Imaging for whom: patient or physician?

Use of Shoulder Imaging in the Outpatient Setting: A Pilot Study

PURPOSE

Characterize the clinical utility of diagnostic shoulder imaging modalities commonly used in the outpatient workup of shoulder pain.

MATERIALS/METHODS

Retrospective review of adults imaged for outpatient shoulder pain from 1/1/2013 to 9/1/2015. To be categorized as "useful", a study had to meet one of the following criteria: change the clinical diagnosis or treatment plan, provide a final diagnosis, or guide definitive treatment. A utility score was assigned to each study based on the number of utility criteria met (range 0-4). A score of 1 was considered low utility; a score of greater than or equal to 2 was considered high utility. Statistical analysis included binary logistic regression and generalized estimating equations.

RESULTS

210 subjects (65% male); mean age 47 (range 18-84), underwent 302 imaging studies (159 X-ray, 137 MRI, 2 CT, 4 ultrasound) during the study period. 92.1% of all studies met minimum criteria for utility (score >1). Most commonly, diagnostic studies obtained during the outpatient workup of shoulder pain were found to guide definitive treatment (70.5%) or provide a final diagnosis (53%). Most X-rays were categorized as no or low utility (85.5%). 97.8% of the MRI studies were categorized as useful with most being high utility (73%). Overall, MRI was the most useful modality in all clinical scenarios (P = 0.002) and more likely to be high utility (P < 0.001) compared to X-rays. None of the investigated patient or injury characteristics were significant predictors of useful imaging.

CONCLUSION

Our study suggests that both radiographs and MRI are useful in the evaluation of adult unilateral shoulder pain in the outpatient setting. MRI appears to be the most useful imaging modality in terms of helping guide diagnosis and treatment selection. This serves as a potential first step towards the development of evidence based imaging algorithms that can be used and tested in future studies.

Adaptive Tutorials Versus Web-Based Resources in Radiology: A Mixed Methods Comparison of Efficacy and Student Engagement

RATIONALE AND OBJECTIVES

Diagnostic imaging is under-represented in medical curricula globally. Adaptive tutorials, online intelligent tutoring systems that provide a personalized learning experience, have the potential to bridge this gap. However, there is limited evidence of their effectiveness for learning about diagnostic imaging.

MATERIALS AND METHODS

We performed a randomized mixed methods crossover trial to determine the impact of adaptive tutorials on perceived engagement and understanding of the appropriate use and interpretation of common diagnostic imaging investigations. Although concurrently engaged in disparate blocks of study, 99 volunteer medical students (from years 1-4 of the 6-year program) were randomly allocated to one of two groups. In the first arm of the trial on chest X-rays, one group received access to an adaptive tutorial, whereas the other received links to an existing peer-reviewed Web resource. These two groups crossed over in the second arm of the trial, which focused on computed tomography scans of the head, chest, and abdomen. At the conclusion of each arm of the trial, both groups completed an examination-style assessment, comprising questions both related and unrelated to the topics covered by the relevant adaptive tutorial. Online questionnaires were used to evaluate student perceptions of both learning resources.

RESULTS

In both arms of the trial, the group using adaptive tutorials obtained significantly higher assessment scores than controls. This was because of higher assessment scores by senior students in the adaptive tutorial group when answering questions related to topics covered in those tutorials. Furthermore, students indicated significantly better engagement with adaptive tutorials than the Web resource and rated the tutorials as a significantly more valuable tool for learning.

CONCLUSIONS

Medical students overwhelmingly accept adaptive tutorials for diagnostic imaging. The tutorials significantly improve the understanding of diagnostic imaging by senior students.

Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis

BACKGROUND

Meta-analyses were performed to examine the utility of ultrasonography, computed tomography (CT), positron emission tomography (PET), and a combination of both (PET-CT) for the staging and surveillance of melanoma patients.

METHOD

Patient-level data from 74 studies containing 10,528 patients (between January 1, 1990, and June, 30, 2009) were used to derive characteristics of the diagnostic tests used. Meta-analyses were conducted by use of Bayesian bivariate binomial models to estimate sensitivity and specificity. Diagnostic odds ratios [ie, true-positive results/false-negative results)/(false-positive results/true-negative results)] and their 95% credible intervals (CrIs) and positive predictive values were used as indicators of test performance.

RESULTS

Among the four imaging methods examined for the staging of regional lymph nodes, ultrasonography had the highest sensitivity (60%, 95% CrI = 33% to 83%), specificity (97%, 95% CrI = 88% to 99%), and diagnostic odds ratio (42, 95% CrI = 8.08 to 249.8). For staging of distant metastases, PET-CT had the highest sensitivity (80%, 95% CrI = 53% to 93%), specificity (87%, 95% CrI = 54% to 97%), and diagnostic odds ratio (25, 95% CrI = 3.58 to 198.7). Similar trends were observed for melanoma surveillance of lymph node involvement, with ultrasonography having the highest sensitivity (96%, 95% CrI = 85% to 99%), specificity (99%, 95% CrI = 95% to 100%), and diagnostic odds ratio (1675, 95% CrI = 226.6 to 15,920). For distant metastases, PET-CT had the highest sensitivity (86%, 95% CrI = 76% to 93%), specificity (91%, 95% CrI = 79% to 97%), and diagnostic odds ratio (67, 95% CrI = 20.42 to 229.7). Positive predictive values were likewise highest for ultrasonography in lymph node staging and for PET-CT in detecting distant metastases.

CONCLUSION

Among the compared modalities, ultrasonography was superior for detecting lymph node metastases, and PET-CT was superior for the detection of distant metastases in both the staging and surveillance of melanoma patients.

Flying in the plane you service: patient-centered radiology

If you were about to undergo a radiologic procedure, what 5 things would you want? The authors propose a construct for patient-centered radiology. Five wishes of a prospective radiology patient are described: 1) the information to choose, 2) the right examination, 3) a safe examination, 4) effective communication of correctly interpreted results, and 5) a fair price. The authors posit that the American practice of radiology would be considerably different if our profession practiced patient-centered radiology.

Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era

AIM

To determine the association between the increasing computed tomography (CT) use for suspected pulmonary embolism (PE) on the annual rates of PE diagnosis and mortality, using time as a surrogate for CT use.

MATERIALS AND METHODS

New York State's (NYS) Statewide Planning and Research Cooperative System (SPARCS) database was used to determine the rate of PE diagnosis and mortality between 1 January 1994 and 31 December 2004. Risk factors for PE were investigated. Bivariate and multivariate analyses were performed to determine the relationships between variables.

RESULTS

The study population consisted of 24,871,131 NYS patients. The number of patients with a primary diagnosis of PE nearly doubled over the study period, from 2590 in 1994 to 4920 in 2004, while total admissions remained stable. PE deaths did not vary significantly over time, from 157 in 1994 to 159 in 2004 and did not vary with the diagnoses of PE. Age-adjusted multivariate analysis did not reveal a significant association between the rates of PE diagnosis or mortality and corresponding risk factors.

CONCLUSION

This study suggests that the increased use of CT in patients with suspected PE has led to an increase in the diagnosis of PE without a corresponding decline in mortality. Further evidence, using data on individual patients, is needed to determine the appropriate role of CT in evaluating patients with suspected PE.

Accuracy of information on imaging requisitions: does it matter?

Imaging requisitions are the major manner in which clinicians communicate to radiologists with regard to imaging studies they are requesting. Errors in the information provided on requisitions may have a deleterious effect on the quality of the imaging reports and services provided by radiologists. The author reviews all of the many problems and errors that can occur on imaging requisitions in addition to inadequate clinical histories. The author then discusses how to identify and resolve these errors.