

[Patient-centered, value-based management of incidental findings in radiology]

As a byproduct of the increased use of high-resolution radiological imaging, the prevalence of incidental findings (IFs) has been increasing for years. The discovery of an incidental finding can allow early treatment of a potentially health-threatening disease and thus decisively change the course of the disease. However, many incidental findings are of low risk with little or no health impact, and yet their discovery often leads to a cascade of additional investigations. It is undisputed that incidental findings can have a direct impact on the life of the person and that not only psychosocial aspects such as worries and anxiety due to false-positive findings play a role, but that insurance, legal or professional problems can also occur under certain circumstances, which is why the correct handling of incidental findings and the accompanying ethical challenges that apply to them regularly give rise to discussions. General principles to consider when managing incidental findings are responsibility for the well-being of the patient/study participant and of society. In order to avoid overdiagnosis and overtreatment and to achieve high patient benefit, radiologists and clinicians must know how to properly deal with IFs. In recent years, various national and international societies have published important guidelines ("white papers") on how to deal with the management of IFs. It is important that radiologists are fully aware of and follow these guidelines and are also available to referring physicians for further discussions and advice. The most important fact is that the well-being of the patient must always be at the center of all decisions.

Early Definitive Diagnosis and Management of Incidental Neuroendocrine Tumors Found on Gastrointestinal Endoscopy

Neuroendocrine tumors (NETs) are tumors that originate from neuroendocrine cells and can be found throughout the body but are most commonly seen in the gastrointestinal tract, pancreas, and lungs. There is an increase in the diagnosis of NETs due to advances in diagnostic modalities. Although mucosal tumors are easily visualized on upper GI endoscopic imaging, neuroendocrine tumors are often missed due to their deep mucosal origin with normal overlying mucosa. We first present the case of a 46-year-old woman with anemia and epigastric discomfort who was found to have an incidental submucosal mass in the duodenal bulb on esophagogastroduodenoscopy (EGD), which on endoscopic ultrasound (EUS) with a fine needle biopsy (FNB) showed a neuroendocrine tumor. Imaging with CT, however, failed to detect the presence of the mass in the duodenum. Furthermore, a DOTATATE scan showed only a nonspecific signal near the liver. The patient then underwent an EGD-guided, laparoscopic, robot-assisted transduodenal resection of the tumor, together with the removal of enlarged peritumoral lymph nodes. Pathology showed a well-differentiated neuroendocrine tumor of the duodenal bulb with metastasis to one lymph node, which was confirmed via immunohistochemistry staining. The second case is of a 51-year-old female who presented with occasional constipation and rectal pain and was found to have a rectal polypoid lesion on her colonoscopy, jumbo biopsies of which revealed a NET. An EUS done for staging and endoscopic mucosal resection (EMR) revealed a grade 1 well-differentiated NET on pathology, which was confirmed by immunohistochemistry staining. These cases stress the need for timely, definitive diagnosis and intervention. Here, we discuss the clinical features and investigations of neuroendocrine tumors for early diagnosis and management.

Addressing Challenges of Opportunistic Computed Tomography Bone Mineral Density Analysis

Computed tomography (CT) offers advanced biomedical imaging of the body and is broadly utilized for clinical diagnosis. Traditionally, clinical CT scans have not been used for volumetric bone mineral density (vBMD) assessment; however, computational advances can now leverage clinically obtained CT data for the secondary analysis of bone, known as opportunistic CT analysis. Initial applications focused on using clinically acquired CT scans for secondary osteoporosis screening, but opportunistic CT analysis can also be applied to answer research questions related to vBMD changes in response to various disease states. There are several considerations for opportunistic CT analysis, including scan acquisition, contrast enhancement, the internal calibration technique, and bone segmentation, but there remains no consensus on applying these methods. These factors may influence vBMD measures and therefore the robustness of the opportunistic CT analysis. Further research and standardization efforts are needed to establish a consensus and optimize the application of opportunistic CT analysis for accurate and reliable assessment of vBMD in clinical and research settings. This review summarizes the current state of opportunistic CT analysis, highlighting its potential and addressing the associated challenges.

How [18F]-FDG-PET/CT Affects Clinical Management of Patients with Germ Cell Tumors in the Real World

OBJECTIVE

The aim of this study was to evaluate the impact of PET/CT on clinical management of patients with germ cell tumors (GCTs) conducted in a real-world setting, including avoidance of invasive procedures, additional diagnostic imaging, and changes in treatment.

METHODS

Patients with GCTs were prospectively enrolled into a PET/CT registry study between May 2013 and April 2021. Intended patient management prior and after PET/CT was documented using standardized questionnaires. Changes in oncologic staging and clinical management after PET/CT were recorded, including planned treatment and planned additional diagnostics.

RESULTS

Forty-three male patients with GCTs were included consecutively in this study. After PET/CT, oncologic staging changed in 22/43 patients (51%), with upstaging in seven cases (16%), downstaging in ten cases (23%), and cancer relapse in five cases (11%). The number of patients with intended curative treatment remained stable, while a considerable change in intended therapeutic intervention was noted after PET/CT, with an increase in planned chemotherapy from three to eleven patients and a decrease in planned surgical resection from eleven to two patients. In addition, PET/CT contributed to preventing patients from intended invasive procedures including biopsy and surgery in 8/43 (19%) cases and from additional diagnostic procedures in 25 (58%) cases.

CONCLUSION

With the use of FDG-PET/CT as a tool to guide patient management in GCTs, we observed a notable impact on clinical staging and a consequent reduction in the need for additional invasive and diagnostic procedures. These findings are expected to be even more consequential in the future as treatment modalities improve and the life expectancy of GCT patients further increases.

KEY POINTS

PET/CT considerably influences the clinical stage of GCT patients. PET/CT has remarkable influence on the choice of therapeutic interventions and reduces additional diagnostic procedures.

Fatty Degeneration of the Autochthonous Muscles Is Significantly Associated with Incidental Non-Traumatic Vertebral Body Fractures of the Lower Thoracic Spine in Elderly Patients

PURPOSE

We investigated loco-regional degenerative changes' association with incidentally found non-traumatic vertebral body fractures of the lower thoracic and lumbar spine in older patients. Methods: The patient collective included patients in the age range of 50 to 90 years. Vertebral bodies from T7 to L5 were included. Vertebral body fractures were classified according to Genant. The following loco-regional osseous and extra-osseous degenerative changes were included: osteochondrosis, spondylarthritis, facet joint asymmetries, spondylolisthesis, scoliosis as well as fatty degeneration and asymmetry of the autochthonous back muscles. Patients with traumatic and tumor-related vertebral body fractures were excluded. Non-traumatic fractures of the lower thoracic and lumbar spine were evaluated separately. The Mann-Whitney U-test was used, and relative risks (RRs) were calculated for statistics. Pearson's correlations (Rs) were used to correlate grades of degenerative changes and fracture severities. Results: 105 patients were included. Fatty deposits in the autochthonous muscles of the lower thoracic and the lumbar spine were associated with non-traumatic vertebral body fractures in the lower thoracic spine (p = 0.005, RR = 4.92). In contrast, muscle fatness of the autochthonous muscles was not a risk factor for lumbar spine fractures (p = 0.157, RR = 2.04). Additionally, we found a moderate correlation between fatty degeneration of the autochthonous muscles and the severity of fractures in the lower thoracic spine (RR = 0.34, p < 0.001). The other degenerative changes did not present any significant difference or correlation between the evaluated groups. Conclusions: Fatty degeneration of the autochthonous spinal musculature is associated with incidentally found non-traumatic fractures of the lower thoracic spine.

Prevalence and Clinical Implications of Incidental Aortic Arch Abnormalities on Contrast-Enhanced Neck MR Angiography: A Single-Center Experience

Background and Objectives: Vascular abnormalities within the anatomical coverage are frequently encountered in imaging studies. The aortic arch is often overlooked as an anatomical blind spot, especially in neck magnetic resonance (MR) angiography. This study investigated the prevalence of incidental aortic arch abnormalities. We also estimated the potential clinical significance of aortic arch abnormalities as blind spots detected on contrast-enhanced neck MR angiography. Materials and Methods: Between February 2016 and March 2023, 348 patients were identified based on contrast-enhanced neck MR angiography reports. The clinical and radiological characteristics of the patients and the presence of additional imaging studies were assessed. The aortic arch abnormalities and coexisting non-aortic arterial abnormalities were classified into two categories according to their clinical significance. We performed the χ² test and Fisher's exact test for group comparisons. Results: Of the 348 study patients, only 29 (8.3%) had clinically significant incidental aortic arch abnormalities. Among these 348 patients, 250 (71.8%) and 136 (39%) had intracranial and extracranial abnormalities, respectively; the clinically significant intracranial abnormalities in the two groups were 130 lesions (52.0%) and 38 lesions (27.9%), respectively. In addition, there was a significantly higher tendency of clinically significant aortic arch abnormalities (13/29, 44.8%) in the patients who had clinically significant coexisting non-aortic arterial abnormalities than in the other group (87/319, 27.3%) (p = 0.044). The patient groups with clinically significant intracranial or extracranial arterial abnormalities had higher rates of clinically significant aortic abnormalities (31.0% and 17.2%), but there was no statistical significance (p = 0.136). Conclusions: The incidence of clinically significant aortic arch abnormalities was 8.3% on neck MR angiography, with a significant association between aortic and coexisting non-aortic arterial abnormalities. The findings of this study could improve the understanding of incidental aortic arch lesions on neck MR angiography, which is of crucial clinical importance for radiologists to achieve accurate diagnoses and management.

Incidental diagnosis of bladder cancer in a national observational study in spain

INTRODUCTION

Bladder cancer (BC) is a common malignancy in Spain. The aims of this study were: to identify the proportion of patients diagnosed with BC incidentally or after symptomatic presentation in a contemporary period in Spain; to compare demographic, clinical, and pathologic characteristics between these groups.

METHODS

This was a retrospective analysis of a multi-centre observational study of 26 hospitals in the Spanish National Health System of all BCs newly diagnosed in 2011. The study represented 21.5% of the Spanish population and hospitals were selected in proportion to Spain's regions to ensure a representative sample. Patients were categorized by whether the cancer was diagnosed incidentally or after symptomatic presentation and baseline demographic, pathologic, and clinical characteristics were analyzed.

RESULTS

2472 were newly diagnosed with BC at the 26 participating Spanish hospitals with 308 (12.5%) of cases diagnosed incidentally and 2164 (87.5%) diagnosed after symptomatic presentation. No differences were observed between patients diagnosed incidentally vs. symptomatically in terms of demographics or measured co-morbidities. Compared to symptomatically diagnosed bladder tumours, those diagnosed incidentally were more likely to have a papillary appearance, to be significantly smaller, and less likely to have positive/suspicious cytology. Additionally, incidentally diagnosed bladder tumours were less likely to be muscle-invasive (11.7% vs. 25.0%, p < 0.01) nor aggressive at pathology, with 33.6% Grade 3 compared to 50.1%, (p < 0.01).

CONCLUSIONS

We identified a significant percentage (12.5%) of new bladder cancer diagnosis made incidentally in a representative sample of the Spanish population. These tumours exhibited less aggressive pathologic characteristics than their symptomatic counterparts.

Implementing a Streamlined Radiology Workflow to Close the Loop on Incidental Imaging Findings in the Emergency Department

Actionable incidental findings (AIFs) are common imaging findings unrelated to the clinical indication for the imaging test for which follow-up is recommended. Increasing utilization of imaging in the emergency department (ED) in recent years has resulted in more patients with AIFs. When these findings are not properly communicated and followed up upon, there is harm to the patient's health outcome as well as possible increased financial costs for the patient, the health system, and potential litigation. Tracking these findings can be difficult, especially so in a large health system. In this report, we detail our experience implementing a closed-loop AIF program within the ED of 11 satellite hospitals of a large academic health system. Our new workflow streamlined radiologist reporting of AIFs through system macros and by using a standardized form integrated into the dictation software. Upon completion of the form, an automatic email is sent to a dedicated nurse navigator who documented the findings and closed the loop by coordinating follow-up imaging or clinic visits with patients, primary care providers, and specialists. Through the new workflow, a total of 1207 incidental finding reports have been submitted from July 2021 to May 2022. The vast majority of AIFs were identified on CT, and the most common categories included lung nodules, pancreas lesions, liver lesions, and other potentially cancerous lesions. At least 10 new cancers have been detected. We hope this report can help guide other health systems in the design of a closed-loop incidental findings program.

The FIND Program: Improving Follow-up of Incidental Imaging Findings

Incidental findings are findings identified on imaging which are unrelated to the original reason for examination and require follow-up. The Radiology Finding Incidental Disease (FIND) Program was designed to track and improve follow-up of incidental imaging findings. The purpose of this study was to determine the frequency of incidental findings on cross-sectional imaging and the adherence to suggested follow-up of incidental findings prior to and after implementation of a structured reporting and tracking system. A retrospective analysis of 2000 patients with computed tomographic cross-sectional imaging was performed: 1000 patients prior to implementation of the FIND Program and 1000 patients 1 year after establishment of the program. Data collected included the frequency of incidental findings, inclusion of follow-up recommendations in the radiology report, and adherence to suggested follow-up. There was a higher rate of completion of recommended follow-up imaging in the post-implementation group (34/67, 50.7%) compared to the pre-implementation (16/52, 30.8%) (p = 0.03). Implementation of an incidental findings tracking program resulted in improved follow-up of incidental imaging findings. This has the potential to reduce the burden of clinically significant incidental findings possibly resulting in later presentation of advanced disease.

Use of radiological information system data in Clinical Portal database to screen for missed abdominal aortic aneurysms

INTRODUCTION

New Zealand lacks a formal abdominal aortic aneurysm screening programme and owing to its rural nature, many patients have limited access to vascular surgery. Patients with vascular emergencies often have limited treatment options locally, especially if they present perimortem. In our small hospital in Whanganui, with the nearest vascular centre more than 150km away, there are cases of aneurysms diagnosed incidentally on radiology reporting but lost to follow-up.

METHODS

Clinical Portal (CP) is a widely used patient-centred dashboard for viewing health information that is managed by Orion Health. A search strategy utilising the CP common database was devised that aimed to find aneurysms which were not followed up. This search was performed retrospectively for all imaging within a 5-month period.

RESULTS

Some 294 scans were flagged and 53 patients with aneurysms were found. Of these patients, 36 had follow-up by the ordering provider and 17 (32%) were found to have been lost to follow-up.

CONCLUSIONS

Our pilot study demonstrated high rates of loss to follow-up and a lack of communication of important health information across multiple health disciplines in the region, and represents a potential method for identifying 'lost' aneurysms. For patients in rural communities, this may be critical to preventing future complications from aneurysmal disease.

White Paper: Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging

PURPOSE

Actionable incidental findings (AIFs) are common in radiologic imaging. Imaging is commonly performed in emergency department (ED) visits, and AIFs are frequently encountered, but the ED presents unique challenges for communication and follow-up of these findings. The authors formed a multidisciplinary panel to seek consensus regarding best practices in the reporting, communication, and follow-up of AIFs on ED imaging tests.

METHODS

A 15-member panel was formed, nominated by the ACR and American College of Emergency Physicians, to represent radiologists, emergency physicians, patients, and those involved in health care systems and quality. A modified Delphi process was used to identify areas of best practice and seek consensus. The panel identified four areas: (1) report elements and structure, (2) communication of findings with patients, (3) communication of findings with clinicians, and (4) follow-up and tracking systems. A survey was constructed to seek consensus and was anonymously administered in two rounds, with a priori agreement requiring at least 80% consensus. Discussion occurred after the first round, with readministration of questions where consensus was not initially achieved.

RESULTS

Consensus was reached in the four areas identified. There was particularly strong consensus that AIFs represent a system-level issue, with need for approaches that do not depend on individual clinicians or patients to ensure communication and completion of recommended follow-up.

CONCLUSIONS

This multidisciplinary collaboration represents consensus results on best practices regarding the reporting and communication of AIFs in the ED setting.

Drivers for low-value imaging: a qualitative study of stakeholders' perspectives in Norway

BACKGROUND

One kind of overutilization of diagnostic imaging is low-value imaging, i.e., imaging that does not lead to altered clinical pathways or improved health outcomes. Despite having well-documented extension and consequences, low-value imaging is still widespread. The objective of this study was to identify the drivers for the use of low-value imaging in the Norwegian healthcare services.

METHODS

We conducted individual, semi-structured interviews among representatives from the health authorities, general practitioners, specialists working in hospitals, radiologists, radiographers, and managers of imaging departments. Data analysis was carried out in line with framework analysis consisting of five steps: Familiarization, indexing, charting, mapping, and interpretation.

RESULTS

The analysis included 27 participants and resulted in two themes. The stakeholders identified drivers in the healthcare system and in the interaction between radiologists, referrers, and patients. The identified drivers were categorized in sub-themes, such as organization, communication, competence, expectations, defensive medicine, roles and responsibilities, and referral quality and time constraints. The drivers interact with each other and may strengthen the effect of other drivers.

CONCLUSIONS

Several drivers for low-value imaging in Norway were identified at all levels of the healthcare system. The drivers work simultaneously and synergistically. To free resources for high-value imaging, drivers should be targeted by appropriate measures at several levels to reduce low-value imaging.

Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession

Plain Radiography of the spine (PROTS) is utilized in many forms of healthcare including the chiropractic profession; however, the literature reflects conflicting opinions regarding utilization and value. Despite being an essential part of Evidence-Based Practice (EBP), few studies assess Doctors of Chiropractic (DCs) clinical opinions and experience regarding the utilization of (PROTS) in practice. In this study, DCs were surveyed regarding utilization of PROTS in practice. The survey was administered to an estimated 50,000 licensed DCs by email. A total of 4301 surveys were completed, of which 3641 were United States (US) DCs. The Clinician Opinion and Experience on Chiropractic Radiography (COECR) scale was designed to analyze survey responses. This valid and reliable scale demonstrated good internal consistency using confirmatory factor analysis and the Rasch model. Survey responses show that 73.3% of respondents utilize PROTS in practice and 26.7% refer patients out for PROTS. Survey responses show that, among US DCs, 91.9% indicate PROTS has value beyond identification of pathology, 86.7% indicate that PROTS is important regarding biomechanical analysis of the spine, 82.9% indicate that PROTS is vital to practice, 67.4% indicate that PROTS aids in measuring outcomes, 98.6% indicate the opinion that PROTS presents very low to no risk to patients, and 93.0% indicate that sharing clinical findings from PROTS studies with patients is beneficial to clinical outcomes. The results of the study indicated that based on clinical experience, the majority of DCs find PROTS to be vital to practice and valuable beyond the identification of red flags.

Applying Implementation Science Principles to Systematize High-Quality Care for Potentially Significant Imaging Findings

OBJECTIVE

Use principles of implementation science to improve the diagnosis and management of potentially significant imaging findings.

METHODS

Multidisciplinary stakeholders codified the diagnosis and management of potentially significant imaging findings in eight organs and created a finding tracking management system that was embedded in radiologist workflows and IT systems. Radiologists were trained to use this system. An automated finding tracking management system was created to support consistent high-quality care through care pathway visualizations, increased awareness of specific findings in the electronic medical record, templated notifications, and creation of an electronic safety net. Primary outcome was the rate of quality reviews related to eight targeted imaging findings. Secondary outcome was radiologist use of the finding tracking management tool.

RESULTS

In the 4 years after implementation, the tool was used to track findings in 7,843 patients who received 10,015 ultrasound, CT, MRI, x-ray, and nuclear medicine examinations that were interpreted by all 34 radiologists. Use of the tool lead to a decrease in related quality reviews (from 8.0% to 0.0%, P < .007). Use of the system increased from 1.7% of examinations in the early implementation phase to 3.1% (+82%, P < .00001) in the postimplementation phase. Each radiologist used the tool on an average of 294.6 unique examinations (SD 404.8). Overall, radiologists currently use the tool approximately 4,000 times per year.

DISCUSSION

Radiologists frequently used a finding tracking management system to ensure effective communication and raise awareness of the importance of recommended future follow-up studies. Use of this system was associated with a decrease in the rate of quality review requests in this domain.

Incidental Paranasal Sinus Findings on Computed Tomography Images of Pediatric Patients: A Cross-sectional Prevalence Study

Objectives

The study was conducted to assess the prevalence of incidental paranasal sinus pathologies in children on computed tomography (CT) scans.

Materials and methods

A nonrandomized retrospective study was done on CT scans of 232 pediatric patients taken in the past 6 months duration. These scans were evaluated in different age groups from 0-13 years who had visited or were admitted to the hospital for various other head and neck-related problems. Each scan was examined for incidental pathologic findings in all the paranasal sinuses. The data were analyzed using descriptive statistics and Fisher's exact test to determine non-random associations between variables.

Results

A total of 232 subjects were examined, amongst which 72 (31.03%) had incidental sinus pathologies. Multiple sinus pathologies were found in 36 subjects, 28 had single sinus involvement, and four showed no development of frontal sinus at the age of 11 years. Four subjects had pathology in multiple sinuses as well as no development of frontal sinus at the age of 6-7 years age range.

Conclusion

Sinus pathologies are not unusual in the asymptomatic children population, and the incidence is almost equivalent to that of the adult population. Early identification can aid in diagnosing orofacial pain of unknown origin and also if children are susceptible to upper respiratory tract infections and their secondary effects like sleep apnea, mouth breathers, etc.

How to cite this article

Talwade P, Deshpande PS, Pene S, et al. Incidental Paranasal Sinus Findings on Computed Tomography Images of Pediatric Patients: A Cross-sectional Prevalence Study. Int J Clin Pediatr Dent 2023;16(2):292-294.

Incidentalomas at abdominal imaging

As all radiologists are well aware, cross-sectional abdominal imaging tests such as CT, MR, and ultrasound generally include organs and structures that are not directly related to the clinical indication for obtaining the examination. As a result, unsuspected additional findings or "incidentalomas" must be handled in a responsible manner that balances any need for reporting and management against the potential harms that may result from such actions. The majority of abdominal incidentalomas detected at imaging will not cause downstream harm to the patient, unless perhaps the radiologist unleashes an unnecessary work-up cascade that results in patient anxiety, inconvenience, added costs, or complications. Applying the principle of primum non-nocere, an argument can be made for not even reporting incidental imaging findings that have an exceedingly low likelihood of clinical relevance, such as small, simple-appearing sporadic cysts that are commonly seen in many abdominal organs. The situation becomes more challenging, however, when "likely benign" yet indeterminate lesions are encountered. At some threshold, which is difficult to precisely define for all cases, further action may be indicated, be it imaging follow-up to confirm resolution or stability, more definitive imaging characterization, or even tissue sampling. For more concerning or ominous incidentalomas, the need for further work-up will be more clear cut.

Prevalence of extra-hepatic incidental findings on ultrasound screening for hepatocellular carcinoma

PURPOSE

Abdominal ultrasound is a cost-effective method for screening for hepatocellular carcinoma (HCC) in high-risk individuals. Currently, at many institutions the protocol for obtaining HCC screening ultrasounds includes a traditional examination of the right upper quadrant, including the pancreas and right kidney. There is no consensus on the role of imaging of extra-hepatic structures and there are limited data describing the frequency and clinical significance of incidental findings discovered during HCC screening. The purpose of this retrospective study is to assess the prevalence and significance of extra-hepatic incidental findings during HCC screening ultrasounds.

METHODS

A single-center retrospective review of all right upper quadrant HCC screening ultrasounds identified 432 HCC screening ultrasounds performed on 294 adults over a 2.5-year period. Findings in all organs evaluated were recorded. Any incidental finding was classified as minor, moderate, or major clinical significance.

RESULTS

At least one extra-hepatic finding was documented in 57.4% of examinations. The most common extra-hepatic findings occurred in the gallbladder (40.3%), most commonly gallstones (25.4%). Four moderate clinically significant incidental findings were recorded (0.9%). Only one of these incidental findings required specific imaging follow up (0.2%). No major clinical significance incidental findings were identified.

CONCLUSIONS

Potentially clinically significant incidental findings during ultrasound HCC screenings are rare. Incidental findings identified on HCC screening did not result in significant additional follow-up imaging or interventions.

Ethical impact of suboptimal referrals on delivery of care in radiology department

The referral is the key source of information that enables radiologists and radiographers to provide quality services. However, the frequency of suboptimal referrals is widely reported. This research reviews the literature to illuminate the challenges suboptimal referrals present to the delivery of care in radiology departments. The concept of suboptimal referral includes information, that is; missing, insufficient, inconsistent, misleading, hard to interpret or wrong. The research uses the four ethical principles of non-maleficence, beneficence, Autonomy and Justice as an analytic framework.Suboptimal referrals can cause harm by hindering safe contrast-media administration, proper radiation protection by justification of procedures, and compassionate patient care. Suboptimal referrals also hinder promoting patient benefits from the correct choice of imaging modality and protocol, an optimal performed examination, and an accurate radiology report. Additionally, patient autonomy is compromised from the lack of information needed to facilitate benefit-risk communication. Finally, suboptimal referrals challenge justice based on lack of reasonable patient prioritising and the unfairness caused by unnecessary examinations.These findings illuminate how suboptimal referrals can inhibit good health and well-being for patients in relation to safety, missed opportunities, patient anxiety and dissatisfaction. The ethical challenges identified calls for solutions. Referral-decision support tools and artificial intelligence may improve referral quality, when implemented. Strategies addressing efforts of radiology professionals are inevitable, including gatekeeping, shared decision-making and inter-professional communication; thereby raising awareness of the importance of good referral quality and promoting commitment to ethical professional conduct.

Thoracic Inlet in Cervical Spine CT of Blunt Trauma Patients: Prevalence of Pathologies and Importance of CT Interpretation

BACKGROUND

The thoracic inlet of blunt trauma patients may have pathologies that can be diagnosed on cervical spine computed tomography (CT) but that are not evident on concurrent portable chest radiography (pCXR). This retrospective investigation aimed to identify the prevalence of thoracic inlet pathologies on cervical spine CT and their importance by measuring the diagnostic performance of pCXR and the predictive factors of such abnormalities.

METHODS

This investigation was performed at a level-1 trauma center and included CT and concurrent pCXR of 385 consecutive adult patients (280 men, mean age of 47.6 years) who presented with suspected cervical spine injury. CT and pCXR findings were independently re-reviewed, and CT was considered the reference standard.

RESULTS

Traumatic, significant nontraumatic and nonsignificant pathologies were present at 23.4%, 23.6% and 58.2%, respectively. The most common traumatic diagnoses were pneumothorax (12.7%) and pulmonary contusion (10.4%). The most common significant nontraumatic findings were pulmonary nodules (8.1%), micronodules (6.8%) and septal thickening (4.2%). The prevalence of active tuberculosis was 3.4%. The sensitivity and positive predictive value of pCXR was 56.67% and 49.51% in diagnosing traumatic and 8.89% and 50% in significant nontraumatic pathologies. No demographic or pre-admission clinical factors could predict these abnormalities.

CONCLUSIONS

Several significant pathologies of the thoracic inlet were visualized on trauma cervical spine CT. Since a concurrent pCXR was not sensitive and no demographic or clinical factors could predict these abnormalities, a liberal use of chest CT is suggested, particularly among those experiencing high-energy trauma with significant injuries of the thoracic inlet. If chest CT is not available, a meticulous evaluation of the thoracic inlet in the cervical spine CT of blunt trauma patients is important.

The clinical significance of biliary findings in magnetic resonance enterography of patients with inflammatory bowel disease

PURPOSE

Given the association of inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC), we aimed to investigate the clinical relevance of abnormal hepatobiliary findings on magnetic resonance enterography (MRE) of IBD patients considering the risk of over- or underestimation of PSC at MRE.

MATERIAL AND METHODS

Using the MRE dataset of patients referring to a tertiary hospital and the National Registry of Crohn's and Colitis, 69 MREs, including 23 IBD-PSC, 23 IBD-without PSC, and 23 healthy controls (HC), were retrospectively reviewed by 2 experienced radiologists blinded to the clinical data, to evaluate hepatobiliary abnormalities. Sensitivity, specificity, and likelihood ratios were calculated.

RESULTS

Bile duct irregularities were the most common finding in the IBD-PSC group, with a frequency of 91%. Intra- and extrahepatic bile duct (IHBD and EHBD) irregularities were observed in 87% and 78% of PSC patients, respectively. Higher frequency of IHBD and EHBD wall thickening, bile duct dilation, EHBD stricture, and periportal oedema were observed in the IBD-PSC group. Peribiliary T2-weighted hyperintensities and contrast-enhancement were significantly more common in the IBD-PSC group than in the IBD and HC groups (48% and 35%, respectively) (p < 0.001). Detection of biliary irregularities on MRE had a specificity of 94% (95% CI: 82-99%), a sensitivity of 91% (95% CI: 72-99%), and a positive likelihood ratio of 14.0 (95% CI: 4.7-42.1) for the diagnosis of PSC.

CONCLUSIONS

This study emphasizes the importance of assessing and reporting hepatobiliary abnormalities visible in the MRE of patients with IBD to avoid a delayed diagnosis of PSC.

Increased use of computed tomography in Denmark: stage shift toward early stage lung cancer through incidental findings

BACKGROUND

Computed tomography (CT) examinations are increasingly used worldwide and incidental findings are growing likewise. Lung cancer stage at diagnosis is pivotal to survival. The earliest stage of lung cancer, stage IA is in most cases asymptomatic. Potentially, increased use of clinical CTs could induce a stage shift toward earlier lung cancer diagnosis.

MATERIALS AND METHODS

Data on the number of CT thorax in Denmark and the stage distribution of Danish lung cancer patients 2013-2020 were acquired from, respectively, the Danish Health Data Authority and the Danish Lung Cancer Registry. Clinical auditing of stage IA lung cancer patients was performed in the period 2019-2021 in a Danish region to assess the reasons for referral. Auditing of stage IV lung cancer patients was done to see whether a CT thorax was performed in a two-year period before diagnosis.

RESULTS

All regions showed an increase in CTs per 1000 inhabitants. However, the number of CTs performed in 2013 differed by more than 50% among regions, and the increase per year also differed, from an increase of 1.9 to 3.4 more examinations per year. A significant correlation between CTs and fraction of stage IA lung cancers was seen in four out of the five regions. The audit of stage IA lung cancer cases revealed that 86.8% were incidental findings. Audit of stage IV lung cancer found that 4.3% had a nodule/infiltrate on a previous CT within a 2-year period prior to the diagnosis of lung cancer that was the probable origin of stage IV lung cancer.

CONCLUSION

The study found that the vast majority of early-stage lung cancers were incidental findings. It highlights that follow-up algorithms of incidental findings should be used in accordance with guidelines and it should be unequivocally how the CT follow-up of pulmonary infiltrates is managed.

Urgent and unexpected findings in oncology and hematology patients: A practical approach to imaging

Urgent and unexpected findings are very common in oncology and haematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumours and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.

Effect of an ultrasound-first clinical decision tool in emergency department patients with suspected nephrolithiasis: A randomized trial

INTRODUCTION

Previously, we found that the use of ultrasonography for patients with suspected nephrolithiasis resulted in similar outcomes and less radiation exposure vs. CT scan. In this study, we evaluated the implementation of an ultrasound-first clinical decision support (CDS) tool in patients with suspected nephrolithiasis.

METHODS

This randomized trial was conducted at an academic emergency department (ED). We implemented the ultrasound-first CDS tool, deployed when an ED provider placed a CT order for suspected nephrolithiasis. Providers were randomized to receiving the CDS tool vs. usual care. The primary outcome was receipt of CT during the index ED visit. Secondary outcomes included radiation dose and ED revisit.

RESULTS

64 ED Providers and 254 patients with suspected nephrolithiasis were enrolled from January 2019 through Dec 2020. The US-First CDS tool was deployed for 128 patients and was not deployed for 126 patients. 86.7% of patients in the CDS arm received a CT vs. 94.4% in the usual care arm, resulting in an absolute risk difference of -7.7% (-14.8 to -0.6%). Mean radiation dose in the CDS arm was 6.8 mSv (95% CI 5.7-7.9 mSv) vs. 6.1 mSv (95% CI 5.1-7.1 mSv) in the usual care arm. The CDS arm did not result in increased ED revisits, CT scans, or hospitalizations at 7 or 30 days.

CONCLUSIONS AND RELEVANCE

Implementation of the US-first CDS tool resulted in lower CT use for ED patients with suspected nephrolithiasis. The use of this decision support may improve the evaluation of a common problem in the ED.

TRIAL REGISTRATION

ClinicalTrials.gov#NCT03461536.

Prevalence and clinical significance of incidental findings on CT attenuation correction for myocardial perfusion imaging

BACKGROUND

The appropriate clinical approach to incidentally detected lesions (IDLs) on CT attenuation correction (CTAC) images in myocardial perfusion imaging (MPI) remains uncertain. We sought to establish their prevalence and clinical significance in a large cohort and compared to previous studies to help provide further clarity and guide future clinical practice.

METHODS AND RESULTS

A total of 3758 MPI studies were reviewed retrospectively. IDLs of potential clinical significance-not known before MPI - were reported in 245 (6.5%) of these cases. Following appropriate further investigation/follow-up, these were of proven clinical significance in 30 (12.2%) cases with 14 patients (5.7%) harboring previously undiagnosed or progressive malignancies. The positive predictive value (PPV) for clinically significant incidental findings on CTAC images was 17.2% and the PPV value for incidental malignant findings was 8.0%.

CONCLUSION

Although incidental findings on CTAC images in MPI are common and often clearly insignificant at time of MPI reporting, many are clinically significant with a relatively high positive predictive value. This is especially so for malignancies. Our findings, therefore, in combination with previous studies as described here support routine reporting and appropriate further investigation of incidental CTAC findings in MPI.

Prevalence of Brain Incidental Lesions Detected by 68Ga-DOTA Peptides PET/CT

Background and Objectives: ⁶⁸Ga-DOTA peptides positron emission tomography/computed tomography (PET/CT) is usually applied for the study of neuroendocrine tumours, but other tumours such as meningioma may also have an increased radiopharmaceutical uptake. The aim of this retrospective study was to establish the prevalence and the meaning of brain incidental uptake among patients who performed ⁶⁸Ga-DOTA peptides PET/CT for other reasons. Materials and Methods: Overall, 510 ⁶⁸Ga-DOTA peptides PET/CT scans performed between January 2018 and February 2022 from 430 patients were reviewed for the analysis of incidental brain radiopharmaceutical uptake. All brain incidentalomas were compared with brain magnetic resonance imaging (MRI) and/or contrast-enhanced CT performed within an average time interval of ±60 days from PET/CT scan. Results: A total of 48 patients (14%) presented incidental focal intracranial radiotracer uptake. Thirty-eight (11%) of them had a suspected meningioma confirmed by MRI or contrast-enhanced CT imaging features. The remaining 10 had a final diagnosis different from meningioma (5 as brain metastases and 2 as venous anomalies) or were lost during the follow-up without performing MRI (n = 3). The average maximal standardized uptake value (SUVmax) of the suspected meningioma was 16.5 (range 5-33), and the average lesion to brain SUVmax ratio was 351 (range 80-550). Conclusions: Brain incidental uptake from the ⁶⁸Ga-DOTA peptides PET/CT is not so rare, and meningioma is the most frequent cause.

The value of referral information and assessment - a cross sectional study of radiographers' perceptions

Background

Radiology professionals are frequently confronted with referrals containing insufficient clinical information, which hinders delivery of safe and quality medical imaging services. There is however lack of knowledge on why and how referral information is important for radiographers in clinical practice. This study explores what purposes referral information is used/ useful for the radiographers, and the benefits of involving them in assessing referrals.

Methods

A cross sectional study was conducted of radiographers recruited through the International Society of Radiographers and Radiological Technologists (ISRRT) networks. A questionnaire was developed and distributed consisting of 5-point Likert scale questions on a) use/usefulness of referral information for 12 listed purposes and b) the benefits of radiographers assessing referrals for 8 possible reasons. The questionnaire was validated using a test–retest reliability analysis. Kappa values ≥0.6 were accepted. SPSS software was used for data analysis and chi-square tests to determine associations between using referral information and background variables.

Results

Total respondents were 279 (n = 233 currently in clinical practice and n = 46 in other positions). The participants in clinical practice ranked high all 12 listed purposes for use of referral information, and all except one received ≥60% ‘frequent’/‘very frequent’ responses. Use for patient identification purposes received the highest score (97% ‘frequently’/‘very frequently’ responses), followed by ensuring imaging of the correct body region (79% ‘very frequently’ responses). Radiographers not currently working in clinical practice ranked the ‘usefulness’ of listed items similarly. Significant associations between frequent use of referral information and education level were not observed, and only three items were significantly associated with modality of practice. All items on benefits of radiographers assessing referrals received ≥75% ‘agree’/‘strongly agree’ scores. The items ranked highest were promotes radiographers’ professional responsibility and improves collaboration with radiologists and referring clinicians, with 72 and 67% strongly agreed responses, respectively.

Conclusion

Radiographers use referral information frequently for several purposes. The referral information is needed for justifying and optimising radiological procedures, hence crucial for ensuring patient safety and high-quality services. This further emphasis why radiographers perceive several benefits of being involved in assessing the referral information.

Characteristics and mortality of 561,379 hospitalized COVID-19 patients in Germany until December 2021 based on real-life data

The ongoing SARS-CoV-2 pandemic is characterized by poor outcome and a high mortality especially in the older patient cohort. Up to this point there is a lack of data characterising COVID-19 patients in Germany admitted to intensive care (ICU) vs. non-ICU patients. German Reimbursement inpatient data covering the period in Germany from January 1st, 2020 to December 31th, 2021 were analyzed. 561,379 patients were hospitalized with COVID-19. 24.54% (n = 137,750) were admitted to ICU. Overall hospital mortality was 16.69% (n = 93,668) and 33.36% (n = 45,947) in the ICU group. 28.66% (n = 160,881) of all patients suffer from Cardiac arrhythmia and 17.98% (n = 100,926) developed renal failure. Obesity showed an odds-ratio ranging from 0.83 (0.79-0.87) for WHO grade I to 1.13 (1.08-1.19) for grade III. Mortality-rates peaked in April 2020 and January 2021 being 21.23% (n = 4539) and 22.99% (n = 15,724). A third peak was observed November and December 2021 (16.82%, n = 7173 and 16.54%, n = 9416). Hospitalized COVID-19 patient mortality in Germany is lower than previously shown in other studies. 24.54% of all patients had to be treated in the ICU with a mortality rate of 33.36%. Congestive heart failure was associated with a higher risk of death whereas low grade obesity might have a protective effect on patient survival. High admission numbers are accompanied by a higher mortality rate.