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Endometriosis is the presence of ectopic endometrial glands outside of the uterus. MR imaging is particularly useful for characterizing deep infiltrating endometriosis but can also be useful in characterizing endometriomas and hematosalpinges, characterizing broad ligament deposits, assessing for endometriosis-associated malignancy, and differentiating malignancy from decidualized endometriomas. Masses and cysts with hemorrhagic or proteinaceous contents can sometimes be difficult to distinguish from endometriomas. Imaging protocols should include pre-contrast T1-weighted imaging with fat saturation, T2-weighted imaging without fat saturation, opposed- and in-phase or Dixon imaging, administration of contrast media, and subtraction imaging.

PURPOSE: Fat-suppressed T2-weighted imaging (T2-FS) requires a long scan time and can be wrought with motion artifacts, urging the development of a shorter and more motion robust sequence. We compare the image quality of a single-shot T2-weighted MRI prototype with deep-learning-based image reconstruction (DL HASTE-FS) with a standard T2-FS sequence for 3 T liver MRI. METHODS: 41 consecutive patients with 3 T abdominal MRI examinations including standard T2-FS and DL HASTE-FS, between 5/6/2020 and 11/23/2020, comprised the study cohort. Three radiologists independently reviewed images using a 5-point Likert scale for artifact and image quality measures, while also assessing for liver lesions. RESULTS: DL HASTE-FS acquisition time was 54.93 ± 16.69, significantly (p < .001) shorter than standard T2-FS (114.00 ± 32.98 s). DL HASTE-FS received significantly higher scores for sharpness of liver margin (4.3 vs 3.3; p < .001), hepatic vessel margin (4.2 vs 3.3; p < .001), pancreatic duct margin (4.0 vs 1.9; p < .001); in-plane (4.0 vs 3.2; p < .001) and through-plane (3.9 vs 3.4; p < .001) motion artifacts; other ghosting artifacts (4.3 vs 2.9; p < .001); and overall image quality (4.0 vs 2.9; p < .001), in addition to receiving a higher score for homogeneity of fat suppression (3.7 vs 3.4; p = .04) and liver-fat contrast (p = .03). For liver lesions, DL HASTE-FS received significantly higher scores for sharpness of lesion margin (4.4 vs 3.7; p = .03). CONCLUSION: Novel single-shot T2-weighted MRI with deep-learning-based image reconstruction demonstrated superior image quality compared with the standard T2-FS sequence for 3 T liver MRI, while being acquired in less than half the time.

This work aimed to develop a modified stack-of-stars golden-angle radial sampling scheme with variable-density acceleration along the slice (kz) dimension (referred to as VD-stack-of-stars) and to test this new sampling trajectory with multi-coil compressed sensing reconstruction for rapid motion-robust 3D liver MRI. VD-stack-of-stars sampling implements additional variable-density undersampling along the kz dimension, so that slice resolution (or volumetric coverage) can be increased without prolonging scan time. The new sampling trajectory (with increased slice resolution) was compared with standard stack-of-stars sampling with fully sampled kz (with standard slice resolution) in both non-contrast-enhanced free-breathing liver MRI and dynamic contrast-enhanced MRI (DCE-MRI) of the liver in volunteers. For both sampling trajectories, respiratory motion was extracted from the acquired radial data, and images were reconstructed using motion-compensated (respiratory-resolved or respiratory-weighted) dynamic radial compressed sensing reconstruction techniques. Qualitative image quality assessment (visual assessment by experienced radiologists) and quantitative analysis (as a metric of image sharpness) were performed to compare images acquired using the new and standard stack-of-stars sampling trajectories. Compared to standard stack-of-stars sampling, both non-contrast-enhanced and DCE liver MR images acquired with VD-stack-of-stars sampling presented improved overall image quality, sharper liver edges and increased hepatic vessel clarity in all image planes. The results have suggested that the proposed VD-stack-of-stars sampling scheme can achieve improved performance (increased slice resolution or volumetric coverage with better image quality) over standard stack-of-stars sampling in free-breathing DCE-MRI without increasing scan time. The reformatted coronal and sagittal images with better slice resolution may provide added clinical value.

BACKGROUND: Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately. AIMS: Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit. METHODS: We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data. RESULTS: Thirty-two patients with a total of 123 physicians’ orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians’ orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration. CONCLUSIONS: Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.

Despite increasing overall healthcare spending over the past several decades, little is known about long-term patterns of spending among US patients with gout. Current approaches to assessing spending typically focus on composite measures or patients agnostic to disease state; in contrast, examining spending using longitudinal measures may better discriminate patients and target interventions to those in need. We used a data-driven approach to classifying and predicting spending patterns in patients with gout.Using insurance claims data from 2017-2019, we used group-based trajectory modeling to classify patients aged ≥40 years diagnosed with gout and treated with urate-lowering therapy (ULT) by their total healthcare spending over 2 years. We assessed the ability to predict membership in each spending group using logistic and generalized boosted regression with split-sample validation. Models were estimated using different sets of predictors and evaluated using C-statistics.In 57,980 patients, mean age was 71.0 (SD:10.5) years, and 17,194 (29.7%) were female. The best-fitting model included the following groups: minimal-spending (13.2%), moderate-spending (37.4%), and high-spending (49.4%). The ability to predict groups was high overall (e.g., boosted C-statistics with all predictors: minimal-spending [0.89], moderate-spending [0.78], and high-spending [0.90]). While average adherence was relatively high in the population, for the high-spending group, the most influential predictors were greater gout medication adherence and diabetes diagnosis.We identified distinct long-term healthcare spending patterns in patients with gout using ULT with high accuracy. Several clinical predictors could be key areas for intervention, such as gout medication use or diabetes.

To compare the image quality of an accelerated single-shot T2-weighted fat-suppressed (FS) MRI of the liver with deep learning-based image reconstruction (DL HASTE-FS) with conventional T2-weighted FS sequence (conventional T2 FS) at 1.5 T.One hundred consecutive patients who underwent clinical MRI of the liver at 1.5 T including the conventional T2-weighted fat-suppressed sequence (T2 FS) and accelerated single-shot T2-weighted MRI of the liver with deep learning-based image reconstruction (DL HASTE-FS) were included. Images were reviewed independently by three blinded observers who used a 5-point confidence scale for multiple measures regarding the artifacts and image quality. Descriptive statistics and McNemar's test were used to compare image quality scores and percentage of lesions detected by each sequence, respectively. Intra-class correlation coefficient (ICC) was used to assess consistency in reader scores.Acquisition time for DL HASTE-FS was 51.23 +/ 10.1 s, significantly (p0.001) shorter than conventional T2-FS (178.9 ± 85.3 s). DL HASTE-FS received significantly higher scores than conventional T2-FS for strength and homogeneity of fat suppression; sharpness of liver margin; sharpness of intra-hepatic vessel margin; in-plane and through-plane respiratory motion; other ghosting artefacts; liver-fat contrast; and overall image quality (all, p0.0001). DL HASTE-FS also received higher scores for lesion conspicuity and sharpness of lesion margin (all, p.001), without significant difference for liver lesion contrast (p0.05).Accelerated single-shot T2-weighted MRI of the liver with deep learning-based image reconstruction showed superior image quality compared to the conventional T2-weighted fat-suppressed sequence despite a 4-fold reduction in acquisition time.• Conventional fat-suppressed T2-weighted sequence (conventional T2 FS) can take unacceptably long to acquire and is the most commonly repeated sequence in liver MRI due to motion. • DL HASTE-FS demonstrated superior image quality, improved respiratory motion and other ghosting artefacts, and increased lesion conspicuity with comparable liver-to-lesion contrast compared to conventional T2FS sequence. • DL HASTE- FS has the potential to replace conventional T2 FS sequence in routine clinical MRI of the liver, reducing the scan time, and improving the image quality.

To determine whether multi-parametric magnetic resonance imaging (mpMRI) can reliably predict proximity of prostate cancer to the prostatic urethra in a contemporary series of men undergoing radical prostatectomy (RP) at two academic centers. Clinical characteristics of consecutive men undergoing pre-operative mpMRI prior to RP and whole-mount axial serial step-sectioned pathology examination at two academic centers between Jun 2016 and Oct 2018 were analyzed retrospectively. Every tumor was characterized by its pathologic minimum distance to the prostatic urethral lumen (pMDUL). Only the cancer closest to the urethra represented the prostatic urethral index lesion. The radiologic minimum distance of the index lesion to the prostatic urethral lumen was measured and noted as ≤ 5 mm versus > 5 mm. The sensitivity, specificity, positive and negative predicting values (PPV and NPV) and area under the receivers operating characteristics curve (AUC) were calculated for performance of mpMRI for predicting pMDUL ≤ 5 mm. Of the 163 surgical specimens examined, 112 (69%) exhibited a pMDUL ≤ 5 mm. These men had significantly higher grade group (GG) and advanced pathological and clinical stage. The rates of high PI-RADS score and presence of gross extracapsular extension were also significantly greater for the group with pMDUL ≤ 5 mm. The AUC, sensitivity, specificity, PPV, and NPV were 0.641, 51.8, 76.5, 82.9, and 42.4%, respectively, for mpMRI to predict pMDUL

The aim of the study was to compare the distribution of Prostate Imaging and Reporting Data System (PI-RADS) scores, interreader agreement, and diagnostic performance of PI-RADS v2.0 and v2.1 for transition zone (TZ) lesions.The study included 202 lesions in 202 patients who underwent 3T prostate magnetic resonance imaging showing a TZ lesion that was later biopsied with magnetic resonance imaging/ultrasound fusion. Five abdominal imaging faculty reviewed T2-weighted imaging and high b value/apparent diffusion coefficient images in 2 sessions. Cases were randomized using a crossover design whereby half in the first session were reviewed using v2.0 and the other half using v2.1, and vice versa for the 2nd session. Readers provided T2-weighted imaging and DWI scores, from which PI-RADS scores were derived.Interreader agreement for all PI-RADS scores had κ of 0.37 (v2.0) and 0.26 (v2.1). For 4 readers, the percentage of lesions retrospectively scored PI-RADS 1 increased greater than 5% and PI-RADS 2 score decreased greater than 5% from v2.0 to v2.1. For 2 readers, the percentage scored PI-RADS 3 decreased greater than 5% and, for 2 readers, increased greater than 5%. The percentage of PI-RADS 4 and 5 lesions changed less than 5% for all readers. For the 4 readers with increased frequency of PI-RADS 1 using v2.1, 4% to 16% were Gleason score ≥3 + 4 tumor. Frequency of Gleason score ≥3 + 4 in PI-RADS 3 lesions increased for 2 readers and decreased for 1 reader. Sensitivity of PI-RADS of 3 or greater for Gleason score ≥3 + 4 ranged 76% to 90% (v2.0) and 69% to 96% (v2.1). Specificity ranged 32% to 64% (v2.0) and 25% to 72% (v2.1). Positive predictive value ranged 43% to 55% (v2.0) and 41% to 58% (v2.1). Negative predictive value ranged 82% to 87% (v2.0) and 81% to 91% (v2.1).Poor interreader agreement and lack of improvement in diagnostic performance indicate an ongoing need to refine evaluation of TZ lesions.

OBJECTIVE. The objective of this article is to assess radiologist concordance in characterizing thyroid nodules using the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS), focusing on the effect of radiologist experience on reader concordance. MATERIALS AND METHODS. Three experienced and three less experienced radiologists assessed 150 thyroid nodules using the TI-RADS lexicon. Percent concordance was determined for various endpoints. RESULTS. Interreader concordance for the five TI-RADS categories was 87.2% for shape, 81.2% for composition, 76.1% for echogenicity, 72.9% for margins, and 69.8% for echogenic foci. Concordance for individual features was 96.3% for rim calcifications, 90.8% for macrocalcifications, 90.1% for spongiform, 83.5% for comet tail artifact, and 77.7% for punctate echogenic foci. Concordance for the TI-RADS level and recommendation for fine-needle aspiration (FNA) were 50.4% and 78.9%, respectively. Concordance was significantly (p 0.05) for the remaining categories and features. CONCLUSION. A range of TI-RADS categories, features, and recommendations for FNA had generally moderate interreader agreement among six radiologists. Our results show that concordance for numerous characteristics was significantly higher for the less experienced versus the more experienced readers. These results suggest that less experienced readers relied more on the explicit TI-RADS criteria, whereas the experienced radiologists partially relied on their accumulated experience when forming impressions. However, the overall TI-RADS level and recommendation for FNA were unaffected, supporting the robustness of the TI-RADS lexicon and its continued use in practice.

Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.

Item does not contain fulltext OBJECTIVES: To evaluate the effect of a deep learning-based computer-aided diagnosis (DL-CAD) system on experienced and less-experienced radiologists in reading prostate mpMRI. METHODS: In this retrospective, multi-reader multi-case study, a consecutive set of 184 patients examined between 01/2018 and 08/2019 were enrolled. Ground truth was combined targeted and 12-core systematic transrectal ultrasound-guided biopsy. Four radiologists, two experienced and two less-experienced, evaluated each case twice, once without (DL-CAD-) and once assisted by DL-CAD (DL-CAD+). ROC analysis, sensitivities, specificities, PPV and NPV were calculated to compare the diagnostic accuracy for the diagnosis of prostate cancer (PCa) between the two groups (DL-CAD- vs. DL-CAD+). Spearman's correlation coefficients were evaluated to assess the relationship between PI-RADS category and Gleason score (GS). Also, the median reading times were compared for the two reading groups. RESULTS: In total, 172 patients were included in the final analysis. With DL-CAD assistance, the overall AUC of the less-experienced radiologists increased significantly from 0.66 to 0.80 (p = 0.001; cutoff ISUP GG >/= 1) and from 0.68 to 0.80 (p = 0.002; cutoff ISUP GG >/= 2). Experienced radiologists showed an AUC increase from 0.81 to 0.86 (p = 0.146; cutoff ISUP GG >/= 1) and from 0.81 to 0.84 (p = 0.433; cutoff ISUP GG >/= 2). Furthermore, the correlation between PI-RADS category and GS improved significantly in the DL-CAD + group (0.45 vs. 0.57; p = 0.03), while the median reading time was reduced from 157 to 150 s (p = 0.023). CONCLUSIONS: DL-CAD assistance increased the mean detection performance, with the most significant benefit for the less-experienced radiologist; with the help of DL-CAD less-experienced radiologists reached performances comparable to that of experienced radiologists. KEY POINTS: * DL-CAD used as a concurrent reading aid helps radiologists to distinguish between benign and cancerous lesions in prostate MRI. * With the help of DL-CAD, less-experienced radiologists may achieve detection performances comparable to that of experienced radiologists. * DL-CAD assistance increases the correlation between PI-RADS category and cancer grade.

312 Background: The use of rectal spacers in the management of localized prostate cancer treated with definitive radiotherapy has become ubiquitous in recent years. However, pre-treatment MRIs often identify varying degrees of hydrogel involvement within the rectal wall. In the present study, we evaluate the geometry of spacer placement and its association with radiological rectal wall infiltration. Methods: We identified all patients who underwent hydrogel rectal spacer placement in preparation for 5-fraction prostate SBRT from 1/2020 to 9/2021. Two specialty trained body radiologists evaluated all MRIs independently. Scans were evaluated for the following spacer parameters: spacer thickness, prostate-rectal distance, symmetry, and degree of rectal wall infiltration. Prostate-rectal distance was measured at the level of the prostatic apex, midgland, and base. Symmetry of the rectal spacer was measured using right or left lateralization from midgland. Degree of rectal wall invasion was categorized as follows: none, muscularis, submucosal, and intraluminal. Results: A total of 336 patients underwent MRI following hydrogel rectal spacer placement from 1/2020 to 9/2021. Patients were excluded from MRI if they had AICD/pacemaker, foreign body, or patient refusal. In those patients with any rectal wall invasion, gel thickness as measured at the base (11 vs. 10 mm, p = 0.02), midgland (14 vs. 10 mm, p < 0.001), and apex (12 vs. 8 mm, P < 0.001) was significantly larger than those patients without invasion. This translated into significantly larger distances between the posterior aspect of the prostate and anterior aspect of the rectum at the level of the apex (12 vs. 8 mm, p < 0.001) and midgland (13 vs. 11, p < 0.001), but not at the base (14 vs. 14 mm, p = 0.5). There was no association seen with asymmetrical spacer placement and rectal wall invasion (p = 0.7). Subgroup analysis of patients with more extensive invasion into the muscularis or submucosa confirmed significantly larger gel thickness at all prostate levels, as well as a larger prostate-rectal distance at the level of the apex and midgland. Significant associations remained consistent with both independent radiological evaluations. Conclusions: Hydrogel spacer rectal wall infiltration was associated with increased axial gel thickness, specifically at the level of the prostatic midgland and apex. Rectal wall infiltration was not associated with lateralization of gel. Rectal infiltration may be a result of surplus hydrogel placed particularly in the region where the potential space between the prostate and the rectum is limited.

BACKGROUND: Early diagnosis and treatment of prostate cancer (PCa) can be curative, however prostate specific antigen is a suboptimal screening test for clinically significant PCa. While prostate MRI has demonstrated value for the diagnosis of PCa, the acquisition time is too long for a first-line screening modality. PURPOSE: To accelerate prostate MRI exams, utilizing a variational network (VN) for image reconstruction. STUDY TYPE: Retrospective SUBJECTS: 113 subjects (train/val/test: 70/13/30) undergoing prostate MRI. FIELD STRENGTH/SEQUENCE: 3.0 T; A T2 Turbo spin echo (TSE) T2 weighted image (T2WI) sequence in axial and coronal planes, and axial echo-planar diffusion weighted imaging (DWI). ASSESSMENT: Four abdominal radiologists evaluated the image quality of VN reconstructions of retrospectively under-sampled biparametric MRIs (bpMRI), and standard bpMRI reconstructions for 20 test subjects (studies). The studies included axial and coronal T2WI, DWI B50 s/mm(2) and B1000 s/mm (4-fold T2WI, 3-fold DWI), all of which were evaluated separately for image quality on a Likert scale (1: non-diagnostic to 5: excellent quality). In another 10 test subjects, three readers graded lesions on bi-parametric MRIs (bpMRI) – which additionally included calculated B1500 s/mm(2), and apparent diffusion coefficient (ADC) map – according to the Prostate Imaging Reporting and Data System (PI-RADS v2.1), for both VN and standard reconstructions. Accuracy of PI-RADS ≥ 3 for clinically significant cancer was computed. Projected scan time of the retrospectively under-sampled bi-parametric exam was also computed. STATISTICAL TESTS: One-sided Wilcoxon signed-rank test was used for comparison of image quality. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for lesion detection and grading. Generalized estimating equation with cluster effect was used to compare differences between standard and VN bpMRI. A p value of

The objective of the study was to determine whether Axumin (This prospective study enrolled men with at least one PI-RADS 4/5 ROI on multi-parametric MRI and no csPCa on prior biopsy defined as Gleason grade group (GGG) 1. All men underwent an Axumin PET/MRI and only-persistent PI-RADS 2 ROI were advised to undergo a repeat biopsy. A PET cancer suspicion score (PETCSS) was internally developed to stratify PET avid lesions according to their suspicion of harboring csPCa. The sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of the PETCSS for predicting csPCa were assessed. Relative risk was calculated to analyze the association of baseline variables with csPCa on repeat biopsy.Thirty-eight ROI on 36 enrolled men were analyzed. Fourteen (36.8%) were downgraded to PI-RADS 1/2 and were not subjected to repeat biopsy. Thirteen (92.9%) of these downgraded scans also exhibited low-risk PETCSS. Overall, 18/22 (81.2%) subjects underwent a repeat per protocol biopsy. Of the 20 ROI subjected to repeat biopsy, eight (40%) were found to harbour csPCa. The sensitivity, specificity, PPV and NPV of the PETCSS were 50, 50, 40, and 60%, respectively. No predictor of csPCa was found in the risk analysis.Our pilot study showed that both MRI and PET sequences have limited performance for identifying those persistently suspicious PI-RADS 4/5 ROI that are found to harbor csPCa on repeat biopsy.

Background The use of treatment planning prostate MRI for Stereotactic Body Radiation Therapy (SBRT) is largely a standard, yet not all patients can receive MRI for a variety of clinical reasons. Thus, we aim to investigate the safety of patients who received CT alone based SBRT planning for the definitive treatment of localized prostate cancer. Methods Our study analyzed 3410 patients with localized prostate cancer who were treated with SBRT at a single academic institution between 2006 and 2020. Acute and late toxicity was evaluated using the Common Terminology Criteria for Adverse Events version 5.0. Expanded Prostate Cancer Index Composite (EPIC) questionnaires evaluated QOL and PSA nadir was evaluated to detect biochemical failures. Results A total of 162 patients (4.75%) received CT alone for treatment planning. The CT alone group was older relative to the MRI group (69.9 vs 67.2, p p p = 0.055), lower total radiation doses (p = 0.048), and more frequent pelvic nodal radiation versus the MRI group (p Conclusions While clinical differences existed between the MRI and CT alone group, we observed tolerable toxicity profiles in the CT alone cohort, which was further supported by EPIC questionnaire data. The overall clinical outcomes appear comparable in patients unable to receive MRI for their SBRT treatment plan with early clinical follow up.

PURPOSE: To propose a highly-accelerated, high-resolution dynamic contrast-enhanced MRI (DCE-MRI) technique called GRASP-Pro (Golden-angle RAdial Sparse Parallel imaging with imProved performance) through a joint sparsity and self-calibrating explicit subspace-constraint with automated selection of contrast phases. METHODS: GRASP-Pro reconstruction enforces a combination of self-calibrating explicit low-rank subspace-constraint and temporal sparsity constraint. The temporal basis used to construct subspace is estimated from an intermediate reconstruction using the low-resolution portion of radial k-space, which eliminates the need for generating the basis using auxiliary data or a physical signal model. A convolutional neural network was trained to generate the contrast enhancement curve in the artery, from which clinically-relevant contrast phases are automatically selected for evaluation. The performance of GRASP-Pro was demonstrated for high spatiotemporal resolution DCE-MRI of the prostate and was compared against standard GRASP in terms of overall image quality, image sharpness, and residual streaks/noise level. RESULTS: Compared to GRASP, GRASP-Pro was able to reconstruct dynamic images with enhanced sharpness, less residual streaks/noise and finer delineation of the prostate without prolonging reconstruction time. The image quality improvement reaches statistical significance (P

BACKGROUND Evaluation of prostate MRI relies on diffusion-weighted imaging (DWI), commonly distorted by susceptibility artifacts, thereby creating a need for approaches to correct such distortion. PURPOSE To compare geometric distortion on prostate MRI between standard DWI and a geometric distortion correction method for DWI described as static distortion correction DWI (SDC DWI). STUDY TYPE Retrospective case study. POPULATION Thirty patients (ages 31-81 years) undergoing prostate MRI. SEQUENCE Geometric distortions from echo planar imaging were corrected with the SDC DWI protocol, which first acquires a B0 -field map to estimate geometric distortions. ASSESSMENT Contours of the prostate were placed on axial T2 -weighted imaging (T2 WI) as an anatomic standard. Pixel shifts and apparent diffusion coefficient (ADC) values were compared between prostate contours applied to the SDC DWI and standard DWI sequences. Detailed characterization of the impact of SDC DWI was performed in three representative patients. STATISTICAL TESTS One-way analysis of variance (ANOVA) test, Spearman correlation test, and Bland-Altman plots were calculated. RESULTS There was significantly greater overlap of the SDC DWI prostate region of interest (ROI) with T2 WI than standard DWI with T2 WI (10.56 cm2 ± 3.14, P < 0.05). R2 of ADC values from standard DWI vs. SDC DWI in the 30 patients ranged from 0.02-0.94 (mean 0.60). A patient without susceptibility artifact demonstrated minimal pixel shift ranging from 0.6-1.3 mm and high correlation of ADC values (R2 = 0.89) between SDC DWI and standard DWI. A patient with rectal gas showed greater pixel shift (range: -2.5 to -0.5 mm) and less ADC value correlation (R2 = 0.69). A patient with a pelvic phlebolith adjacent to the prostate showed an even greater pixel shift (range: 10-16 mm) and decreased ADC correlation (R2 = 0.21). DATA CONCLUSION SDC DWI appears to correct for susceptibility-related pixel shifts in the prostate compared with standard DWI, which may have value for assessing prostate lesions obscured by geometric warping. Level of Evidence 4 Technical Efficacy Stage 1 J. Magn. Reson. Imaging 2019;50:1614-1619.

Background Uterine fibroids are a common benign tumor and can be symptomatic, necessitating resection. Surgical myomectomy is an effective treatment option with a risk of disseminating occult uterine leiomyosarcoma (LMS), creating a need for an effective presurgical screening protocol. Clinical collaboration with contrast-enhanced MRI including T2 and diffusion-weighted imaging (DWI) can be utilized as a screening exam. Purpose To review the accuracy and feasibility of an interdisciplinary prospective contrast-enhanced MRI pelvis with DWI screening system for LMS prior to fibroid resection. Study type Retrospective cohort study. Population In all, 1960 adult female patients aged 18-87 undergoing screening MRI pelvis prior to uterine fibroid resection. Field strength/sequence T1 and T2 -weighted imaging, DWI, and contrast-enhanced images were acquired at 1.5 T and 3.0 T. Assessment Each radiologist at the time of clinical study prospectively designated a confidence level of presence of LMS in the impression, which was reviewed retrospectively. A separate retrospective evaluation of the histologically proven LMS and the false positives was performed for the presence of five MRI features of LMS including low ADC values, intermediate/high T2 signal intensity, irregular margins, hemorrhage, and necrosis. A preliminary cost-effectiveness analysis was performed, comparing the costs of treatment of uterine fibroids with vs. without a collaborative screening protocol using MRI. Statistical tests Sensitivity, specificity, positive predictive value, and negative predictive value were obtained from the prospective evaluations. Student's t-tests were used to compare demographics and apparent diffusion coefficient values between LMS and false-positive results. Results We prospectively identified LMS patients with 100% sensitivity and 97% specificity. Preliminary cost analysis demonstrated that the MR screening protocol increased life expectancy by 0.04 years at a cost of $12,937 per life-year gained. Data conclusion MRI is an effective and potentially economic screening test, especially with standardized reporting and coordination with clinicians. Level of evidence 3 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019.

The approval of new oral disease-modifying drugs (DMDs), such as fingolimod, dimethyl fumarate (DMF), and teriflunamide, has considerably expanded treatment options for relapsing forms of multiple sclerosis (MS). However, data describing the use of these agents in routine clinical practice are limited.To describe time trends and identify factors associated with oral DMD treatment initiation and switching among individuals with MS.Using data from a large sample of commercially insured patients, we evaluated changes over time in the proportion of MS patients who initiated treatment with an oral DMD and who switched from an injectable DMD to an oral DMD between 2009 and 2014 in the United States. We evaluated predictors of oral DMD use using conditional logistic regression in 2 groups matched on calendar time: oral DMD initiators matched to injectable DMDs initiators and oral DMD switchers matched to those who switched to a second injectable DMD.Our cohort included 7,576 individuals who initiated a DMD and 1,342 who switched DMDs, of which oral DMDs accounted for 6% and 39%, respectively. Oral DMD initiation and switching steadily increased from 5% to 16% and 35% to 84%, respectively, between 2011 and 2014, with DMF being the most commonly used agent. Of the potential predictors with clinical significance, a recent neurologist consultation (OR = 1.60; 95% CI = 1.20-2.15) and emergency department visit (OR = 1.43; 95% CI = 1.01-2.01) were significantly associated with oral DMD initiation. History of depression was noted to be a potential predictor of oral DMD initiation; however, the estimate for this predictor did not reach statistical significance (OR = 1.35; 95% CI = 0.99-1.84). No clinically relevant factors measured in our data were associated with switching to an oral DMD.Oral DMDs were found to be routinely used as second-line treatment. However, we identified few factors predictive of oral DMD initiation or switching, which implies that their selection is driven by patient and/or physician preferences.This study was funded by CVS Caremark through an unrestricted research grant to Brigham and Women's Hospital. Shrank and Matlin were employees of, and shareholders in, CVS Health at the time of the study; they report no financial interests in products or services that are related to the subject of this study. Spettell is an employee of, and shareholder in, Aetna. Chitnis serves on clinical trial advisory boards for Novartis and Genzyme-Sanofi; has consulted for Bayer, Biogen Idec, Celgene, Novartis, Merck-Serono, and Genentech-Roche; and has received research support from NIH, National Multiple Sclerosis Society, Peabody Foundation, Consortium for MS Centers, Guthy Jackson Charitable Foundation, EMD-Serono, Novartis Biogen, and Verily. Desai reports receiving a research grant from Merck for unrelated work. Gagne is principal investigator of a research grant from Novartis Pharmaceuticals Corporation to the Brigham and Women's Hospital and has received grant support from Eli Lilly, all for unrelated work. He is also a consultant to Aetion and Optum. Minden reports grants from Biogen and other fees from Genentech, EMD Serano, Avanir, and Novartis, unrelated to this study. The other authors have no conflicts to report. This study was presented as a poster at the International Society for Pharmacoepidemiology 32nd Annual Meeting; August 25-28, 2016; Dublin, Ireland.

Electronic health records (EHR) discontinuity, i.e., receiving care outside of the study EHR system, can lead to information bias in EHR-based real-world evidence (RWE) studies. An algorithm has been previously developed to identify patients with high EHR-continuity. We sought to assess whether applying this algorithm to patient selection for inclusion can reduce bias caused by data-discontinuity in 4 RWE examples. Among Medicare beneficiaries aged >=65 years from 2007 to 2014, we established four cohorts assessing drug effects on short-term or long-term outcomes, respectively. We linked claims data with two US EHR systems and calculated %bias of the multivariable-adjusted effect estimates based on only EHR vs. linked EHR-claims data since the linked data capture medical information recorded outside of the study EHR. Our study cohort included 77,288 patients in system 1 and 60,309 in system 2. We found the sub-cohort in the lowest quartile of EHR-continuity captured 72-81% of the short-term and only 21-31% of the long-term outcome events, leading to %bias of 6-99% for the short-term and 62-112% for the long-term outcome examples. This trend appeared to be more pronounced in the example using a non-user comparison rather than an active comparison. We did not find significant treatment effect heterogeneity by EHR-continuity for most subgroups across empirical examples. In EHR-based RWE studies, investigators may consider excluding patients with low algorithm-predicted EHR-continuity as the EHR data capture relatively few of their actual outcomes, and treatment effect estimates in these patients may be unreliable.

BACKGROUND. Multiple commercial and open-source software applications are available for texture analysis. Nonstandard techniques can cause undesirable variability that impedes result reproducibility and limits clinical utility. OBJECTIVE. The purpose of this study is to measure agreement of texture metrics extracted by six software packages. METHODS. This retrospective study included 40 renal cell carcinomas with contrast-enhanced CT from The Cancer Genome Atlas and Imaging Archive. Images were analyzed by seven readers at six sites. Each reader used one of six software packages to extract commonly studied texture features. Inter- and intrareader agreement for segmentation was assessed with intraclass correlation coefficients (ICCs). First-order (available in six packages) and second-order (available in three packages) texture features were compared between software pairs using Pearson correlation. RESULTS. Inter- and intrareader agreement was excellent (ICC, 0.93-1). First-order feature correlations were strong (r ≥ 0.8, p < .001) between 75% (21/28) of software pairs for mean intensity and SD, 48% (10/21) for entropy, 29% (8/28) for skewness, and 25% (7/28) for kurtosis. Of 15 second-order features, only cooccurrence matrix correlation, gray-level nonuniformity, and run-length nonuniformity showed strong correlation between software packages (r = 0.90-1, p < .001). CONCLUSION. Variability in first- and second-order texture features was common across software configurations and produced inconsistent results. Standardized algorithms and reporting methods are needed before texture data can be reliably used for clinical applications. CLINICAL IMPACT. It is important to be aware of variability related to texture software processing and configuration when reporting and comparing outputs.

Objective Medications frequently require prior authorization from payers before filling is authorized. Obtaining prior authorization can create delays in filling prescriptions and ultimately reduce patient adherence to medication. Electronic prior authorization (ePA), embedded in the electronic health record (EHR), could remove some barriers but has not been rigorously evaluated. We sought to evaluate the impact of implementing an ePA system on prescription filling. Materials and Methods ePA was implemented in 2 phases in September and November 2018 in a large US healthcare system. This staggered implementation enabled the later-implementing sites to be controls. Using EHR data from all prescriptions written and linked information on whether prescriptions were filled at pharmacies, we 1:1 matched ePA prescriptions with non-ePA prescriptions for the same insurance plan, medication, and site, before and after ePA implementation, to evaluate primary adherence, or the proportion of prescriptions filled within 30 days, using generalized estimating equations. We also conducted concurrent analyses across sites during the peri-implementation period (Sept–Oct 2018). Results Of 74 546 eligible ePA prescriptions, 38 851 were matched with preimplementation controls. In total, 24 930 (64.2%) ePA prescriptions were filled compared with 26 731 (68.8%) control prescriptions (Adjusted Relative Risk [aRR]: 0.92, 95%CI: 0.91–0.93). Concurrent analyses revealed similar findings (64.7% for ePA vs 62.3% control prescriptions, aRR: 1.03, 95%CI: 0.98–1.09). Discussion Challenges with implementation, such as misfiring and insurance fragmentation, could have undermined its effectiveness, providing implications for other health informatics interventions deployed in outpatient care. Conclusion Despite increasing interest in implementing ePA to improve prescription filling, adoption did not change medication adherence.

OBJECTIVE The aim of this study was to evaluate the effect of a deep learning based computer-aided diagnosis (DL-CAD) system on radiologists' interpretation accuracy and efficiency in reading biparametric prostate magnetic resonance imaging scans. MATERIALS AND METHODS We selected 100 consecutive prostate magnetic resonance imaging cases from a publicly available data set (PROSTATEx Challenge) with and without histopathologically confirmed prostate cancer. Seven board-certified radiologists were tasked to read each case twice in 2 reading blocks (with and without the assistance of a DL-CAD), with a separation between the 2 reading sessions of at least 2 weeks. Reading tasks were to localize and classify lesions according to Prostate Imaging Reporting and Data System (PI-RADS) v2.0 and to assign a radiologist's level of suspicion score (scale from 1-5 in 0.5 increments; 1, benign; 5, malignant). Ground truth was established by consensus readings of 3 experienced radiologists. The detection performance (receiver operating characteristic curves), variability (Fleiss κ), and average reading time without DL-CAD assistance were evaluated. RESULTS The average accuracy of radiologists in terms of area under the curve in detecting clinically significant cases (PI-RADS ≥4) was 0.84 (95% confidence interval [CI], 0.79-0.89), whereas the same using DL-CAD was 0.88 (95% CI, 0.83-0.94) with an improvement of 4.4% (95% CI, 1.1%-7.7%; P = 0.010). Interreader concordance (in terms of Fleiss κ) increased from 0.22 to 0.36 (P = 0.003). Accuracy of radiologists in detecting cases with PI-RADS ≥3 was improved by 2.9% (P = 0.10). The median reading time in the unaided/aided scenario was reduced by 21% from 103 to 81 seconds (P < 0.001). CONCLUSIONS Using a DL-CAD system increased the diagnostic accuracy in detecting highly suspicious prostate lesions and reduced both the interreader variability and the reading time.

Background: Several glucagon-like peptide receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated cardiovascular benefit in type 2 diabetes in large randomized controlled trials in patients with established cardiovascular disease or multiple risk factors. However, few trial participants were on both agents, and it remains unknown whether the addition of SGLT2i to GLP-1RA therapy has further cardiovascular benefits. Methods: Patients adding either SGLT2i or sulfonylureas to baseline GLP-1RA were identified within 3 US claims datasets (2013–2018) and were 1:1 propensity score–matched, adjusting for >95 baseline covariates. The primary outcomes were a composite cardiovascular end point (comprising myocardial infarction, stroke, and all-cause mortality) and heart failure hospitalization. Adjusted hazard ratios (HRs) and 95% CIs were estimated in each dataset and pooled through fixed-effects meta-analysis. Results: Among 12 584 propensity score–matched pairs (mean [SD] age, 58.3 [10.9] years; 48.2% male) across the 3 datasets, there were 107 composite cardiovascular end point events (incidence rate per 1000 person-years, 9.9 [95% CI, 8.1–11.9]) among SGLT2i initiators compared with 129 events (incidence rate, 13.0 [95% CI, 10.9–15.3]) among sulfonylurea initiators, corresponding to an adjusted pooled HR of 0.76 (95% CI, 0.59–0.98); this decrease in composite cardiovascular end point was driven by numeric decreases in the risk of myocardial infarction (HR, 0.71 [95% CI, 0.51–1.003]) and all-cause mortality (HR, 0.68 [95% CI, 0.40–1.14]) but not stroke (HR, 1.05 [95% CI, 0.62–1.79]). For the outcome of heart failure hospitalization, there were 141 events (incidence rate, 13.0 [95% CI, 11.0–15.2]) among SGLT2i initiators versus 206 events (incidence rate, 20.8 [95% CI, 18.1–23.8]) among sulfonylurea initiators, corresponding to an adjusted pooled HR of 0.65 (95% CI, 0.50–0.82). Conclusions: Risk of residual confounding cannot be fully excluded. Individual therapeutic agents within each class may have different magnitudes of effect. In this large real-world cohort of patients with diabetes already on GLP-1RA, addition of SGLT2i conferred greater cardiovascular benefit compared with addition of sulfonylurea. The magnitude of the cardiovascular risk reduction was comparable with the benefit seen in cardiovascular outcome trials of SGLT2i versus placebo, where baseline GLP-1RA use was minimal.

Purpose With clinical volumes decreased, radiologists volunteered to participate virtually in daily clinical rounds and provide communication between frontline physicians and patients with coronavirus disease 2019 (COVID-19) and their families affected by restrictive hospital visitation policies. The purpose of this survey-based assessment was to demonstrate the beneficial effects of radiologist engagement during this pandemic and potentially in future crises if needed. Methods After the program’s completion, a survey consisting of 13 multiple-choice and open-ended questions was distributed to the 69 radiologists who volunteered for a minimum of 7 days. The survey focused on how the experience would change future practice, the nature of interaction with medical students, and the motivation for volunteering. The electronic medical record system identified the patients who tested positive for or were suspected of having COVID-19 and the number of notes documenting family communication. Results In all, 69 radiologists signed or cosigned 7,027 notes. Of the 69 radiologists, 60 (87.0%) responded to the survey. All found the experience increased their understanding of COVID-19 and its effect on the health care system. Overall, 59.6% agreed that participation would result in future change in communication with patients and their families. Nearly all (98.1%) who worked with medical students agreed that their experience with medical students was rewarding. A majority (82.7%) chose to participate as a way to provide service to the patient population. Conclusion This program provided support to frontline inpatient teams while also positively affecting the radiologist participants. If a similar situation arises in the future, this communication tool could be redeployed, especially with the collaboration of medical students.

INTRODUCTION AND OBJECTIVE:Historically, whole-gland cryoablation (WCRYO) caused significant voiding dysfunction and lower urinary tract symptoms, which was attributed to ablation of the prostatic ...

Clinical practice guidelines recommend co-prescribing naloxone to patients at high risk of opioid overdose, but few such patients receive naloxone. High costs of naloxone may contribute to limited dispensing. The aim of this study was to evaluate rates and costs of dispensing naloxone to patients receiving opioid prescriptions and at high risk for opioid overdose. Using claims data from a large US commercial insurance company, we conducted a retrospective cohort study of new opioid initiators between January 2014 and December 2018. We identified patients at high risk for overdose defined as a diagnosis of opioid use disorder, prior overdose, an opioid prescription of ≥ 50 mg morphine equivalents/day for ≥ 90 days, and/or concurrent benzodiazepine prescriptions. Among 5,292,098 new opioid initiators, 616,444 (12%) met criteria for high risk of overdose during follow-up, and, of those, 3096 (0.5%) were dispensed naloxone. The average copayment was US$24.83 for naloxone (standard deviation [SD] 67.66) versus US$9.74 for the index opioid (SD 19.75). The average deductible was US$6.18 for naloxone (SD 27.32) versus US$3.74 for the index opioid (SD 25.56), with 94% and 88% having deductibles of US$0 for their naloxone and opioid prescriptions, respectively. The average out-of-pocket cost was US$31.01 for naloxone (SD 73.64) versus US$13.48 for the index opioid (SD 34.95). Rates of dispensing naloxone to high risk patients were extremely low, and prescription costs varied greatly. Since improving naloxone’s affordability may increase access, whether naloxone’s high cost is associated with low dispensing rates should be evaluated.

Funding for research has become increasingly difficult to obtain in an environment of decreasing clinical revenue, increasing research costs, and growing competition for federal and nonfederal funding sources. This paper identifies critical requirements to build and sustain a successful radiology research program (eg, key personnel and leadership, research training and mentorship, infrastructure, institutional and departmental funding or support), reviews the current state of available funding for radiology (including federal, nonfederal, philanthropy, crowdfunding, and industry), and describes promising opportunities for future funding (eg, health services, comparative effectiveness, and patient-centered outcomes research). The funding climate, especially at the federal level, changes periodically, so it is important to have radiology-specific organizations such as the American College of Radiology and the Academy of Radiology Research serving as our key advocates. Key to obtaining any funding, no matter what the source, is a well-formulated grant proposal, so a review of opportunities specifically available to radiologists to develop and hone their grant-writing skills is provided. Effective and sustained funding for radiology research has the potential to cultivate young researchers, bolster quality research, and enhance health care. Those interested in pursuing research need to be aware of the ever-changing funding landscape, research priority areas, and the resources available to them to succeed. To succeed, radiology researchers need to think about diversification and flexibility in their interests, developing multidisciplinary and multi-institutional projects, and engaging a broader base of stakeholders that includes patients.

Endometriosis is a common gynecologic disorder characterized by the presence of ectopic endometrial tissue outside the endometrial cavity. Magnetic Resonance Imaging (MRI) has become a mainstay for diagnosis and staging of this disease. In the literature, significant heterogeneity exists in the descriptions of imaging findings and anatomic sites of involvement. The Society of Abdominal Radiology's Endometriosis Disease-Focused Panel presents this consensus document to establish an MRI lexicon for endometriosis MRI evaluation and anatomic localization.

Prior studies evaluating risk for severe urinary tract infections (UTIs) with sodium-glucose cotransporter-2 (SGLT-2) inhibitors have reported conflicting findings.To assess whether patients initiating use of SGLT-2 inhibitors were at increased risk for severe UTI events compared with those initiating use of dipeptidyl peptidase-4 (DPP-4) inhibitors or glucagon-like peptide-1 receptor (GLP-1) agonists.Population-based cohort study.2 large, U.S.-based databases of commercial claims (March 2013 to September 2015).Within each database, 2 cohorts were created and matched 1:1 on propensity score. Patients were aged 18 years or older, had type 2 diabetes mellitus, and were initiating use of SGLT-2 inhibitors versus DPP-4 inhibitors (cohort 1) or GLP-1 agonists (cohort 2).The primary outcome was a severe UTI event, defined as a hospitalization for primary UTI, sepsis with UTI, or pyelonephritis; the secondary outcome was outpatient UTI treated with antibiotics. Hazard ratios (HRs) were estimated in each propensity score-matched cohort, with adjustment for more than 90 baseline characteristics.After 1:1 matching on propensity score, 123 752 patients were identified in cohort 1 and 111 978 in cohort 2 in the 2 databases. In cohort 1, persons newly receiving SGLT-2 inhibitors had 61 severe UTI events (incidence rate [IR] per 1000 person-years, 1.76), compared with 57 events in the DPP-4 inhibitor group (IR, 1.77) (HR, 0.98 [95% CI, 0.68 to 1.41]). In cohort 2, those receiving SGLT-2 inhibitors had 73 events (IR, 2.15), compared with 87 events in the GLP-1 agonist group (IR, 2.96) (HR, 0.72 [CI, 0.53 to 0.99]). Findings were robust across sensitivity analyses; within several subgroups of age, sex, and frailty; and for canagliflozin and dapagliflozin individually. In addition, SGLT-2 inhibitors were not associated with increased risk for outpatient UTIs (cohort 1: HR, 0.96 [CI, 0.89 to 1.04]; cohort 2: HR, 0.91 [CI, 0.84 to 0.99]).Generalizability of the study findings may be limited to patients with commercial insurance.In a large cohort of patients seen in routine clinical practice, risk for severe and nonsevere UTI events among those initiating SGLT-2 inhibitor therapy was similar to that among patients initiating treatment with other second-line antidiabetic medications.Brigham and Women's Hospital, Division of Pharmacoepidemiology and Pharmacoeconomics.

Evaluation of prostate MRI relies on diffusion-weighted imaging (DWI), commonly distorted by susceptibility artifacts, thereby creating a need for approaches to correct such distortion.To compare geometric distortion on prostate MRI between standard DWI and a geometric distortion correction method for DWI described as static distortion correction DWI (SDC DWI).Retrospective case study.Thirty patients (ages 31-81 years) undergoing prostate MRI.Geometric distortions from echo planar imaging were corrected with the SDC DWI protocol, which first acquires a BContours of the prostate were placed on axial TOne-way analysis of variance (ANOVA) test, Spearman correlation test, and Bland-Altman plots were calculated.There was significantly greater overlap of the SDC DWI prostate region of interest (ROI) with TSDC DWI appears to correct for susceptibility-related pixel shifts in the prostate compared with standard DWI, which may have value for assessing prostate lesions obscured by geometric warping. Level of Evidence 4 Technical Efficacy Stage 1 J. Magn. Reson. Imaging 2019;50:1614-1619.