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INTRODUCTION: There has been a rapid increase in the utilization of magnetic resonance imaging (MRI) for prostate cancer detection. The objective of this study was to measure the increase in utilization of MRI before prostate biopsy and the effects on the distribution of Prostate Imaging Reporting and Data System (PI-RAD) scores and Gleason grades over a 5-year interval in an integrated health system. METHODS: The authors conducted a retrospective analysis of prostate MRI studies prior to biopsy in the calendar years of 2017 and 2022. Peak PI-RADS score, peak Gleason grade of suspected prostatic lesions, and the number of biopsy cores were collected from radiology reports and pathology reports from patients’ electronic health records, respectively. All statistical tests were 2-tailed with a significance level set at p < 0.05. Categorical data analyses were performed using Mann–Whitney tests. Continuous data analyses were performed using t-tests. RESULTS: The total number of prostate MRIs and the number of MRIs with subsequent biopsy respectively increased by 178% and 215% over a 5-year interval (2017–2022). There was a higher proportion of MRI studies with an associated biopsy given a PIRADS score of ≥ 3 (91%) and a Gleason grade of ≥ 7 (61%) in 2022 than in 2017 (PI-RADS: 75%; Gleason: 28%). CONCLUSIONS: Increased utilization of prostate MRI has been associated with a higher proportion of biopsies with high PI-RADS and Gleason scores consistent with improved patient selection in this integrated health system. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIM: Data on prevalence of nonalcoholic fatty liver disease in Hawaii is limited. This study determined the prevalence of moderate to severe hepatic steatosis within a multicultural, multiethnic, and multiracial cohort in Hawaii undergoing computerized tomography (CT) for reasons unrelated to fatty liver disease. METHODS: The authors performed a retrospective analysis of all patients who were members of an integrated health care system with CT scans including the liver between January 1, 2020, and December 31, 2020. Moderate to severe hepatic steatosis was determined by an average attenuation value < 40 Hounsfield units for non-contrast-enhanced CT and a mean attenuation value < 90 Hounsfield units for contrast-enhanced CT. Patients' electronic medical records were reviewed for existing diagnoses of hepatic steatosis, obesity, and diabetes mellitus type 2 and data to calculate a Fibrosis-4 (FIB-4) index. RESULTS: Approximately 26.6% had moderate to severe hepatic steatosis, while only 11.3% of those patients had an active diagnosis of fatty liver disease. Native Hawaiians and Pacific Islanders (33.1%) had the greatest prevalence of hepatic steatosis, followed by White people (28.4%), Asian people (27.7%), and other ethnicities (10.8%). About 61.4% patients with fatty liver had a diagnosis of obesity, while 33.4% had a body mass index < 30.0 kg/m². Finally, 86.2% patients had enough information in their electronic medical records from which to calculate a FIB-4 score and the mean FIB-4 index was 1.66 ± 3.50. CONCLUSIONS: Moderate to severe hepatic steatosis is common among patients undergoing CT studies for reasons not related to hepatic steatosis in this multiethnic population most of whom did not have a diagnosis of fatty liver disease. [ABSTRACT FROM AUTHOR]

Computed tomography pulmonary angiography (CTPA) is an imaging study for which there is substantial evidence for its overuse in the evaluation of acute pulmonary embolism (PE). Prior literature has reported low positive PE rates, but the variability in positive rates among the ordering physicians has not been as well studied. The purpose of this study was to evaluate variation in ordering and positive rates among physicians in an emergency department (ED) within an integrated health care system. This study was based in a single ED that is part of a geographically isolated integrated health care system. We reviewed the patient records for all patients who underwent a CTPA for the evaluation for acute PE in the ED between January 1, 2018, and December 31, 2019. For each CTPA examination, we recorded the ordering ED physician, serum d-dimer value (mcg/mL), if any, and the results of the CTPA. Review of CTPAs over the 2-year period revealed 1380 CTPAs ordered by 23 ED physicians with a range of 25-141 studies per physician (mean of 60 + 31 CTPAs). The overall positive rate for PE was 6.9%. Individual ED physician positivity rates showed wide variability ranging from 0% to 18.4% (mean positive rate 7.6 + 4.4%). The results of this study confirm the need for greater adherence to existing guidelines using clinical decision rules and d-dimer testing when appropriate among all ED physicians but especially those who order a greater number of studies and have low rates for positive PE. [ABSTRACT FROM AUTHOR]

Introduction: We implemented a new thyroid nodule classification system in which a biopsy was recommended for thyroid lesions = 1 cm with at least 2 or more suspicious features. Methods: Three consecutive years of thyroid biopsies using the new classification system were reviewed for patient demographics, biopsy recommendation based on nodule size and imaging characteristics, and pathology results. The primary outcome was malignancy rates for thyroid biopsies. These results were compared to a 3-year historical data set. Results: Review of thyroid biopsies from 2010 to 2012, prior to the implementation of current recommendations, revealed 996 thyroid biopsies with a malignancy rate of 12.8%. Subsequent to the new classification system in 2017, 483 thyroid biopsies were performed over the next 3 years with a malignancy rate of 21.9%. Discussion: Implementation of the new classification system with a higher threshold for biopsy reduced our yearly biopsy volume by approximately 50% while also increasing our malignancy rate from 12.8% to 21.9%, which is more in line with published rates of malignancy. Conclusion: In a community setting performing less than 200 biopsies per year, the use of more stringent requirements for thyroid biopsy are necessary to achieve malignancy rates comparable to the published literature. [ABSTRACT FROM AUTHOR]

Background: In our health maintenance organization, we have seen a trend among our referring physicians to order simultaneous brain magnetic resonance imaging (MRI), head magnetic resonance angiography (MRA), and neck MRA in the evaluation of patients for acute stroke. However, there are little data to demonstrate any improvement in patient care resulting from ordering this triple study. The objective of this study was to analyze the utility of the triple MRI/MRA study for patients who experience stroke-like symptoms. Methods: We reviewed all triple-study cases between January 1, 2013 and December 31, 2016. We recorded whether or not an acute stroke occurred, the presence or absence of a major stenosis in the intracranial and/or neck arteries, subsequent percutaneous endovascular or open surgical intervention within 90 days, and any follow-up computed tomography angiography or carotid ultrasound studies within 30 days. Results: During the studied period, 591 triple studies were ordered, and 162 patients (27.4%) were found to have moderate or severe stenosis. Of the patients who had an acute stroke, 100 (48.3%) also had a major stenosis. Of 591 patients, only 15 (2.5%) underwent percutaneous endovascular or open surgical intervention within 90 days. Of these, 4 patients had an intervention in less than a week; in all of the cases, the triple study did not need to be ordered simultaneously to achieve the same clinical outcome. Conclusion: Brain MRI, head MRA, and neck MRA studies should not be ordered simultaneously as a generalized response to patients presenting with acute stroke-like symptoms. [ABSTRACT FROM AUTHOR]

Context: The frequency at which patients should undergo follow-up imaging of small pancreatic cysts is problematic because different medical societies have different follow-up guidelines. Objective: To determine whether short-term follow-up of small pancreatic cysts is necessary to detect pancreatic cancer or cystic neoplasia. Design: We retrospectively reviewed all abdominal magnetic resonance imaging (MRI) studies obtained in a geographically isolated health maintenance organization between January 1, 2012, and December 31, 2014, looking for pancreatic cysts. For each patient with one or more simple cysts, we recorded the size of the largest cyst. For patients with cysts, all their other computed tomography and MRI studies were reviewed to determine any change in size or morphology. The electronic medical record of every patient who underwent MRI was reviewed to determine development of pancreatic cancer. Main Outcome Measures: Change in cyst size on images. Results: Of 1946 patients, 342 were found to have at least 1 pancreatic cyst. A total of 228 patients had additional imaging from which to determine rates of change. The mean rate (standard deviation) of change for these cysts was 0.1 ± 2.0 mm/y. None of those cysts measuring 2 cm or smaller on MRI grew more than 5 mm in 2 years. Conclusion: Our data validate the clinical efficacy of obtaining follow-up imaging no sooner than 24 months after the initial detection of a simple pancreatic cyst 2 cm or smaller. Patients with cysts are more likely to have pancreatic cancer, but earlier follow-up imaging would not change their diagnosis of pancreatic cancer. [ABSTRACT FROM AUTHOR]

Context: The optimal lower extremity venous ultrasound (US) protocol to diagnose deep venous thrombosis of the popliteal and more proximal veins is unclear. Objective: To determine the three-month rate of symptomatic venous thromboembolism (VTE) and clinical outcomes of inpatients and ambulatory patients with normal findings on single venous ultrasound of the popliteal and more proximal veins (single proximal US). Design: Single proximal US results and clinical data of all inpatient and ambulatory patients with suspected acute deep venous thrombosis were retrospectively reviewed during a 12-month period between January and December 2014. Three-month follow-up data were reviewed for all these patients, who received all their care from a single geographically isolated health maintenance organization. Main Outcome Measures: Three-month rate of symptomatic VTE and clinical outcomes after an initially normal single proximal US result. Results: Of 1295 patients, 111 (8.6%) were found to have acute deep venous thrombosis on the initial proximal US. Of the remaining 1184 patients with initially normal results on proximal US who were sampled at 3-month follow-up, 1075 patients (90.8%) had no venous thromboembolic event. Among the others, 11 (0.9%) had a subsequent imaging-confirmed venous thromboembolic event, 53 (4.5%) died (none owing to venous thromboembolism), and 45 (3.8%) did not complete follow-up. Conclusion: Symptomatic VTE after an initially normal single proximal US result occurred in less than 1% of this cohort. Therefore, serial proximal US is unnecessary for most of our patients, and its elimination will save time and out-of-pocket expenses. [ABSTRACT FROM AUTHOR]

Introduction: Low incidence of adrenal cortical carcinoma in the general adult population has prompted a reevaluation of current protocol for the assessment of adrenal incidentalomas. Objective: To determine whether follow-up imaging for small (≤ 4 cm) incidental adrenal nodules is necessary for patients without known cancer. Methods: We performed a retrospective analysis of all patients found to have an incidental adrenal nodule on abdominal computed tomography (CT) scan during a 27-month period. The electronic medical record was reviewed to determine clinical outcomes in all patients with a minimum of 3 years of follow-up (mean follow-up = 6.7 years). Patients with a known primary cancer were excluded from the analysis unless they had a prior CT scan that documented an incidental adrenal nodule. Unenhanced CT attenuation was measured for all nodules, if available. Results: A total of 392 patients with an incidental adrenal nodule had a mean (standard deviation [SD]) clinical follow-up of 6.7 (2.7) years. There were 200 men and 192 women with a mean (SD) age of 66.0 (13.2) years. None of these patients developed primary adrenocortical carcinoma during the follow-up period. Two hundred forty of these patients also had a minimum 3 years of imaging followup (mean [SD], 6.4 [2.4] years; range, 3.1-13.6 years). There were 173 left-sided and 91 right-sided nodules on index CT scan. There was no significant difference in the mean (SD) rate of growth between left- and right-sided nodules (0.1 [0.8] mm/year vs 0.1 [0.8] mm/year, p = 0.58). Mean unenhanced CT attenuation of adrenal nodules did not affect the likelihood of adrenal malignancy during follow-up. Conclusion: Patients with small incidental adrenal nodules do not require additional imaging to exclude the possibility of adrenocortical carcinoma. [ABSTRACT FROM AUTHOR]

Context: As the use of computed tomography (CT) scans, which are expensive and result in considerable radiation exposure to the patient, continues to increase, communication between physicians and radiologists remains vital to explain the clinical context for the examination. However, the clinical information provided to the radiologist is often lacking. Objective: To determine whether the clinical information provided in CT scan requests me ets minimum criteria for requesting the examination. Methods: We reviewed the clinical indications for 400 CT chest scans and 400 CT abdomen/pelvis scans performed from January 1, 2016, through March 8, 2016. We determined whether each CT study indication was complete on the basis of whether the clinical information included an adequate clinical history with 1) a primary symptom, 2) the location of the symptom, and 3) the duration of the symptom as well as a suspected etiology. Results: Of the CT chest indications, 56 (14.0 %) of the clinical histories were considered complete and 17 (4.3%) had none of the components. A principal etiology was included in 195 (48.8%) of the indications. Of the CT abdomen/pelvis indications, 94 (23.5%) of the clinical histories were complete and 13 (3.3%) had none of the components. A principal etiology was included in 173 (43.3%) of the indications. Only 23 (5.8%) of the CT chest studies and 35 (8.8%) of the CT abdomen/pelvis studies had information considered sufficient for the radiologist. Conclusion: The percentage of complete clinical indications for both CT chest and abdomen/pelvis scans was much lower than 50%, suggesting that more emphasis should be placed on providing complete clinical indications. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the implementation of an increased D-dimer threshold value and clinical probability assessment increases the prevalence of pulmonary embolism (PE) in patients undergoing pulmonary computed tomography angiography (PCTA) in an Emergency Department setting. Methods: A retrospective review of all patients undergoing PCTA during 2 separate 12-month intervals, 1 before the implementation of an increased D-dimer threshold and recommendation for formal clinical probability assessment and the other after regional implementation. The primary outcome measure was the prevalence of acute PE in each of the samples. Results: After the implementation of the increased D-dimer threshold and recommendation for formal clinical probability assessment, the prevalence of PE detected by PCTA increased from 4.7% to 11.7% (p < 0.001). Among all PCTAs performed after the new guidelines were promulgated, 8.6% were still performed on patients who had serum D-dimer values lower than the threshold of 1.0 µg/mL. Despite the recommendation for formal clinical probability assessment before ordering a PCTA, only 4% of patients had a formal clinical probability assessment recorded in their electronic medical record. Conclusion: The implementation of an increased D-dimer threshold value increased the prevalence of PE in patients undergoing PCTA in an Emergency Department setting, but more consistent application of clinical probability assessment remains an elusive target. [ABSTRACT FROM AUTHOR]