Publications

PURPOSE: Emergent spinal MRI is recommended for patients with back pain and red flags for infection. However, many of these studies are negative due to low prevalence of spinal infections. Our purpose was to assess if C-reactive protein (CRP) can be used to guide effective utilization of emergent MRI for spinal infections.

METHODS: 316/960 (33%) MRIs performed for infection by the emergency department over 75-month period had CRP levels obtained at presentation, after excluding patients receiving antibiotic or had spinal surgery in < 1 month. An MRI was considered positive when there was imaging evidence of spinal infection confirmed on follow-up by surgery/biopsy/drainage or definitive therapy. A CRP of ≤ 10 mg/L was considered normal and > 100 mg/L as highly elevated.

RESULTS: CRP was normal in 95/316 (30%) and abnormal in 221/316 (70%) patients. MRI was positive in 43/316 (13.6%) patients, all of whom had abnormal CRP. CRP (p < 0.001) and intravenous drug use (IVDU; p = 0.002) were independently associated with a positive MRI. Receiver operator characteristic (ROC) analysis showed AUC of 0.76 for CRP, slightly improving with IVDU. Sensitivity, specificity, and negative predictive values for CRP level cut-off: 10 mg/L, 100%, 35%, and 100%, and 100 mg/L, 58%, 70% and 91%, respectively.

CONCLUSION: Abnormal CRP, although extremely sensitive, lacks specificity in predicting a positive MRI for spinal infection unless highly elevated. However, a normal CRP (absent recent antibiotic or surgery) makes spinal infection unlikely, and its routine use as a screening test can help reducing utilization of emergent MRI for this purpose.

OBJECTIVE: To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality.

BACKGROUND: RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce.

METHODS: A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; <June 2012) and "after training" (RADP and ODP; >June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy.

RESULTS: After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP.

CONCLUSION: Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

Incidental splenic focal findings are commonly encountered in clinical practice and frequently represent a diagnostic dilemma due to nonspecific imaging features. Most are benign, particularly in patients without a history of malignancy and without symptoms of fever, weight loss, or left upper quadrant or epigastric pain. Incidental malignant splenic processes are exceedingly rare. This article reviews imaging characteristics of incidental focal splenic findings, and proposes a practical approach for management of such findings, which can prevent unnecessary workup and its related drawbacks in clinical practice.

Diagnostic and evidential static image, video clip, and sound multimedia are captured during routine clinical care in cardiology, dermatology, ophthalmology, pathology, physiatry, radiation oncology, radiology, endoscopic procedural specialties, and other medical disciplines. Providers typically describe the multimedia findings in contemporaneous electronic health record clinical notes or associate a textual interpretative report. Visual communication aids commonly used to connect, synthesize, and supplement multimedia and descriptive text outside medicine remain technically challenging to integrate into patient care. Such beneficial interactive elements may include hyperlinks between text, multimedia elements, alphanumeric and geometric annotations, tables, graphs, timelines, diagrams, anatomic maps, and hyperlinks to external educational references that patients or provider consumers may find valuable. This HIMSS-SIIM Enterprise Imaging Community workgroup white paper outlines the current and desired clinical future state of interactive multimedia reporting (IMR). The workgroup adopted a consensus definition of IMR as "interactive medical documentation that combines clinical images, videos, sound, imaging metadata, and/or image annotations with text, typographic emphases, tables, graphs, event timelines, anatomic maps, hyperlinks, and/or educational resources to optimize communication between medical professionals, and between medical professionals and their patients." This white paper also serves as a precursor for future efforts toward solving technical issues impeding routine interactive multimedia report creation and ingestion into electronic health records.

HCC incidence continues to increase worldwide and is most frequently discovered at an advanced stage when limited curative options are available. Combination locoregional therapies have emerged to improve patient survival and quality of life or downstage patients to curative options. The increasing options for locoregional therapy combinations require an understanding of the expected post-treatment imaging appearance in order to assess treatment response. This review aims to describe the synergy between TACE combined with thermal ablation and TACE combined with SBRT. We will also illustrate expected imaging findings that determine treatment efficacy based on the mechanism of tissue injury using the LI-RADS Treatment Response Algorithm.

BACKGROUND: The perceived acuity of intracerebral hemorrhage (ICH) impacts the management of patients, both within emergent and outpatient/urgent settings. Morphology enabled dipole inversion (MEDI) quantitative susceptibility imaging (QSM) has improved characterization of ICH acuity, despite outstanding limitations in distinguishing blood products.

PURPOSE/HYPOTHESIS: Using improved susceptibility quantification, novel postprocessing QSM method from multiecho complex total field inversion (mcTFI) may better discriminate between acute and subacute ICH, compared to MEDI.

STUDY TYPE: Retrospective cohort study.

SUBJECTS: A total of 121 subjects enrolled following positive computerized tomography (CT) findings for ICH. Subjects were grouped based on time between admission and MR imaging: hyperacute (<24 hours), acute (1-3 days), early subacute (3-7 days), and late subacute (7-18 days).

FIELD STRENGTH/SEQUENCE: A multiecho gradient echo sequence at 3.0 T was paired with clinical noncontrast CT imaging.

ASSESSMENT: A quantitative index (CTindex ) was derived based on relative intensities of blood on noncontrast CT. All images were co-registered, from which QSM parameters within the ICH area were assessed across groups, as well as the correlation with CTindex .

STATISTICAL TESTS: Group differences were assessed using ANOVAs. Linear regressions between the CTindex , MEDI, and mcTFI measurements were used to assess their relationships. Statistical significance was set at P < 0.05.

RESULTS: A total of 21 hyperacute, 72 acute, 21 early subacute, and 7 late-subacute patients were included in this analysis. Significant changes in blood susceptibility were found over time for the MEDI and mcTFI, although mcTFI better differentiated the hyperacute/acute from subacute stages. CTindex values within the ICH were more strongly correlated with mcTFI QSM (r = 0.727) than MEDI (r = 0.412) QSM.

DATA CONCLUSION: McTFI susceptibility estimation demonstrated better correlation with ICH acuity as suggested by CT, providing an improved method to assess acuity of intracranial blood products in clinical settings to identify cases that may require acute intervention.

LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 2.