The Value of Using Patient-Specific 3D-Printed Anatomical Models in Surgical Planning for Patients With Complex Multifibroid Uteri

OBJECTIVES

To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging.

METHODS

3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models.

RESULTS

Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference.

CONCLUSIONS

Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology.

Utility of chest radiograph severity scoring in emergency department for predicting outcomes in COVID-19: A study of 1275 patients

OBJECTIVE

To measure the reliability and reproducibility of a chest radiograph severity score (CSS) in prognosticating patient's severity of disease and outcomes at the time of disease presentation in the emergency department (ED) with coronavirus disease 2019 (COVID-19).

MATERIALS AND METHODS

We retrospectively studied 1275 consecutive RT-PCR confirmed COVID-19 adult patients presenting to ED from March 2020 through June 2020. Chest radiograph severity score was assessed for each patient by two blinded radiologists. Clinical and laboratory parameters were collected. The rate of admission to intensive care unit, mechanical ventilation or death up to 60 days after the baseline chest radiograph were collected. Primary outcome was defined as occurrence of ICU admission or death. Multivariate logistic regression was performed to evaluate the relationship between clinical parameters, chest radiograph severity score, and primary outcome.

RESULTS

CSS of 3 or more was associated with ICU admission (78 % sensitivity; 73.1 % specificity; area under curve 0.81). CSS and pre-existing diabetes were independent predictors of primary outcome (odds ratio, 7; 95 % CI: 3.87, 11.73; p < 0.001 & odds ratio, 2; 95 % CI: 1-3.4, p 0.02 respectively). No significant difference in primary outcome was observed for those with history of hypertension, asthma, chronic kidney disease or coronary artery disease.

CONCLUSION

Semi-quantitative assessment of CSS at the time of disease presentation in the ED predicted outcomes in adults of all age with COVID-19.

Deep ROC Analysis and AUC as Balanced Average Accuracy, for Improved Classifier Selection, Audit and Explanation

Optimal performance is desired for decision-making in any field with binary classifiers and diagnostic tests, however common performance measures lack depth in information. The area under the receiver operating characteristic curve (AUC) and the area under the precision recall curve are too general because they evaluate all decision thresholds including unrealistic ones. Conversely, accuracy, sensitivity, specificity, positive predictive value and the F1 score are too specific-they are measured at a single threshold that is optimal for some instances, but not others, which is not equitable. In between both approaches, we propose deep ROC analysis to measure performance in multiple groups of predicted risk (like calibration), or groups of true positive rate or false positive rate. In each group, we measure the group AUC (properly), normalized group AUC, and averages of: sensitivity, specificity, positive and negative predictive value, and likelihood ratio positive and negative. The measurements can be compared between groups, to whole measures, to point measures and between models. We also provide a new interpretation of AUC in whole or part, as balanced average accuracy, relevant to individuals instead of pairs. We evaluate models in three case studies using our method and Python toolkit and confirm its utility.

Pancreatic Cystic Lesions on MRI: What Is The Likelihood of a Present or Future Diagnosis of Pancreatic Carcinoma?

BACKGROUND

Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship.

PURPOSE

To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma.

STUDY TYPE

Single-center retrospective cohort.

POPULATION

A total of 192 patients (111 female, 58%) with median age 66 years (range 26-87 years) with PCLs on abdominal MRI from 2011 to 2016.

FIELD STRENGTH/SEQUENCES

1.5 T and 3 T, including T₂ WI, T₁ WI, diffusion weighted imaging and contrast-enhanced T₁ WI.

ASSESSMENT

Each PCL was reviewed independently by 2 of 10 fellowship-trained abdominal radiologists. Fukuoka guideline worrisome features and high-risk stigmata were evaluated. Follow-up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow-up of 67 months (interquartile range: 43-88 months).

STATISTICAL TESTS

Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank-sum test were used to assess PCL morphologic features with the Kolmogorov-Smirnov test used to assess for normality. P < 0.05 defined statistical significance.

RESULTS

The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high-grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person-years, respectively.

DATA CONCLUSION

A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67 months of follow-up.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: 5.

Utility of material-specific fat images derived from rapid-kVp-switch dual-energy renal mass CT for diagnosis of renal angiomyolipoma

BACKGROUND

Renal angiomyolipoma (AML) are benign masses that require detection of macroscopic fat for accurate diagnosis.

PURPOSE

To evaluate fat material-specific images derived from dual-energy computed tomography (DECT) to diagnose renal AML.

MATERIAL AND METHODS

This retrospective case-control study evaluated 25 renal AML and 44 solid renal masses (41 renal cell carcinomas, three other tumors) imaged with rapid-kVp-switch DECT (120 kVp non-contrast-enhanced [NECT], 70-keV corticomedullary [CM], and 120-kVp nephrographic [NG]-phase CECT) during 2017-2018. A radiologist measured attenuation (Hounsfield Units [HU]) on NECT, CM-CECT, NG-CECT, and fat concentration (mg/mL) using fat-water base-pair images.

RESULTS

At NECT, 100% (44/44) non-AML and 4.0% (1/25) AML measured >-15 HU. At CM-CECT and NG-CECT, 24.0% (6/25) and 20.0% (5/25) AML measured >-15 HU (size 6-20 mm). To diagnose AML, area under receiver operating characteristic curve (AUC) using -15 HU was: 0.98 (95% confidence interval [CI] 0.98-1.00) NECT, 0.88 (95% CI 0.79-0.91) CM-CECT, and 0.90 (95% CI 0.82-0.98) NG-CECT. At DECT, fat concentration was higher in AML (163.7 ± 333.9 [-553.0 to 723.5] vs. -2858.1 ± 460.3 [-2421.2 to -206.0] mg/mL, P<0.001). AUC to diagnose AML using ≥-206.0 mg/mL threshold was 0.98 (95% CI 0.95-1.0) with sensitivity/specificity of 92.0%/96.7%. Of AML, 8.0% (2/25) were incorrectly classified; one of these was fat-poor. AUC was higher for fat concentration compared to HU measurements on CM-CECT and NG-CECT (P=0.009-0.050) and similar to NECT (P=0.98).

CONCLUSION

DECT material-specific fat images can help confirm the presence of macroscopic fat in renal AML which may be useful to establish a diagnosis if unenhanced CT is unavailable.

Diagnostic accuracy and inter-observer agreement with the CO-RADS lexicon for CT chest reporting in COVID-19

PURPOSE

To measure the diagnostic accuracy and inter-observer agreement with the use of COVID-19 Reporting and Data System (CO-RADS) for detection of COVID-19 on CT chest imaging.

METHODS

This retrospective study included 164 consecutive patients with clinical suspicion of COVID-19 in whom a CT chest examination was performed at a single institution between April 2020 and July 2020. Of them, 101 patients was RT-PCR positive for COVID-19. Six readers with varying radiological experience (two each of chest radiologists, general radiologists, and radiologists in training) independently assigned a CO-RADS assessment category for each CT chest study. The Fleiss' K was used to quantify inter-observer agreement. The inter-observer agreement was also assessed based on the duration of onset of symptoms to CT scan. ROC curve analysis was used to determine the diagnostic accuracy of CO-RADS. The area under curve was calculated to determine the reader accuracy for detection of COVID-19 lung involvement with RT-PCR as reference standards. The data sets were plotted in ROC space, and Youden's J statistic was calculated to determine the threshold cut-off CO-RADS category for COVID-19 positivity.

RESULTS

There was overall moderate inter-observer agreement between all readers (Fleiss' K 0.54 [95% CI 0.54, 0.54]), with substantial agreement among chest radiologists (Fleiss' K 0.68 [95% CI 0.67, 0.68]), general radiologists (Fleiss' K 0.61 [95% CI 0.61, 0.61]), and moderate agreement among radiologists-in-training (Fleiss' K 0.56 [95% CI 0.56, 0.56]). There was overall moderate inter-observer agreement in early disease (stages 1 and 2), with cumulative Fleiss' K 0.45 [95% CI 0.45, 0.45]). The overall AUC for CO-RADS lexicon scheme to accurately diagnose COVID-19 yielded 0.92 (95% CI 0.91, 0.94) with strong concordance within and between groups, of chests radiologists with AUC of 0.91 (95% CI 0.88, 0.94), general radiologists with AUC 0.96 (95% CI 0.94, 0.98), and radiologists in training with AUC of 0.90 (95% CI 0.87, 0.94). For detecting COVID-19, ROC curve analysis yielded CO-RADS > 3 as the cut-off threshold with sensitivity 90% (95% CI 0.88, 0.93), and specificity of 87% (95% CI 0.83, 0.91).

CONCLUSION

Readers across different levels of experience could accurately identify COVID-19 positive patients using the CO-RADS lexicon with moderate inter-observer agreement and high diagnostic accuracy.

Developing a reporting guideline for artificial intelligence-centred diagnostic test accuracy studies: the STARD-AI protocol

INTRODUCTION

Standards for Reporting of Diagnostic Accuracy Study (STARD) was developed to improve the completeness and transparency of reporting in studies investigating diagnostic test accuracy. However, its current form, STARD 2015 does not address the issues and challenges raised by artificial intelligence (AI)-centred interventions. As such, we propose an AI-specific version of the STARD checklist (STARD-AI), which focuses on the reporting of AI diagnostic test accuracy studies. This paper describes the methods that will be used to develop STARD-AI.

METHODS AND ANALYSIS

The development of the STARD-AI checklist can be distilled into six stages. (1) A project organisation phase has been undertaken, during which a Project Team and a Steering Committee were established; (2) An item generation process has been completed following a literature review, a patient and public involvement and engagement exercise and an online scoping survey of international experts; (3) A three-round modified Delphi consensus methodology is underway, which will culminate in a teleconference consensus meeting of experts; (4) Thereafter, the Project Team will draft the initial STARD-AI checklist and the accompanying documents; (5) A piloting phase among expert users will be undertaken to identify items which are either unclear or missing. This process, consisting of surveys and semistructured interviews, will contribute towards the explanation and elaboration document and (6) On finalisation of the manuscripts, the group's efforts turn towards an organised dissemination and implementation strategy to maximise end-user adoption.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Joint Research Compliance Office at Imperial College London (reference number: 19IC5679). A dissemination strategy will be aimed towards five groups of stakeholders: (1) academia, (2) policy, (3) guidelines and regulation, (4) industry and (5) public and non-specific stakeholders. We anticipate that dissemination will take place in Q3 of 2021.

Diagnostic Accuracy of MRI for Differentiation of Benign and Malignant Pancreatic Cystic Lesions Compared to CT and Endoscopic Ultrasound: Systematic Review and Meta-analysis

BACKGROUND

Differentiation of benign and malignant pancreatic cystic lesions on MRI, computed tomography (CT), and endoscopic ultrasound (EUS) is critical for determining management.

PURPOSE

To perform a systematic review evaluating the diagnostic accuracy of MRI for diagnosing malignant pancreatic cystic lesions, and to compare the accuracy of MRI to CT and EUS.

STUDY TYPE

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched until February 2020 for studies reporting MRI accuracy for assessing pancreatic cystic lesions.

FIELD STRENGTH

1.5T or 3.0T.

ASSESSMENT

Methodologic and outcome data were extracted by two reviewers (AU and MA, 2 years of experience each). All studies of pancreatic cystic lesions on MRI were identified. Studies with incomplete MRI technique were excluded. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool.

STATISTICAL TESTS

Sensitivity/specificity was pooled using bivariate random-effects meta-analysis with 95% confidence intervals (95%CI). Pairwise-comparison of MRI to CT and EUS was performed. The impact of gadolinium-based contrast agents, mucinous lesions, and risk of bias were explored using meta-regression.

RESULTS

MRI pooled sensitivity was 76% (95%CI 67% to 84%) and specificity was 80% (95%CI 74% to 85%) for distinguishing benign and malignant lesions. MRI and CT had similar sensitivity (P = 0.822) and specificity (P = 0.096), but MRI was more specific than EUS (80% vs. 75%, P < 0.05). Studies including only contrast-enhanced MRI were more sensitive than those including unenhanced exams (P < 0.05). MRI sensitivity and specificity did not differ for mucinous lesions (P = 0.537 and P = 0.384, respectively) or for studies at risk of bias (P = 0.789 and P = 0.791, respectively).

DATA CONCLUSION

MRI and CT demonstrate comparable accuracy for diagnosing malignant pancreatic cystic lesions. EUS is less specific than MRI, which suggests that, in some cases, management should be guided by MRI findings rather than EUS.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

Safety of Intrathecal Administration of Gadolinium-based Contrast Agents: A Systematic Review and Meta-Analysis

Background The use of MR cisternography with intrathecal administration of gadolinium-based contrast agents (GBCAs) is limited by a lack of understanding of the relationship between intrathecal GBCA exposure and dose-related adverse events. Purpose To perform a systematic review to establish an understanding of the dose-response relationship of intrathecal GBCAs and to characterize related adverse events, particularly at higher doses. Materials and Methods Medline, Embase, CINAHL, and Central databases were searched for studies reporting intrathecal GBCA use. Data extraction included studies focused on rates and types of adverse events after intrathecal GBCA exposure. A two-tailed independent sample t test statistic was used to evaluate the relationship between GBCA dose and the presence of serious versus nonserious adverse events. Meta-analysis was used to determine the overall incidence of adverse events. Study quality and publication bias were assessed using the modified Newcastle-Ottawa scale and a funnel plot (effect size measured using Hedges' g followed by the Egger test), respectively. Results Fifty-three studies with a total of 1036 patients were included for analysis. The overall rate of adverse events after intrathecal administration of GBCA was 13% (95% confidence interval [CI]: 9.3%, 18%). Meta-analysis revealed moderate heterogeneity (I² = 62%). Serious adverse event rates could not be determined with meta-analysis. They were reported in 10 studies and were primarily neurologic in nature, with two cases of coma-one resulting in death. Serious adverse events were associated with significantly higher GBCA doses when compared with nonserious adverse events (mean difference, 4.5 mmol; 95% CI: 2.3 mmol, 6.6 mmol; P = .008). For serious adverse events, there was no clear dose-dependent increase in severity above 2.0 mmol. Conclusion Overall, intrathecal administration of GBCAs at doses greater than 1.0 mmol are associated with serious neurotoxic complications with relative clinical safety at lower doses. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Kanal in this issue.

Imaging Manifestations of Acute and Chronic Renal Infection That Mimics Malignancy: How to Make the Diagnosis Using Computed Tomography and Magnetic Resonance Imaging

PURPOSE

To review the computed tomography and magnetic resonance imaging manifestations of acute and chronic renal infections that may mimic malignancy and to provide useful tips to establish an imaging diagnosis.

CONCLUSION

Acute and chronic bacterial pyelonephritis are usually readily diagnosed clinically and on imaging when the diagnosis is suspected based upon clinical presentation. When unsuspected, focal, extensive or mass-like, acute and chronic bacterial pyelonephritis may mimic infiltrative tumours such as urothelial cell carcinoma (UCC), lymphoma, and metastatic disease. Infection may be suspected when patients are young and otherwise healthy when there is marked associated perinephric changes and in the absence of metastatic adenopathy or disease elsewhere in the abdomen and pelvis. Renal abscesses, from bacterial or atypical microbial agents, can appear as complex cystic renal masses mimicking cystic renal cell carcinoma. Associated inflammatory changes in and around the kidney and local invasion favour infection. Emphysematous pyelonephritis can mimic necrotic or fistulizing tumour; however, infection is more likely and should always be considered first. Xanthogranulomatous pyelonephritis can mimic malignancy when focal or multifocal and in cases without associated renal calculi. Malacoplakia is an inflammatory process that may mimic malignancy and should be considered in patients with chronic infection. Bacillus Calmette-Guerin (BCG)-induced pyelonephritis is rare but can mimic renal malignancy and should be considered in patients presenting with a renal mass when being treated with BCG for urinary bladder UCC.

Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis

BACKGROUND

Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation.

PURPOSE

To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation.

DATA SOURCES

English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations.

STUDY SELECTION

Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard.

DATA EXTRACTION

Three study investigators independently abstracted data and assessed study quality.

DATA SYNTHESIS

Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%).

LIMITATION

Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias.

CONCLUSION

Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42019124318).

White paper of the Society of Abdominal Radiology hepatocellular carcinoma diagnosis disease-focused panel on LI-RADS v2018 for CT and MRI

The Liver Imaging and Reporting Data System (LI-RADS) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver imaging with the overarching goal of improving communication, clinical care, education, and research relating to patients at risk for or diagnosed with hepatocellular carcinoma (HCC). In 2018, the American Association for the Study of Liver Diseases (AASLD) integrated LI-RADS into its clinical practice guidance for the imaging-based diagnosis of HCC. The harmonization between the AASLD and LI-RADS diagnostic imaging criteria required minor modifications to the recently released LI-RADS v2017 guidelines, necessitating a LI-RADS v2018 update. This article provides an overview of the key changes included in LI-RADS v2018 as well as a look at the LI-RADS v2018 diagnostic algorithm and criteria, technical recommendations, and management suggestions. Substantive changes in LI-RADS v2018 are the removal of the requirement for visibility on antecedent surveillance ultrasound for LI-RADS 5 (LR-5) categorization of 10-19 mm observations with nonrim arterial phase hyper-enhancement and nonperipheral "washout", and adoption of the Organ Procurement and Transplantation Network definition of threshold growth (≥ 50% size increase of a mass in ≤ 6 months). Nomenclatural changes in LI-RADS v2018 are the removal of -us and -g as LR-5 qualifiers.

Perceptions of vascular access for intravenous systemic therapy and risk factors for lymphedema in early-stage breast cancer-a patient survey

Background

The choice of vascular access for systemic therapy administration in breast cancer remains an area of clinical equipoise, and patient preference is not consistently acknowledged. Using a patient survey, we evaluated the patient experience with vascular access during treatment for early-stage breast cancer and explored perceived risk factors for lymphedema.

Methods

Patients who had received systemic therapy for early-stage breast cancer were surveyed at 2 Canadian cancer centres.

Results

Responses were received from 187 patients (94%). The route of vascular access was peripheral intravenous line (IV) in 24%, a peripherally inserted central catheter (picc) in 42%, and a surgically inserted central catheter (port) in 34%. Anthracycline-based regimens were associated with a greater use of central vascular access devices (cvads- that is, a picc or port; 86/97, 89%). Trastuzumab use was associated with greater use of ports (49/64, 77%). Although few patients (7%) reported being involved in the decisions about vascular access, most were satisfied or very satisfied (88%) with their access type. Patient preference centred mainly on avoiding delays in the initiation of chemotherapy. Self-reported rates of complications (183 evaluable responses) were infiltration with peripheral IVs (9/44, 20%), local skin infections with piccs (7/77, 9%), and thrombosis with ports (4/62, 6%). Perceived risk factors for lymphedema included use of the surgical arm for blood draws (117/156, 75%) and blood pressure measurement (115/156, 74%).

Conclusions

Most patients reported being satisfied with the vascular access used for their treatment. Improved education and understanding about the evidence-based requirements for vascular access are needed. Perceived risk factors for lymphedema remain variable and are not evidence-based.

Optimizing vascular access for patients receiving intravenous systemic therapy for early-stage breast cancer-a survey of oncology nurses and physicians

Background

Despite advances in systemic therapy choices for patients with early-stage breast cancer, optimal practices for intravenous (IV) access remain unknown. That lack of knowledge holds particularly true for the use of central venous access devices (cvads) such as peripherally inserted central catheters (piccs) and implanted vascular access devices (ports).

Methods

Using a survey of Canadian oncologists and oncology nurses responsible for the care of breast cancer patients, we evaluated current access practices, perceptions of complications, and perceptions of risk, and we estimated complication rates and evaluated perceived risk factors for lymphedema.

Results

Survey responses were received from 25 physicians and 57 oncology nurses. Administration of trastuzumab or an anthracycline was associated with a higher likelihood of a cvad being recommended. Other factors associated with recommendation of a cvad included prior difficult IV access and a recommendation from the chemotherapy nurse. Although the complication rates perceived to be associated with the use of piccs and ports remained high, respondents felt that cvads might improve patient quality of life. Risk factors perceived to be associated with the risk of lymphedema were axillary lymph node dissection, radiation to the axilla, and line-associated infection. Factors known to be unrelated to lymphedema risk (specifically, blood draws and blood pressure measurement) continue to be perceived as posing a higher risk.

Conclusions

Despite widespread use of chemotherapy for patients with breast cancer, the type of venous access used for treatment varies significantly, as do perceptions about the risks of cvad use and the risk for lymphedema development. Further prospective studies are needed to identify best-practice strategies.

Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study

BACKGROUND

Practice guidelines recommend that imaging to detect metastatic disease not be performed in the majority of patients with early-stage breast cancer who are asymptomatic. We aimed to determine whether practice patterns in Ontario conform with these recommendations.

METHODS

We used provincial registry data to identify a population-based cohort of Ontario women in whom early-stage, operable breast cancer was diagnosed between 2007 and 2012. We then determined whether imaging of the skeleton, thorax, and abdomen or pelvis had been performed within 3 months of tissue diagnosis. We calculated rates of confirmatory imaging of the same body site.

RESULTS

Of 26,547 patients with early-stage disease, 22,811 (85.9%) had at least one imaging test, and a total of 83,249 imaging tests were performed (mean of 3.7 imaging tests per patient imaged). Among patients with pathologic stage I and II disease, imaging was performed in 79.6% (10,921/13,724) and 92.7% (11,882/12,823) of cases, respectively. Of all imaging tests, 19,784 (23.8%) were classified as confirmatory investigations. Imaging was more likely for patients who were younger, had greater comorbidity, had tumours of higher grade or stage or had undergone preoperative breast ultrasonography, mastectomy or surgery in the community setting.

INTERPRETATION

Despite recommendations from multiple international guidelines, most Ontario women with early-stage breast cancer underwent imaging to detect distant metastases. Inappropriate imaging in asymptomatic patients with early-stage disease is costly and may lead to harm. The use of population datasets will allow investigators to evaluate whether or not strategies to implement practice guidelines lead to meaningful and sustained change in physician practice.

Designing a multi-disciplinary undergraduate medical school ultrasonography curriculum

Objectives: Although there is increasing demand for physicians from various specialties to be trained in ultrasonography (US), it is currently not being taught at most Canadian undergraduate medical schools in a comprehensive manner. The purpose of this study was to develop objectives to form the foundation of a comprehensive undergraduate US curriculum. Methods: After completing an environmental assessment, which included a review of our current undergraduate objectives, a literature review was performed to identify published undergraduate US objectives. Using this information, a preliminary list of objectives was developed. The list was distributed electronically to 12 content experts from 10 disciplines and, using a two-round modified Delphi process, consensus about the inclusion of educational objectives was obtained. An a priori consensus criterion of 75% agreement was used to determine objectives that would be included in the curriculum. Objectives that met consensus in the first round of the survey were excluded from second round evaluation. Results: Review of our undergraduate curriculum revealed that there were already 10 objectives relating to US. Combining existing objectives with those found during the literature review, an initial list of 79 objectives was produced. Sixteen of these were approved during the first Delphi round, while the remaining 63 objectives required rating during a second round. A final list of 25 objectives was produced. Conclusions: Using a modified Delphi process, physicians from diverse backgrounds reflecting current and future use of US developed 25 multi-disciplinary objectives for a comprehensive undergraduate medical school US curriculum. RÉSUMÉObjectifs: Bien qu’on demande de plus en plus que les médecins de diverses disciplines suivent une formation en échographie, cette méthode d’exploration n’est pas encore enseignée de façon exhaustive dans la plupart des programmes d’études de premier cycle des facultés de médecine canadiennes. Le but de cette étude est d’élaborer des objectifs qui serviront de fondation à la création d’un programme d’enseignement de l’échographie au premier cycle. Méthodes: Après avoir terminé une analyse de contexte qui incluait une revue de nos objectifs d’apprentissage actuels, une revue de la littérature a été effectuée afin de faire ressortir les objectifs publiés pour l’enseignement de l’échographie au premier cycle de médecine. Avec cette information, une liste préliminaire d’objectifs a ensuite été élaborée. La liste a été envoyée électroniquement à 12 experts de contenu dans 10 disciplines différentes. Utilisant un processus de Delphi modifié en deux étapes, un consensus a été établi pour l’inclusion des objectifs d’apprentissage. Un consensus à priori de 75 % approuvant les objectifs a été utilisé pour choisir ceux qui seraient inclus dans le cursus. Les objectifs qui avaient satisfait au consensus lors de la première étape ont été exclus des évaluations lors de la deuxième étape. Résultats: La revue de notre programme d’études de premier cycle a démontré qu’il y avait déjà dix objectifs portant sur l’échographie. En combinant les objectifs actuels et ceux qui ont été relevés lors de la revue de la littérature, une liste initiale de 79 objectifs a été produite. Seize de ces objectifs ont été approuvés lors du premier tour Delphi. Les 63 autres objectifs ont dû être évalués dans le cadre du deuxième tour. Une liste finale de 25 objectifs a été produite. Conclusion: À l’aide d’un processus de Delphi modifié, des médecins provenant de diverses disciplines reflétant l’utilisation courante et éventuelle de l’échographie ont élaboré 25 objectifs multidisciplinaires pour offrir un programme complet de formation en échographie dans le cursus du programme de premier cycle de médecine.

The Mysterious Organ. Spectrum of Focal Lesions within the Splenic Parenchyma: Cross-Sectional Imaging with Emphasis on Magnetic Resonance Imaging

Incidental splenic lesions are frequently encountered at imaging performed for unrelated causes. Splenic cysts, hemangiomas, and lymphomatous involvement are the most frequently encountered entities. Computed tomography and sonography are commonly used for initial evaluation with magnetic resonance imaging reserved as a useful problem-solving tool for characterizing atypical and uncommon lesions. The value of magnetic resonance imaging lies in classifying these lesions as either benign or malignant by virtue of their signal-intensity characteristics on T1- and T2-weighted imaging and optimal depiction of internal hemorrhage. Dynamic contrast-enhanced sequences may improve the evaluation of focal splenic lesions and allow characterization of cysts, smaller hemangiomas, and hamartomas. Any atypical or unexplained imaging feature related to an incidental splenic lesion requires additional evaluation and/or follow-up. Occasionally, biopsy or splenectomy may be required for definitive assessment given that some of tumours may demonstrate uncertain biologic behavior.

Associations between residency selection strategies and doctor performance: a meta-analysis

OBJECTIVES

The purpose of this study was to use meta-analysis to establish which of the information available to the resident selection committee is associated with resident or doctor performance.

METHODS

Multiple electronic databases were searched to 4 September 2012. Two reviewers independently selected studies that met the present inclusion criteria and extracted data in duplicate; disagreement was resolved by consensus. Risk for bias was assessed using a customised bias assessment tool. Measures of association were converted to a common effect size (Hedges' g). Meta-analysis was performed using the random-effects model for each selection strategy and all outcomes without pooling. Sensitivity analysis for each selection strategy-outcome pair was performed with pooling of effect size.

RESULTS

Eighty studies involving a total of 41 704 participants were included in the meta-analysis. Seventeen different selection strategies and 17 outcomes were assessed across these studies. The strongest positive associations referred to examination-based selection strategies, such as the US Medical Licensing Examination (USMLE) Step 1, and examination-based outcomes, such as scores on in-training examinations. Moderate positive associations were present for medical school marks and both examination-based and subjective outcomes. Minimal or no associations were seen for the selection tools represented by interviews, reference letters and deans' letters.

CONCLUSIONS

Standardised examination performance and medical school grades show the strongest associations with current measures of doctor performance. Deans' letters, reference letters and interviews all show a lower than expected strength of association given the relative value often assigned to them during resident doctor selection. Objective selection strategies are potentially the most useful to residency selection committees based on current evaluative methods. However, reports in the literature of validated long-term doctor performance outcomes are scant.

Can American College of Radiology in-training examination scores be used to predict Canadian radiology licensing examination results? A respective study

BACKGROUND

The purpose of this study is to evaluate the relationship between American College of Radiology (ACR) in-training examination scores and performance on the Royal College of Physicians and Surgeons of Canada (RCPSC) radiology licensing examination.

METHODS

Percentile ACR examination scores for 67 residents were obtained from 1995 to 2011 for four years of training and compared with results of the RCPSC examination. Mean ACR scores of residents who passed and residents who failed their RCPSC examination were compared with a t-test. ACR scores and licensing examination results were correlated. Logistic regression was used to predict the probability of failure given an individual's ACR score. Receiver Operating Characteristic (ROC) curves were developed in order to estimate a threshold ACR score at or above which the risk of failure was negligible.

RESULTS

The ACR scores between residents who passed their licensing exam and those who failed were significantly different. There was moderate correlation between ACR scores and exam results. Using ROC curves for each year of training, the threshold ACR scores at or above which there was a negligible risk of exam failure were 32, 42, 63, and 47 for training years 1, 2, 3 and 4 respectively. Logistic regression curves, with 95% confidence intervals, were plotted for each year of training to predict RCPSC exam results based on an individual's ACR score.

CONCLUSIONS

ACR exam scores are a strong predictor of RCPSC examination performance. Percentile ACR scores can be used to identify residents at risk for future examination failure.

Introduction of QUIP (quality information program) as a semi-automated quality assessment endeavor allowing retrospective review of errors in cross-sectional abdominal imaging

RATIONALE AND OBJECTIVES

The aims of this study were to review the role of a quality information program (QUIP) as a semiautomated educational feedback mechanism and to review common errors in cross-sectional abdominal and pelvic studies as an initiative for continuing medical education and improving patient care.

MATERIALS AND METHODS

Abdominal and pelvic errors identified by QUIP and cases collected from morbidity and mortality conferences were reviewed. Errors were classified and graded to levels of morbidity.

RESULTS

There were 222 errors in 218 patients over 4 years in this study. One hundred thirteen (51%) were identified after the introduction of QUIP (January to December 2009). One hundred thirty-eight studies (61%) were read independently, while 84 (39%) were double-read. Sixty-five percent of errors (145 of 222) were false-negatives, of which 45 (31%) were "satisfaction-of-search" errors. There were 62 cognitive errors (28%), nine technical errors (4%), eight communication errors (4%), six ordering errors (3%), and five false-positives identified. Seventy-six percent of errors were identified on computed tomography (n = 168); fewer cases involved ultrasound (n = 20 [9%]) and magnetic resonance (n = 34 [15%]). Forty-one percent resulted in no changes to patient outcomes. Forty-percent caused minor patient morbidity, and 19% caused major patient morbidity, including three cases (1%) that likely contributed to patient death.

CONCLUSIONS

Most abdominopelvic errors in this study were classified as false-negatives. Many can be attributed to satisfaction-of-search errors. Implementing a simple, semiautomated QUIP allows timely feedback regarding errors to radiologists. This may improve the quality of health care while allowing radiologists the opportunity to learn from each case they are involved in.

The Potential Value of Adding Colonic Sonography to Routine Abdominal Protocol in Patients With Active Pain

Abdominal sonography examinations include evaluation of solid intra-abdominal organs but do not routinely include assessment of the colon. The focus of this study was to determine the utility of colonic sonography in addition to abdominal imaging in the prospective evaluation of patients with nonspecific acute or subacute abdominal symptoms. Patients referred for abdominal sonography for investigation of abdominal pain were evaluated by performing routine abdominal sonography followed by a detailed colonic sonographic examination. Final diagnosis was established by a clinical history questionnaire. Twelve colon (46%) or colon-related pathologies were identified, occurring in the cohort of 26 patients with a mean age of 23 years (range, 18—77 years). Sonographic findings included normal colon ( n = 13), inflammatory bowel diseases ( n = 6), diverticular disease ( n = 5), and colon-related ancillary findings ( n = 1). The dedicated colon sonographic examination yielded a sensitivity of 91.6%, specificity of 92.8%, positive predictive value of 91.6%, and negative predictive value of 92.8% ( P < .17). Integrating the dedicated colon sonographic examination in addition to the routine abdominal sonography identified significant bowel disease and provided additional information regarding causes of patient symptoms. As this is a pilot study, additional prospective studies in larger populations are required to confirm the results and conclusions.

Thinking beyond peritoneal carcinomatosis: imaging spectrum of unusual disseminated peritoneal entities

Although peritoneal carcinomatosis is the most common entity involving the peritoneum diffusely, a vast array of unusual diseases may affect the peritoneal surfaces. These entities can be further categorized into infectious, neoplastic, and miscellaneous, and miscellaneous conditions. Cross-sectional imaging, including computed tomography and magnetic resonance imaging are excellent modalities for further characterization of these unusual diseases. For some of the conditions, imaging-specific is achievable. For others, the diagnosis can be favored when clinical and/or cross-sectional features coexist.

A survey of social outcome in schizophrenia in Tasmania

OBJECTIVE

To survey the social outcome of patients with schizophrenia attending State mental health facilities in southern Tasmania.

METHOD

Using the Statewide Mental Health Register, patients using inpatient and outpatient facilities who received a diagnosis of schizophrenia between 1981 and 1988 were identified (n = 771), and demographic and illness measures, and admissions and length of inpatient stay were compiled. The Life Skills Profile (LSP) was completed by mental health personnel for the 247 who were regular attenders or inpatients in 1991.

RESULTS

Social morbidity as indexed by the LSP was highest in psychiatric hospital inpatients and patients in long-term rehabilitation programs, and lower in patients attending community centres. The majority of patients in suburban settings and attending community centres lived with their families, whereas patients in the inner city or in the rehabilitation service were mainly in hostel accommodation or living alone. Patients with schizophrenia attending State services were of a similar age range but had a longer duration of illness and more admissions, and had spent more days in hospital than patients who were not in regular contact with the service.

CONCLUSIONS

The distribution of social morbidity in schizophrenia confirms that the public health system is supporting a group with high social morbidity. Patients with the highest morbidity are receiving the highest levels of care and intervention.

Cerebellar Purkinje cells provide target support over a limited spatial range: evidence from lurcher chimeric mice

The distribution of Purkinje cells, granule cells, and olivary neurons was quantitatively analyzed in a lurcher +/Lc in equilibrium C3H/HeJ chimera in which the surviving wild type Purkinje cells were unilaterally distributed in the left hemicerebella. The left hemisphere of this mouse contains 7600 Purkinje cells, approximately 10% of the number of Purkinje cells in inbred C3H/HeJ mice. The right hemisphere contains 300 Purkinje cells, all of which are found within 200 microns of the midline. As in other +/Lc in equilibrium wild type chimeras, the ratio of granule cells to Purkinje cells is increased in the left hemisphere, reflecting increased granule cell survival. In the right hemisphere, however, the number of granule cells is reduced to that found in +/Lc mutants. In the inferior olive, almost twice as many neurons are found in the right nucleus as opposed to the left nucleus. As the projections of olivary neurons are crossed, the number of olivary neurons is increased in the nuclei that project to the cerebellar hemisphere containing Purkinje cells compared to the olivary nuclei that project to the cerebellar hemisphere with almost no Purkinje cells. The preferential survival of granule cells and olivary neurons that either occupy or project to the hemicerebellum containing Purkinje cells suggests that the availability of trophic support from target Purkinje cell neurons is spatially restricted.

Building sickness, are symptoms related to the office lighting?

Office lighting has been suggested as one of the possible factors in producing 'building sickness'. Health questionnaires were completed by 106 out of 109 (97%) workers in six randomly sampled multi-occupied offices in each of two buildings, one air-conditioned and one naturally ventilated. There was a significantly higher prevalence of work-related headache and work-related lethargy in the air-conditioned building than in the naturally ventilated one. There was also less daylight in the air-conditioned building and lower mean luminance and illuminance of the work positions despite there being more lights on (p less than 0.01). The workers had a greater dislike of fluorescent lighting (p less than 0.01) and overall found the lighting to be less comfortable (p less than 0.01) and glare readings were higher. The workers perceived their control of lighting as poorer (p less than 0.001) and consequently there was less agreement about it (p less than 0.001). Those with work-related headache found the lighting less comfortable (p = 0.059) and perceived more glare (p less than 0.05). This study suggests the need to maximize the use of natural light from untinted windows, to reduce the impingement of fluorescent tubes on the line of sight and to return the control of levels of lighting to each individual worker.

Oxytocin: oxytocic of choice in first trimester

Either oxytocin (10 U) or ergometrine (0.25 mg) was given intravenously to patients having suction curettage for termination of pregnancy. There was significantly less blood lost and a lower incidence of vomiting in the group receiving oxytocin.