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Diverticulosis remains the commonest cause for acute lower gastrointestinal tract bleeding (GIB). Conservative management is initially sufficient for most patients, followed by elective diagnostic tests. However, if acute lower GIB persists, it can be investigated with colonoscopy, CT angiography (CTA), or red blood cell (RBC) scan. Colonoscopy can identify the site and cause of bleeding and provide effective treatment. CTA is a noninvasive diagnostic tool that is better tolerated by patients, can identify actively bleeding site or a potential bleeding lesion in vast majority of patients. RBC scan can identify intermittent bleeding, and with single-photon emission computed tomography, can more accurately localize it to a small segment of bowel. If patients are hemodynamically unstable, CTA and transcatheter arteriography/embolization can be performed. Colonoscopy can also be considered in these patients if rapid bowel preparation is feasible. Transcatheter arteriography has a low rate of major complications; however, targeted transcatheter embolization is only feasible if extravasation is seen, which is more likely in hemodynamically unstable patients. If bleeding site has been previously localized but the intervention by colonoscopy and transcatheter embolization have failed to achieve hemostasis, surgery may be required. Among patients with obscure (nonlocalized) recurrent bleeding, capsule endoscopy and CT enterography can be considered to identify culprit mucosal lesion(s). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A large subset of patients undergoing Interventional Radiology procedures are on anticoagulation and/or antiplatelet therapy. Therefore, careful assessment of the coagulation status should be part of every patient's preprocedural evaluation to minimize the risk of bleeding. Every Interventional radiologist should be aware of the different medications that can affect coagulation parameters and how to properly manage them. After a thorough literature search, the most recent and relevant articles on periprocedural management of anticoagulation and antiplatelet medications for patients undergoing percutaneous and endovascular image-guided procedures were reviewed. Consensus guidelines from the Society of Interventional Radiology and other society guidelines showed few differences; however, there is no strong evidence on the definite timing to stop and resume those medications safely in the periprocedural period. Currently used anticoagulation and antiplatelet medications are discussed in this review, with regards to their mechanism of action, pharmacokinetics, indications, and periprocedural management according to recent studies and different societal guidelines. The recommendations are presented in a clear and easy to follow diagram and table, along with recommendations regarding drug reversal. In addition, a brief review of the basic principles, physiology, and pharmacology of hemostasis is discussed.

Purpose Despite an overall reduction in the number of stroke cases presenting to hospitals during the COVID-19 pandemic, a remarkably high incidence of acute cerebrovascular disease associated with the infection has been reported. In this systematic review, we assess the neurological outcomes and complications of endovascular thrombectomy (EVT) for large vessel occlusions (LVO) in COVID-19 patients. Methods A literature search was performed in PubMed from December 1, 2019 through September 1st, 2020 using different combinations of suitable keywords. Ten studies reporting EVT outcomes and complications were identified. Two studies that included non-LVO pathologies and COVID-19 negative patients with the outcomes analysis were excluded. Patient demographics, comorbidities, anatomic thrombus location, neurological and angiographic outcomes were assessed. Results A total of 8 studies, in addition to our institutional case series, were ultimately included in this review. The mean age was 62.2 years, of which 67.6% were males. M1 segment involvement was the most commonly reported (53.8%) thrombus location. The mean NIHSS at presentation was 20.4 with no significant change at 24 h. Successful revascularization (TICI ≥ 2b) was achieved in 89%. Early proximal cerebral re-occlusion was reported in 6 patients (11%) and cerebral hemorrhage in 3 patients (4%). In hospital mortality was reported in 15 patients (28.8%). Conclusion Despite angiographically successful EVT of LVOs in the majority of patients, this literature analysis demonstrates overall poor outcomes and high mortality in COVID-19 patients post EVT. An unusual incidence of early intracerebral proximal arterial re-occlusion was notable.

The clinical applications of fluoroscopy and MR imaging for interventional and diagnostic purposes are rapidly expanding, necessitating a renewed awareness of iatrogenic radiologic skin injuries. This article reviews the risk factors, clinical characteristics, and management strategies for imaging related skin injury relevant to radiologists. Skin injuries resulting from diagnostic imaging or radiologic interventions are rare complications that receive relatively little attention in the medical literature, but confer significant morbidity. The clinical signs of radiation skin reactions may not present for several weeks to months following exposure, beyond the time frame of typical follow-up for most interventional procedures. Increased vigilance and enhanced follow-up protocols are needed to detect clinically relevant skin reactions. An interdisciplinary management approach involving wound care specialists, dermatologists, and plastic surgeons may be warranted. The predictable relationship between fluoroscopic radiation dose exposure and extent of injury, and patient characteristics and equipment with burns when undergoing MRI allows for the determination when practical follow-up approaches are necessary to mitigate harmful long lasting effects.

Increasing recognition within the medical literature and by the Accreditation Council for Graduate Medical Education has been attributed to the need for enhanced resident education on concepts related to public health and health equity. Despite increasing documentation of pervasive inequalities within the scope of radiology, dedicated curricula designed to improve cultural competency and understanding of healthcare disparities among radiology trainees remains sparse. With relatively fewer patient interactions, radiology trainees are particularly susceptible to insufficient contextual awareness of how socioeconomic factors influence patient health and behaviors, physician recommendations, and ultimately clinical outcomes. The purpose of this article is to provide a high-yield background of foundational health equity and disparity concepts for radiology trainees, from which additional educational curricula may be derived. Specifically, this article will discuss the fundamental socioeconomic factors known to contribute to discrepant access and use of imaging services, followed by areas in radiology with well-documented disparities of which trainees should be aware. Lastly, previous and current strategies for addressing disparities in radiology will be discussed with the ultimate goal of stimulating trainee participation and the development of novel approaches.

The proportion of women and under-represented minorities in radiology is not only lower than most specialty fields, but also the rate of change towards the proportions of representation noted in the medical community remains abysmally low. This review was performed to seek the trends in diversity in radiology during recent years. While female medical students account for half of all medical students in the USA during recent years, female radiology residents still make up only about a quarter of all radiology residents, radiology faculty members, and practicing radiologists. Blacks, Hispanics and Latinxs, Asians, American Indians, Alaskan Natives, Native Hawaiians, and Pacific Islanders remain under-represented minorities in radiology. While much attention has been diverted to diversity in radiology during recent years, trends of increasing diversity remain slow. Many papers have discussed proposed barriers to diversity in radiology and the proposed solutions, which we review in this paper.

Objective: To: 1) describe a System for Coordinating Orders for Radiology Exams (SCORE) which aims to manage unscheduled orders for outpatient diagnostic imaging in an electronic health record (EHR) with embedded computerized physician order entry (CPOE), 2) assess the impact of SCORE and other related factors (e.g., demographics) on rate of unscheduled orders, and 3) assess the clinical necessity of orders canceled, expired, scheduled and performed. Methods: This Institutional Review Board-approved retrospective study was conducted in a large academic institution between 10/1/2017–7/1/2019. The design and implementation of SCORE is described, including people (e.g., competencies), processes (e.g., standardized procedures) and tools (e.g., EHR interfaces, dashboard). Rate of unscheduled imaging orders was compared pre-SCORE (10/1/17–9/30/18) and post-SCORE (10/1/18–6/30/19) using chi-square analysis. For 447 randomly selected orders, mode of resolution was obtained from the EHR and factors related to order resolution were assessed via multivariable analysis. Finally, clinical necessity was manually assessed by two physicians. Results: Pre-SCORE, 52,204/607,020 exam orders were unscheduled (8.6% of orders), compared to 20,900/475,000 exam orders (4.4% of orders) post-SCORE (χ2, p

Background and PurposeStroke is a drastic complication and a poor prognostic marker of COVID-19 disease which emphasizes the importance of early identification and management of this complication. In this case series, we describe our experience of mechanical thrombectomy of large vessel occlusions (LVO) in patients with COVID-19.MethodsWe performed a retrospective study of a series of confirmed COVID-19 patients who underwent endovascular thrombectomy for acute cerebrovascular ischemic disease with large vessel occlusion. Patient demographics, presentations, lab values, angiographic and clinical outcomes were also reviewed.ResultsThree COVID-19 patients with large vessel occlusion who underwent endovascular thrombectomy were identified in our multi-center institution. Two patients had respiratory symptoms prior presentation and one patient presented initially with clinical deficits. Two patients had anterior circulation occlusion in the middle cerebral artery territory vs one had posterior circulation occlusion in the basilar artery. There was good angiographic outcome post thrombectomy in all patients, however poor clinical outcomes noted with no significant improvement in neurological manifestations in comparison with baseline at presentation. All patients developed critically severe symptoms during hospitalization requiring intubation and one patient died of COVID-19 related respiratory failure.ConclusionIn this small case series, we noted worse clinical outcomes in COVID-19 related LVO stroke despite effective thrombectomy, which may be related to the underlying COVID-19 disease and/or the nature of clot in these patients.

To evaluate gender distribution in radiology professional society leadership positions. Our study intends to assess and compare the gender distribution among leadership roles and professional society committee memberships of the radiology societies and seek an understanding of potential associations between gender, academic research metrics, institutional academic rank, and leadership roles.We identified radiology professional society committee members to assess relative gender composition in 28 radiology societies in North America, Europe, and Australia/New Zealand. The research metrics were obtained from the SCOPUS database and demographics and institutional affiliation through institutional websites' internet searches. Gender distribution by academic ranks and other discontinuous variables were analyzed using the Chi-Square test. Wallis tests.Of the 3011 members of society committees, 67.9% were male, and 32.1% female. Among all the society members, the data showed that the proportion of committee members holding leadership positions was comparable between males (25.7%) and females (22.5%). However, when we did a subgroup analysis and disaggregated the data by leadership positions, we noted that among those who held the leadership positions, the proportion of males was more significant (n = 526, 70.7%) compared to females (n = 218, 29.3%). Overall, males had higher median publications, citations, H-indices, and active years of research (P0.0001). At all university academic ranks, men outnumbered females (P = 0.0015, Chi-square 15.38), with the most considerable disparity at the rank of professor (71.9% male, 28.1% female, P = 0.0003).There was male predominance amongst committee members in radiology societies. Our study found no significant differences between those in leadership positions, suggesting that once a member of a committee, females are equally likely as males to attain leadership positions. Analysis of committee members' academic rank and committee leaders demonstrated underrepresentation of females at higher academic ranks, and males overall had higher research metrics than females.

The aims of this article are to review the driving forces for increased utilization of imaging within the US and to review the strategies currently being implemented to curtail the use of inappropriate advanced diagnostic imaging (ADI) in the setting of acute uncomplicated low back pain. Strategies aimed at reducing inappropriate ADI in the setting of uncomplicated low back pain, including guideline dissemination, clinical decision support (CDS), audit and feedback, prior authorization, and prior notification. Increasing utilization of inappropriate ADI is a multifactorial problem, and the solution is complex. Like many problems in medicine, it is unlikely that we will be able to identify a single intervention as a solution. Instead, a concerted effort grounded in physician education, CDS, and audit and feedback may be our best tool against inappropriate ADI in the setting of acute uncomplicated low back pain.

To evaluate gender and racial profiles of US academic radiology faculty.This is a retrospective analysis of the American Association of Medical College database of radiology faculty members from 2006 to 2017 by academic rank, chair position, race or ethnicity, and gender. The data were described with annual proportions and average annual counts and fit to a Poisson regression model. Comparison data were taken from American Association of Medical College on matriculants at US medical schools and from ACGME on radiology residents.Women increased significantly in the ranks of professor by 4.5%, associate professor by 4.8%, and assistant professor by 4.8% (P.05). Asian and multiple race non-Hispanic radiologists increased in the rank of professor by 5.9% and 3.1%, respectively (P.05). Among department chairs, only women and Asian faculty increased by 6.4% and 7.5%, respectively (P.05). The proportion of women chairs increased from 10.0% (19 of 191) in 2006 to 17.4% (39 of 224) in 2017. Black and Hispanic chairs collectively represented less than 10% of the total chairs every year.The significant percent annual increase in women faculty in academic ranks and chair positions suggests that the radiology faculty is becoming more diverse. However, the decreasing proportion of women with increasing academic ranks within each year of the study period suggests attrition or lack of promotion of women radiology faculty. The disparity in black and Hispanic faculty members and chairs suggests that emphasis should continue to be placed on tailored recruitment.

OBJECTIVE. Online portals typically allow access to radiology reports, causing a shift in the communication. This article evaluates the studies available in the literature about patient portals and the use of patient portals in radiology. Patient and physician preferences and the impact on radiology reporting are presented. CONCLUSION. Patient portals provide an opportunity for radiologists to engage with their patients via a new method of communication. Radiologist collaboration with referring physicians is important in providing care in accordance with patient preferences.

This article highlights the experience of a single center institution undergoing a change in radiology information system (RIS) software platforms, transitioning to an electronic medical record-RIS driven workflow. Ten planning and execution topics with recommendations are presented in checklist form from the radiology department perspective. The build process of creating a site specific RIS takes many months, beginning with the organization of a steering committee. On Go-Live, several checklist items are offered to help streamline the troubleshooting process and improve communication throughout the radiology department. The groundwork of the group effort in creating the infrastructure of the build process can continue to be useful beyond Go-Live, as RIS features are continually optimized.

Structured radiology reporting has emerged as a necessary tool to achieve value-based medicine and to improve teaching of radiology residents. The pros and cons of structured reporting are compared to shed more light on its uses and aid in its further utilization. Structured reporting is a promising tool that when used in conjunction with artificial intelligence will help boost research, and facilitate extraction of data and integration of decision support tools. This article will provide a review of the pros and cons of structured reporting.

ACR RADPEER® is the leading method of radiologic peer review in the United States. The program has evolved since its inception in 2002 and was most recently updated in 2016. In 2018, a survey was sent to RADPEER participants to gauge the current state of the program and explore opportunities for continued improvement. A total of 26 questions were included, and more than 300 practices responded. In this report, the ACR RADPEER Committee authors summarize the survey results and discuss opportunities for future iterations of the RADPEER program.

Radiology practices across the United States aspire to Joint Commission accreditation, the nation’s gold standard certification of effective, efficient, and safe patient care. Toward that end, radiology department leaders devote substantial effort searching the available literature to better understand the expectations of TJC and thus better prepare their organization for the review process. In this article, we review and summarize current recommendations and standards of practice in order to facilitate the self-assessment process. We present an efficient, interactive survey tool that can aid practice leaders, including radiologists and administrators, as they internally survey their own departments in preparation for The Joint Commission survey process.

A review and comparison of the currently available removal and novel Inferior Vena Cava Filters; including design characteristics, composition, delivery methods, and limitations. This article is aimed at aiding interventionists in filter selection by providing easily accessible data. The Inferior Vena Cava filters has and will continue to play a primary role in the prevention of thromboembolic disease, especially in the acute care setting. There are a plethora of publications regarding the safety and efficacy of the traditional removable filter in addition to multiple comparative analyses discussing their intervariability and design characteristics. Over the last three years, the FDA has approved novel filter designs for widespread use. While the research on these “next-generation” filters is relatively limited compared to the traditional designs, the results are promising. Nine of the most commonly used filters in the United States were included in the final review. Manufacture specifications are listed for each filter. The available literature, including clinical trials on the newer generation filter designs, is summarized. Understanding of the variability between filter options, short- and long-term complications, optimal removal time, delivery methods, and retrieval methods will hopefully aid current and future practitioners in optimizing their filter selection to improve patient care.

Radiology’s leaders in peer review, patient-centered care, quality and safety, legal affairs, and institutional processes can help prepare radiologists to communicate openly with patients and famil...

Nephrogenic systemic fibrosis (NSF) is a rare systemic disease with a high mortality. The purpose of this review is to provide clinicians with guidance regarding safe administration of GBCAs to patients with renal disease. Development of NSF has been linked to the administration of gadolinium-based contrast agents (GBCAs) in patients with renal disease. Due to the wide variety of available GBCAs and recommendations regarding safe administration of these agents, it can be difficult for clinicians to choose the best GBCA for this patient population. Although the current ACR guidelines have virtually eliminated the risk of NSF, future research may lead to the development of alternative contrast agents for patients at risk of NSF who require contrast-enhanced MRIs.

To highlight elements that potentially improve the quality of patient care during the Interventional Radiology procedure. The success of an interventional radiology procedure is not merely dependent on the skill of the operator. Many other factors considerably influence the safety and therefore the outcome of the procedure. The following elements are discussed in depth: universal protocol, preprocedural checklist, physical environment, communication during the procedure, preventing infection, planning and executing the procedure, and radiation safety. Incorporating systems of safety and back-up plans during the procedure is essential in guaranteeing favorable results and decreasing complications.

OBJECTIVE. The purpose of this article is to review the tools and opportunities available for patient-centered care in radiology and to create a quality patient-centered care process map to organize them for radiology practices. CONCLUSION. This article provides a review of the many opportunities to increase and improve patient-centered care in radiology. A process map that organizes and highlights key elements of patient-centered care throughout the radiology care process is provided that can be implemented to enhance the patient experience of our services and improve the quality of care provided.

Endovascular aneurysm repair (EVAR) is a successful technique as well as an excellent alternative to the surgical management of abdominal aortic aneurysms. EVAR has improved the mortality and morbidity of many patients who would have otherwise suffered greatly from the consequences of abdominal aortic aneurysms. However, EVAR is not without complications. Some complications require lifelong surveillance, whereas others may necessitate immediate surgical intervention. We discuss the various modalities available for the surveillance as well as the common complications that can be seen on computed tomography.

The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs.

Magnetic resonance (MR) imaging is gaining increased acceptance in the emergency setting despite the continued dominance of computed tomography. MR has the advantages of more precise tissue characterization, superior soft tissue contrast, and a lack of ionizing radiation. Traditional barriers to emergent MR are being overcome by streamlined imaging protocols and newer rapid-acquisition sequences. As the utilization of MR imaging in the emergency department increases, a strong working knowledge of the MR appearance of the most commonly encountered abdominopelvic pathologies is essential. In this article, MR imaging protocols and findings of acute pelvic, scrotal, and gastrointestinal pathologies are discussed.

Quality assurance (QA) is a fundamental component of every successful radiology operation. A radiology QA program must be able to efficiently and effectively monitor and respond to quality problems. However, as radiology QA has expanded into the depths of radiology operations, the task of defining and measuring quality has become more difficult. Key performance indicators (KPIs) are highly valuable data points and measurement tools that can be used to monitor and evaluate the quality of services provided by a radiology operation. As such, KPIs empower a radiology QA program to bridge normative understandings of health care quality with on-the-ground quality management. This review introduces the importance of KPIs in health care QA, a framework for structuring KPIs, a method to identify and tailor KPIs, and strategies to analyze and communicate KPI data that would drive process improvement. Adopting a KPI-driven QA program is both good for patient care and allows a radiology operation to demonstrate measurable value to other health care stakeholders.

Although most trauma centers have experience with the imaging and management of gunshot wounds, in most regions blast wounds such as the ones encountered in terrorist attacks with the use of improvised explosive devices (IEDs) are infrequently encountered outside the battlefield. As global terrorism becomes a greater concern, it is important that radiologists, particularly those working in urban trauma centers, be aware of the mechanisms of injury and the spectrum of primary, secondary, tertiary, and quaternary blast injury patterns. Primary blast injuries are caused by barotrauma from the initial increased pressure of the explosive detonation and the rarefaction of the atmosphere immediately afterward. Secondary blast injuries are caused by debris carried by the blast wind and most often result in penetrating trauma from small shrapnel. Tertiary blast injuries are caused by the physical displacement of the victim and the wide variety of blunt or penetrating trauma sustained as a result of the patient impacting immovable objects such as surrounding cars, walls, or fences. Quaternary blast injuries include all other injuries, such as burns, crush injuries, and inhalational injuries. Radiography is considered the initial imaging modality for assessment of shrapnel and fractures. Computed tomography is the optimal test to assess penetrating chest, abdominal, and head trauma. The mechanism of blast injuries and the imaging experience of the victims of the Boston Marathon bombing are detailed, as well as musculoskeletal, neurologic, gastrointestinal, and pulmonary injury patterns from blast injuries.

OBJECTIVE. The purposes of this article are to explore the issue of diagnostic uncertainty in radiology and how the radiology report has often fallen short in this regard and to suggest approaches that can be helpful in addressing this challenge. CONCLUSION. The practice of medicine involves a great deal of uncertainty, which is an uncomfortable reality for most physicians. Radiologists are more often than not faced with considerable diagnostic uncertainty and in their written reports are challenged to effectively communicate that uncertainty to referring physicians and others.

To review and contrast varying methods of peer assessment driven practice quality improvement programs in radiology with an emphasis on peer review and peer learning. Review of the literature revealed that the current consensus is that a shift away from the original peer review system toward a peer learning process has the most beneficial effects for organizations seeking to maximally improve performance. This requires altering perceptions towards the peer review process itself, and significant time, effort, and resources. The transition to a peer learning process is a necessity to advance the field of radiology into an era of delivering near faultless quality health care.

The purpose of this article is to classify complaints from patients undergoing image-guided interventions using a coding taxonomy and to test whether single-coded complaints were resolved satisfactorily compared with multifactorial (multiple codes) complaints.In this retrospective study, patients' complaint narratives between April 1999 and December 2012 were reviewed and categorized according to a three-level taxonomy into domains and codes. Resolutions were categorized as satisfactory or unsatisfactory to the patient and were classified as follows: clarification, apology, manager notification, change of provider, reimbursement, and quality review. Complaints were classified as single coded (only one code identified in the patients' description) and multifactorial (multiple codes identified). Statistical analysis was performed with the Fisher test, with the significance level set at 0.05. A run chart with the distribution of complaints by domains (relationships, management, and clinical) by year was performed.A total of 146 codes were extracted from 71 narratives (2.06 codes/complaint) and were classified into the following domains: clinical (52%; n = 76), management (24%; n = 35), and relationships (24%; n = 35). The most common codes included quality of care, safety, and communication breakdown issues. A run chart found a decline in absolute numbers of complaints over the years in the domains studied. The frequency of satisfactory resolution was 86% for multifactorial versus 81% for single-coded complaints with no statistically significant differences observed (p = 0.72). Over 50% of complaints were resolved by providing clarification to patients (n = 36).There were no statistically significant differences between multifactorial and single-coded complaints. Clinical codes and communication breakdown were the most common reasons for patient-reported complaint, with most complaints successfully resolved with clarification.

Dual-energy computed tomography (DECT) is based on obtaining 2 data sets with different peak kilovoltages from the same anatomical region, and material decomposition based on attenuation differences at different energy levels. Several DECT technologies are available such as: the dual-source CT, the fast kilovoltage-switching method, and the sandwich detectors technique. Calculi are detectable using iodine subtraction techniques. DECT also helps characterization of renal stone composition. The advanced postprocessing application enables differentiation of various renal stone types. Calculation of water content using spectral imaging is useful to diagnose urinary obstruction.

PURPOSE To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center. MATERIALS AND METHODS This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident. RESULTS A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290). CONCLUSION MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.

Arriving at a medical diagnosis is a highly complex process that is extremely error prone. Missed or delayed diagnoses often lead to patient harm and missed opportunities for treatment. Since medical imaging is a major contributor to the overall diagnostic process, it is also a major potential source of diagnostic error. Although some diagnoses may be missed because of the technical or physical limitations of the imaging modality, including image resolution, intrinsic or extrinsic contrast, and signal-to-noise ratio, most missed radiologic diagnoses are attributable to image interpretation errors by radiologists. Radiologic interpretation cannot be mechanized or automated; it is a human enterprise based on complex psychophysiologic and cognitive processes and is itself subject to a wide variety of error types, including perceptual errors (those in which an important abnormality is simply not seen on the images) and cognitive errors (those in which the abnormality is visually detected but the meaning or importance of the finding is not correctly understood or appreciated). The overall prevalence of radiologists' errors in practice does not appear to have changed since it was first estimated in the 1960s. The authors review the epidemiology of errors in diagnostic radiology, including a recently proposed taxonomy of radiologists' errors, as well as research findings, in an attempt to elucidate possible underlying causes of these errors. The authors also propose strategies for error reduction in radiology. On the basis of current understanding, specific suggestions are offered as to how radiologists can improve their performance in practice.

Aim We aimed to study luxatio erecta humeri using advanced imaging modalities. Method Patients with luxatio erecta humeri and a subsequent magnetic resonance imaging (MRI) and/or computed tomography (CT) scan were included in this study. Results Among 10 identified cases, we detected 2 rotator cuff, 4 labral, and 2 inferior glenohumeral ligament tears as well as 2 glenohumeral cartilage defects. We observed six comminuted displaced greater tuberosity fractures, four anterior inferior glenoid fractures, and four impaction fractures of humeral head. Conclusion This study provides detailed radiologic findings associated with luxatio erecta humeri using MRI and CT.

The purpose of this study was to determine the incidence of nephrogenic systemic fibrosis (NSF) in patients with chronic kidney disease (CKD) and moderate-to-severe impairment of kidney function who had not previously been exposed to gadolinium-based contrast agents (GBCAs) or referred to undergo contrast-enhanced MRI with gadobenate dimeglumine or gadoteridol.Two multicenter prospective cohort studies evaluated the incidence of unconfounded NSF in patients with stage 3 CKD (estimated glomerular filtration rate [eGFR] in cohort 1, 30-59 mL/min/1.73 m(2)) or stage 4 or 5 CKD (eGFR in cohort 2,30 mL/min/1.73 m(2)) after injection of gadobenate dimeglumine (study A) or gadoteridol (study B). A third study (study C) determined the incidence of NSF in patients with stage 4 or 5 CKD who had not received a GBCA in the 10 years before enrollment. Monitoring for signs and symptoms suggestive of NSF was performed via telephone at 1, 3, 6, and 18 months, with clinic visits occurring at 1 and 2 years.For studies A and B, the populations evaluated for NSF comprised 363 and 171 patients, respectively, with 318 and 159 patients in cohort 1 of each study, respectively, and with 45 and 12 patients in cohort 2, respectively. No signs or symptoms of NSF were reported or detected during the 2 years of patient monitoring. Likewise, no cases of NSF were reported for any of the 405 subjects enrolled in study C.To our knowledge, and consistent with reports in the literature, no association of gadobenate dimeglumine or gadoteridol with unconfounded cases of NSF has yet been established. Study data confirm that both gadoteridol and gadobenate dimeglumine properly belong to the class of GBCAs considered to be associated with the lowest risk of NSF.

The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.

To report the authors' experience with the administration of four gadolinium-based contrast agents (GBCA; gadopentetate dimeglumine, gadofosveset trisodium, gadoxetate disodium and gadobenate dimeglumine) in a large study population at a single, large academic medical centre.The institutional review board approved this retrospective study in which data in the electronic incident reporting system were searched. A total of 194, 400 intravenous administrations of linear ionic GBCAs were assessed for the incidence of adverse reactions and risk factors from 1 January 2007 to 14 January 2014. The severity of reactions (mild, moderate, and severe), patient type (outpatients, inpatients, and emergency), examination type, and treatment options were also investigated.In total, 204/194400 (0.1%) patients (mean age 45.7 ± 14.9) showed adverse reactions, consisting of 6/746 (0.80%), 10/3200 (0.31%), 14/6236 (0.22%) and 174/184218 (0.09%), for gadofosveset trisodium, gadoxetate disodium, gadobenate dimeglumine, and gadopentetate dimeglumine, respectively. An overall significant difference was found between different GBCAs regarding the total number of reactions (p0.0001). When comparing the GBCAs together, significant differences were found between gadofosveset trisodium versus gadopentetate dimeglumine (p0.0001), gadofosveset trisodium versus gadobenate dimeglumine (p = 0.0051), gadoxetate disodium versus gadopentetate dimeglumine (p0.0001) and gadopentetate dimeglumine versus gadobenate dimeglumine (p = 0.0013). Rate of reaction was higher in females (F: 146/113187, 0.13%/M: 58/81213, 0.07%; p0.0001). Rate of reactions was higher in outpatient (180/158885, 0.11%), emergency (10/10413, 0.10%), and inpatients (14/25102, 0.05%), respectively (p0.0001). Most of the patients had mild symptoms 171/204 (83.8%). Abdomen-pelvis, liver, and thoracic examinations had highest rates of reactions (0.17 versus 0.16 versus 0.15).The overall rate of adverse reaction to GBCAs was 0.1%. The rates of reactions were highest in gadofosveset trisodium with (0.80%), followed by gadoxetate disodium (0.31%), gadobenate dimeglumine (0.22%) and gadopentetate dimeglumine (0.09%).

To summarize the frequency of findings on IV contrast, enhanced computer tomography (CT) in 335 patients with pathologically proven ischemic colitis (IC) determine the most frequent locations and patterns of involvement and establish the correlation of these findings with the severity of IC. 231 patients were excluded for not having a concomitant CT or for having underlying comorbidities. 104 cases were analyzed. Scans were evaluated for abnormal wall enhancement (AE), bowel wall thickening (BWT), bowel dilatation (DIL), mesenteric fat stranding (FS), venous engorgement (VE), pericolonic free fluid (FF), and pneumatosis (PN) and portomesenteric venous gas. Segmental versus pancolonic involvement was noted. Severity was determined by histopathology criteria. Data obtained are as follows: female to male incidence, 69 % (70) vs. 31 % (34); average age, 64.5; and positive CT, 102/104 (98.1 %). The most frequent findings include FS (88 %), BWT (88 %), and AE (82 %) regardless of severity of involvement. Statistically significant increased risk ratio and likelihood of severe ischemia for PN, DIL, and FF individually. BWT, DIL, FS, FF, VE, and PN together have a probability for severe IC of 91.8 %. A correlation between fewer findings and milder IC was found (R (2) = 0.6771). The most frequently involved segments: descending (64 %) and sigmoid colon (54 %). Splenic flexure (SF) was infrequently involved (n = 8, 7.84 %). Females had two times higher incidence of IC. The most frequent CT findings in IC are FS, BWT, and AE regardless of the severity. PN is suggestive of severe IC. Segmental involvement is the predominant pattern. The distal colon is more frequently involved. SF contrary to the conventional literature is not disproportionately involved in IC.

Aim To present the authors' experience of contrast medium extravasation (CME) during both CT and MRI examinations in a large academic medical centre. Materials and methods The present retrospective investigation was conducted between June 2008 and June 2013. The radiology data and medical records of patients in whom CME had occurred were reviewed. Results The extravasation rate for CT and MRI was 0.11% (541/502 391); the % was 0.13% during CT and 0.06% during MRI. There was a statistically significant difference between females and males in the overall % ( p = 0.0062), and the number of extravasations between CT and MRI ( p 60 years was statistically significant when compared to the 18–60 year age group ( p = 0.0072). Of 90 MRI patients with extravasation, CME occurred in 51 (0.048%, 51/105,578) patients from manual injections, and 39 (0.087%, 39/44,688) patients from automated injection with statistical significance ( p = 0.0048). A statistical significance was found between females receiving automatic injections and males receiving manual injections ( p = 0.0161). The majority of CME during CT and MRI occurred in the outpatient department [64.5% (291/451) and 64.4% (58/90), respectively], but the overall incidence of CME was highest in inpatients [0.29%, (160/54,664) in CT and 0.16% (32/20,048) in MRI]. Conclusion Patients undergoing CT are at higher risk of developing CME than MRI patients. Females and inpatients were also were more likely to develop CME at both CT and MRI. At MRI CME is more likely in patients above the age of 60 years and for those receiving automated power injections.

The ACR's RADPEER program is currently the leading method for peer review in the United States. To date, more than 18,000 radiologists and more than 1,100 groups participate in the program. The ABR accepted RADPEER as a practice quality improvement in 2009, which can be applied toward maintenance of certification; there are currently over 2,200 practice quality improvement participants. There have been ongoing deliberations regarding the utility of RADPEER, its goals, and its scoring system since the preceding 2009 white paper. This white paper reviews the history and evolution of RADPEER and eRADPEER, the 2016 ACR Peer Review Committee's discussions, the updated recommended scoring system and lexicon for RADPEER, and updates to eRADPEER including the study type, age, and discrepancy classifications. The central goal of RADPEER to aid in nonpunitive peer learning is discussed.

OBJECTIVE. The purpose of this article is to introduce the reader to basic concepts of quality and safety in radiology. CONCLUSION. Concepts are introduced that are keys to identifying, understanding, and utilizing certain quality tools with the aim of making process improvements. Challenges, opportunities, and change drivers can be mapped from the radiology quality perspective. Best practices, informatics, and benchmarks can profoundly affect the outcome of the quality improvement initiative we all aim to achieve.

OBJECTIVE. We implemented an outpatient falls guideline in 2008 in the department of radiology. Here, we describe our multiyear experience. MATERIALS AND METHODS. This was a retrospective study conducted between April 2006 and September 2013 to investigate outpatient falls. The span of the study was divided into eight periods. The incident reporting system was searched for the falls and the fall-related variables. RESULTS. A total of 327 falls occurred during 5,080,512 radiology examinations (rate, 0.64/10,000 total examinations). The highest rate was in period 6 (0.83/10,000 examinations). The average for periods 1 and 2 is 0.39/10,000 examinations (37 falls/945,427 examinations), and the average for periods 3–6 is 0.77/10,000 examinations (204 falls/2,656,805 examinations). The average rate for periods 7 and 8 is 0.58/10,000 examinations (86 falls/1,478,280 examinations). There was a statistically significant increase in the total number of falls reported between period 2 and period 3 (p = 0.02). There ...

RADPEER is a product developed by the ACR that aims to assist radiologists with quality assessment and improvement through peer review. The program opened in 2002, was initially offered to physician groups in 2003, developed an electronic version in 2005 (eRADPEER), revised the scoring system in 2009, and first surveyed the RADPEER membership in 2010. In 2012, a survey was sent to 16,000 ACR member radiologists, both users and nonusers of RADPEER, with the goal of understanding how to make RADPEER more relevant to its members. A total of 31 questions were used, some of which were repeated from the 2010 survey. The ACR's RADPEER committee has published 3 papers on the program since its inception. In this report, the authors summarize the survey results and suggest future opportunities for making RADPEER more useful to its membership.

Nephrogenic systemic fibrosis (NSF) occurs in patients with advanced chronic kidney disease (CKD) or acute renal failure, most commonly following exposure to gadolinium-based contrast agents (GBCAs). NSF can be debilitating and associated with increased mortality. The putative association of NSF with GBCAs prompted the development of guidelines to limit the use of these contrast agents in at-risk patients. Indeed, the incidence of NSF has decreased dramatically following application of these guidelines, which appears to be the only effective means of decreasing NSF incidence. Thus, increasing clinician awareness of these updated guidelines is important. The present review introduces and compares updated guidelines for GBCA use and discusses the latest advances in the understanding of the pathogenic mechanisms and treatment of NSF.

Objective Nephrogenic systemic fibrosis (NSF) is a progressive fibrosing disorder that may develop in patients with chronic kidney disease after administration of gadolinium (Gd)-based contrast agents (GBCAs). In the setting of impaired renal clearance of GBCAs, Gd deposits in various tissues and fibrosis subsequently develops. However, the precise mechanism by which fibrosis occurs in NSF is incompletely understood. Because other profibrotic agents, such as silica or asbestos, activate the nucleotide-binding oligomerisation domain (NOD)-like receptor protein 3 (NLRP3) inflammasome and initiate interleukin (IL)-1β release with the subsequent development of fibrosis, we evaluated the effects of GBCAs on inflammasome activation. Methods Bone marrow derived macrophages from C57BL/6, Nlrp3 −/− and Asc −/− mice were incubated with three Gd-containing compounds and IL-1β activation and secretion was detected by ELISA and western blot analysis. Inflammasome activation and regulation was investigated in IL-4- and interferon (IFN)γ-polarised macrophages by ELISA, quantitative real time (qRT)-PCR and NanoString nCounter analysis. Furthermore, C57BL/6 and Nlrp3 −/− mice were intraperitoneally injected with GBCA and recruitment of inflammatory cells to the peritoneum was analysed by fluorescence-activated cell sorting (FACS). Results Free Gd and GBCAs activate the NLRP3 inflammasome and induce IL-1β secretion in vitro. Gd-diethylenetriaminepentaacetic acid also induces the recruitment of neutrophils and inflammatory monocytes to the peritoneum in vivo. Gd activated IL-4-polarised macrophages more effectively than IFNγ-polarised macrophages, which preferentially expressed genes known to downregulate inflammasome activity. Conclusions These data suggest that Gd released from GBCAs triggers a NLRP3 inflammasome-dependent inflammatory response that leads to fibrosis in an appropriate clinical setting. The preferential activation of IL-4-differentiated macrophages is consistent with the predominantly fibrotic presentation of NSF.

In this review article, the authors provide a detailed series of guidelines for effectively performing root-cause analysis (RCA) and health failure mode and effect analysis (HFMEA). RCA is a retrospective approach used to ascertain the "root cause" of a problem that has already occurred, whereas HFMEA is a prospective risk assessment tool whose aim is to recognize risks to patient safety. RCA and HFMEA are used for the prevention of errors or recurring errors to create a safer workplace, maintain high standards in health care quality, and incorporate time-saving and cost-saving modifications to favorably affect the patient care environment. The principles and techniques provided here should allow reviewers to better understand the features of RCA and HFMEA and how to apply these processes appropriately. These principles include how to organize a team, identify root causes, seed out proximate causes, graphically describe the process, conduct a hazard analysis, and develop and implement potential action plans.

OBJECTIVE. Recent technologic advances in MDCT have led to the introduction of dual-energy CT (DECT). The basic principle of DECT is to acquire images at two different energy levels simultaneously and to use the attenuation differences at these different energy levels for deriving additional information, such as virtual monochromatic images, artifact suppression, and material composition of various tissues. CONCLUSION. A variety of image reconstruction and postprocessing techniques are available for better demonstration and characterization of pathologic abnormalities. DECT can provide both anatomic and functional information of different organ systems. This article focuses on the main applications of DECT in emergency radiology.

Purpose The aim of this study was to assess the outcomes, incidental findings, recommendations, and adherence to recommendations on computed tomography angiography (CTA) studies obtained in the emergency department (ED) to evaluate for aortic dissection. Methods The institutional database of ED patients was retrospectively reviewed to identify CTA examinations for dissection during 2014. The radiology report and electronic medical records were reviewed to assess outcomes, radiology report incidental findings, and recommendations, as well as adherence to these recommendations. Results There were 370 dissection CTAs performed during the 12-month study period. The average age of the patients was 63 years (range, 15-97 years). Eighty-seven patients (23.5%) had clinically significant aortic pathology including 46 patients (12.4%) with dissection and 19 (5.1%) which were new. Three hundred twenty-nine (88.9%) of patients had at least 1 incidental finding. One hundred six (28.6%) of patients had recommendations on the radiology report, and 44.3% of these were for pulmonary nodules. Thirty recommendations (28.3%) were acted upon, most commonly related to pulmonary nodule. Conclusion Computed tomography angiography is useful in detecting aortic pathology. However, emergency physicians should be aware of the potential for clinically significant incidental findings and recommendations. Adherence to recommendations was limited, and future research could investigate mechanisms to improve compliance.

The aims of this study were to review patients' complaints about their care in radiology and to determine key areas for improvement.An institutional review board-approved, HIPAA-compliant study was conducted to retrospectively evaluate all radiology-related patient complaints received by the authors' institution's Office of Patient Advocacy from April 1999 to December 2010. The internal review classified the complaints into those that concerned medical complications, radiology staff members, failure to provide patient-centered care, and those that related to quality on the basis of radiologic benchmarks of safety, systems, and professionalism. The rate of successful complaint resolution was also tallied. The incidence of complaints per modality was calculated as a fraction of the total number of radiologic examinations performed.A total of 153 radiology-related complaints were identified. The majority of complaints (60.1% [92 of 153]) described a failure to provide patient-centered care. Of the remaining complaints, 26.2% (40 of 153) reported physical discomfort, 10.5% (16 of 153) reported a combination of both physical discomfort and lack of patient-centered care, and 3.2% (5 of 153) were not related to either category. Of the complaints regarding quality, 44.5% (68 of 153) were associated with operational systems, 24.2% (37 of 153) with safety, 17% (26 of 153) with professionalism, and 14.3% (22 of 153) with multifactorial events. Delays accounted for 20.2% of complaints (31 of 153), and 49.6% of complaints (76 of 153) concerned radiology staff members. Complaint resolution was achieved in 83.6% of cases (128 of 153). The overall incidence of complaints per radiologic procedure was 0.238 per 10,000. The incidence of complaints associated with interventional procedures (3.26 per 10,000) was significantly (P.05) higher than the incidence of those associated with noninterventional examinations (0.138 per 10,000).Failure to provide patient-centered care was the most common complaint; most of these complaints could be attributed to systems issues. There was a higher incidence of complaints related to interventional procedures than diagnostic examinations. Delays and providers' interactions with patients were identified as key areas for improvement.