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Enormous recent progress in diagnostic testing can enable more accurate diagnosis and improved clinical outcomes. Yet these tests are increasingly challenging and frustrating; the volume and diversity of results may overwhelm the diagnostic acumen of even the most dedicated and experienced clinician. Because they are gathered and processed within the "silo" of each diagnostic discipline, diagnostic data are fragmented, and the electronic health record does little to synthesize new and existing data into usable information. Therefore, despite great promise, diagnoses may still be incorrect, delayed, or never made. Integrative diagnostics represents a vision for the future, wherein diagnostic data, together with clinical data from the electronic health record, are aggregated and contextualized by informatics tools to direct clinical action. Integrative diagnostics has the potential to identify correct therapies more quickly, modify treatment when appropriate, and terminate treatment when not effective, ultimately decreasing morbidity, improving outcomes, and avoiding unnecessary costs. Radiology, laboratory medicine, and pathology already play major roles in medical diagnostics. Our specialties can increase the value of our examinations by taking a holistic approach to their selection, interpretation, and application to the patient's care pathway. We have the means and rationale to incorporate integrative diagnostics into our specialties and guide its implementation in clinical practice., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To describe the prevalence and consequences of incidental findings when implementing routine noncontrast CT prior to cardiac surgery., Methods: In the multicenter randomized controlled CRICKET study, 862 adult patients scheduled for cardiac surgery were randomized 1:1 to undergo standard of care (SoC), which included a chest-radiograph, or an additional preoperative noncontrast chest CT-scan (SoC+CT). In this subanalysis, all incidental findings detected on the chest radiograph and CT-scan were analyzed. The influence of smoking status on incidental findings was also evaluated, adjusting for sex, age, and group allocation., Results: Incidental findings were observed in 11.4% (n = 49) of patients in the SoC+CT group and in 3.7% (n = 16) of patients in the SoC-group (p < 0.001). The largest difference was observed in findings requiring follow-up (SoC+CT 7.7% (n = 33) vs SoC 2.3% (n = 10), p < 0.001). Clinically relevant findings changing the surgical approach or requiring specific treatment were observed in 10 patients (1.2%, SoC+CT: 1.6% SoC: 0.7%), including lung cancer in 0.5% of patients (n = 4) and aortic dilatation requiring replacement in 0.2% of patients (n = 2). Incidental findings were more frequent in patients who stopped smoking (OR 1.91, 1.03-3.63) or who actively smoked (OR 3.91, 1.85-8.23)., Conclusions: Routine CT-screening increases the rate of incidental findings, mainly by identifying more pulmonary findings requiring follow-up. Incidental findings are more prevalent in patients with a history of smoking, and preoperative CT might increase the yield of identifying lung cancer in these patients. Incidental findings, but not specifically the use of routine CT, are associated with delay of surgery., Key Points: • Clinically relevant incidental findings are identified more often after a routine preoperative CT-scan, when compared to a standard of care workup, with some findings changing patient management. • Patients with a history of smoking have a higher rate of incidental findings and a lung cancer rate comparable to that of lung cancer screening trials. • We observed no clear delay in the time to surgery when adding routine CT screening., (© 2022. The Author(s).)

Background: European Association of Urology guidelines recommend a risk-adjusted biopsy strategy for early detection of prostate cancer in biopsy-naïve men. It remains unclear which strategy is most effective. Therefore, we evaluated two risk assessment pathways commonly used in clinical practice., Objective: To compare the diagnostic performance of a risk-based ultrasound (US)-directed pathway (Rotterdam Prostate Cancer Risk Calculator [RPCRC] #3; US volume assessment) and a magnetic resonance imaging (MRI)-directed pathway., Design, Setting, and Participants: This was a prospective multicenter study (MR-PROPER) with 1:1 allocation among 21 centers (US arm in 11 centers, MRI arm in ten). Biopsy-naïve men with suspicion of prostate cancer (age ≥50 yr, prostate-specific antigen 3.0-50 ng/ml, ± abnormal digital rectal examination) were included., Intervention: Biopsy-naïve men with elevated risk of prostate cancer, determined using RPCRC#3 in the US arm and Prostate Imaging Reporting and Data System scores of 3-5 in the MRI arm, underwent systematic biopsies (US arm) or targeted biopsies (MRI arm)., Outcome Measurements and Statistical Analysis: The primary outcome was the proportion of men with grade group (GG) ≥2 cancer. Secondary outcomes were the proportions of biopsies avoided and GG 1 cancers detected. Categorical (nonparametric) data were assessed using the Mann-Whitney U test and χ 2 tests., Results and Limitations: A total of 1965 men were included in the intention-to-treat population (US arm n = 950, MRI arm n = 1015). The US and MRI pathways detected GG ≥2 cancers equally well (235/950, 25% vs 239/1015, 24%; difference 1.2%, 95% confidence interval [CI] -2.6% to 5.0%; p = 0.5). The US pathway detected more GG 1 cancers than the MRI pathway (121/950, 13% vs 84/1015, 8.3%; difference 4.5%, 95% CI 1.8-7.2%; p < 0.01). The US pathway avoided fewer biopsies than the MRI pathway (403/950, 42% vs 559/1015, 55%; difference -13%, 95% CI -17% to -8.3%; p < 0.01). Among men with elevated risk, more GG ≥2 cancers were detected in the MRI group than in the US group (52% vs 43%; difference 9.2%, 95% CI 3.0-15%; p < 0.01)., Conclusions: Risk-adapted US-directed and MRI-directed pathways detected GG ≥2 cancers equally well. The risk-adapted US-directed pathway performs well for prostate cancer diagnosis if prostate MRI capacity and expertise are not available. If prostate MRI availability is sufficient, risk assessment should preferably be performed using MRI, as this avoids more biopsies and detects fewer cases of GG 1 cancer., Patient Summary: Among men with suspected prostate cancer, relevant cancers were equally well detected by risk-based pathways using either ultrasound or magnetic resonance imaging (MRI) to guide biopsy of the prostate. If prostate MRI availability is sufficient, risk assessment should be performed with MRI to reduce unnecessary biopsies and detect fewer irrelevant cancers., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: To assess the associations between: 1) baseline patellar tendon stiffness and clinical outcome after exercise therapy in athletes with patellar tendinopathy and 2) the change in patellar tendon stiffness and clinical outcome during progressive tendon-loading exercise therapy and eccentric exercise therapy., Design: Randomized controlled trial., Methods: Athletes with patellar tendinopathy aged 18-35 years, playing tendon-loading sports at least 3 times per week were randomized in a 1:1 ratio between progressive tendon-loading exercise therapy and eccentric exercise therapy for 24 weeks. Patellar tendinopathy was diagnosed clinically, and confirmed by ultrasound. Patellar tendon stiffness (kilopascal, kPa) was assessed using shear-wave elastography. Clinical outcome was assessed using the validated Victorian Institute of Sports Assessment (VISA-P; range 0-100) questionnaire. Both were assessed at baseline, 12 and 24 week follow-up. Adjusted general linear, mixed-linear models and Generalized Estimating Equations were used., Results: We included 76 athletes (58 men, mean age 24 ± 4 years). No association was found between baseline stiffness and VISA-P after 24 weeks (p = 0.52). Decreased stiffness (adjusted mean difference = 10 kPa (95% CI: 4-15) was significantly associated with improved clinical outcome at 12 weeks in all athletes (p = 0.02), and at both 12 and 24 weeks (p = 0.01) in athletes allocated to progressive tendon-loading exercise therapy., Conclusions: Patellar tendon stiffness, assessed with shear-wave elastography, is unsuitable to use as a single predictive measurement for clinical outcome. Decreasing stiffness during the course of exercise therapy is associated with improved clinical outcome in athletes recovering from patellar tendinopathy., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: To evaluate if routine screening for aortic calcification using unenhanced CT lowers the risk of stroke and alters the surgical approach in patients undergoing general cardiac surgery compared with standard of care (SoC)., Methods: In this prospective, multicenter, randomized controlled trial, adult patients scheduled for cardiac surgery from September 2014 to October 2019 were randomized 1:1 into two groups: SoC alone, including chest radiography, vs. SoC plus preoperative noncontrast CT. The primary endpoint was in-hospital perioperative stroke. Secondary endpoints were preoperative change of the surgical approach, in-hospital mortality, and postoperative delirium. The trial was halted halfway for expected futility, as the conditional power analysis showed a chance < 1% of finding the hypothesized effect., Results: A total of 862 patients were evaluated (SoC-group: 433 patients (66 ± 11 years; 74.1% male) vs. SoC + CT-group: 429 patients (66 ± 10 years; 69.9% male)). The perioperative stroke rate (SoC + CT: 2.1%, 9/429 vs. SoC: 1.2%, 5/433, p = 0.27) and rate of changed surgical approach (SoC + CT: 4.0% (17/429) vs. SoC: 2.8% (12/433, p = 0.35) did not differ between groups. In-hospital mortality and postoperative delirium were comparable between groups. In the SoC + CT group, aortic calcification was observed on CT in the ascending aorta in 28% (108/380) and in the aortic arch in 70% (265/379)., Conclusions: Preoperative noncontrast CT in cardiac surgery candidates did not influence the surgical approach nor the incidence of perioperative stroke compared with standard of care. Aortic calcification is a frequent finding on the CT scan in these patients but results in major surgical alterations to prevent stroke in only few patients., Key Points: • Aortic calcification is a frequent finding on noncontrast computed tomography prior to cardiac surgery. • Routine use of noncontrast computed tomography does not often lead to a change of the surgical approach, when compared to standard of care. • No effect was observed on perioperative stroke after cardiac surgery when using routine noncontrast computed tomography screening on top of standard of care., (© 2021. The Author(s).)

Introduction: Knee osteoarthritis is a common disease with pain as the most prevalent symptom. Previous cohort studies have shown genicular artery embolization to reduce pain symptoms in patients with mild to moderate knee osteoarthritis. Patients resistant to conservative therapy but not eligible yet for surgical treatment due to young age or comorbidities may profit from an effective and sustained pain reduction treatment. This study is a randomized sham-controlled trial to evaluate the efficacy of genicular artery embolization in patients with knee osteoarthritis., Methods and Analysis: Fifty-eight patients with mild-to-moderate knee osteoarthritis will be recruited and randomly allocated to the treatment or control group in a 1:1 ratio. Participants in the treatment group will undergo genicular artery embolization. Patients in the control group will undergo sham treatment. Outcome measurements will be assessed at baseline and after 1, 4, 8, and 12 months with questionnaires, pressure pain threshold testing, and MR imaging. The MR imaging protocol is designed to (semi)quantitatively assess osteoarthritis in the knee joint. The primary outcome is the change from baseline of the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale after 4 months. Secondary outcomes include change in osteoarthritis-related questionnaires, pressure pain threshold, and OA-related MRI features, particularly synovitis and bone marrow lesions., Ethics and Dissemination: This trial will determine the efficacy of genicular artery embolization compared to a sham treatment. This is of importance to assess before proceeding to larger-scale efficiency studies and, ultimately, implementing this treatment into day to day clinical practice., Trial Registration: ClinicalTrials.gov NCT03884049. Registered on 21 March 2019., (© 2022. The Author(s).)

Background: Exercise therapy is considered preferential treatment for patellar tendinopathy (PT). However, there is conflicting evidence for structural patellar tendon adaptation in response to exercise therapy and its association with symptoms is weak., Purpose: To assess the association between 1) T 2 * relaxation times and symptom severity; 2) baseline T 2 * and clinical outcome; and 3) longitudinal T 2 * changes and clinical outcome in athletes with PT performing exercise therapy., Study Type: Randomized controlled clinical trial., Subjects: Seventy-six athletes (18-35 years) with clinically diagnosed and ultrasound-confirmed PT., Field Strength/sequence: 3D gradient echo sequence (3.0 T)., Assessment: Patients were enrolled in a randomized trial of progressive tendon-loading exercises (PTLE) versus eccentric exercise therapy (EET). Symptoms were assessed using the Victorian Institute of Sports Assessment (VISA-P) questionnaire. 3D-Ultrashort echo time (UTE)-MRI was acquired at baseline, 12 and 24 weeks. Voxel-wise T 2 * relaxation times were quantified using mono-exponential and bi-exponential models. T 2 * analysis was performed in three patellar tendon tissue compartments representing: aligned collagen, degenerative tissue, and interface., Statistical Tests: Adjusted general linear, mixed-linear models, and generalized estimating equations., Results: We included 76 patients with PT (58 men, mean age 24 ± 4 years); 38 in the PTLE-group and 38 in the EET-group, of which 57 subjects remained eligible for analysis. T 2 * relaxation times were significantly associated with VISA-P in degenerative and interface tissues of the patellar tendon. No association was found between baseline T 2 * and VISA-P after 24 weeks (P > 0.29). The estimated mean T 2 * in degenerative tissue decreased from 14 msec (95%CI: 12-16) at baseline to 13 msec (95%CI: 11-15) at 12 weeks and to 13 msec (95%CI: 10-15) at 24 weeks. The significant decrease in T 2 * from baseline to 24 weeks was associated with improved clinical outcome., Data Conclusion: Tissue-specific T 2 * relaxation times, identified with 3D-UTE-MRI, decreased significantly in athletes with patellar tendinopathy performing exercise therapy and this decrease was associated with improved clinical outcome., Evidence Level: 1 TECHNICAL EFFICACY: Stage 4., (© 2021 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC. on behalf of International Society for Magnetic Resonance in Medicine.)

Our purpose is to evaluate bias and repeatability of the quantitative MRI sequences QRAPMASTER, based on steady-state imaging, and variable Flip Angle MRF (MRF-VFA), based on the transient response. Both techniques are assessed with a standardized phantom and five volunteers on 1.5 T and 3 T clinical scanners. All scans were repeated eight times in consecutive weeks. In the phantom, the mean bias±95% confidence interval for T1 values with QRAPMASTER was 10 ± 10% on 1.5 T and 4 ± 13% on 3.0 T. The mean bias for T1 values with MRF-vFA was 21 ± 17% on 1.5 T and 9 ± 9% on 3.0 T. For T2 values the mean bias with QRAPMASTER was 12 ± 3% on 1.5 T and 23 ± 1% on 3.0 T. For T2 values the mean bias with MRF-vFA was 17 ± 1% on 1.5 T and 19 ± 2% on 3.0 T. QRAPMASTER estimated lower T1 and T2 values than MRF-vFA. Repeatability was good with low coefficients of variation (CoV). Mean CoV ± 95% confidence interval for T1 were 3.2 ± 0.4% on 1.5 T and 4.5 ± 0.8% on 3.0 T with QRAPMASTER and 2.7% ± 0.2% on 1.5 T and 2.5 ± 0.2% on 3.0 T with MRF-vFA. For T2 were 3.3 ± 1.9% on 1.5 T and 3.2 ± 0.6% on 3.0 T with QRAPMASTER and 2.0 ± 0.4% on 1.5 T and 5.7 ± 1.0% on 3.0 T with MRF-vFA. The in-vivo T1 and T2 are in the range of values previously reported by other authors. The in-vivo mean CoV ± 95% confidence interval in gray matter were for T1 1.7 ± 0.2% using QRAPMASTER and 0.7 ± 0.5% using MRF-vFA and for T2 were 0.9 ± 0.4% using QRAPMASTER and 2.4 ± 0.5% using MRF-vFA. In white matter were for T1 0.9 ± 0.3% using QRAPMASTER and 1.3 ± 1.1% using MRF-vFA and for T2 were 0.7 ± 0.4% using QRAPMASTER and 2.4 ± 0.4% using MRF-vFA. A GLM analysis showed that the variations in T1 and T2 mainly depend on the field strength and the subject, but not on the follow-up repetition in different days. This confirms the high repeatability of QRAPMASTER and MRF-vFA. In summary, QRAPMASTER and MRF-vFA on both systems were highly repeatable with moderate accuracy, providing results comparable to standard references. While repeatability was similar for both methods, QRAPMASTER was more accurate. QRAPMASTER is a tested commercial product but MRF-vFA is 4.77 times faster, which would ease the inclusion of quantitative relaxometry., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Bicuspid aortic valve (BAV) is a complex malformation affecting not merely the aortic valve. However, little is known regarding the dynamic physiology of the aortic annulus in these patients and whether it is similar to tricuspid aortic valves (TAV). Determining the BAV annular plane is more challenging than for TAV. Our aim was to present a standardized methodology to determine BAV annulus and investigate its changes in shape and dimensions during the cardiac cycle., Methods: BAV patients were prospectively included and underwent an ECG-gated cardiac CTA. The annulus plane was manually identified on reconstructions at 5% intervals of the cardiac cycle with a new standardized method for different BAV types. Based on semi-automatically defined contours, maximum and minimum diameter, area, area-derived diameter, perimeter, asymmetry ratio (AR), and relative area were calculated. Differences of dynamic annular parameters were assessed also per BAV type., Results: Of the 55 patients included (38.4 ± 13.3 years; 58% males), 38 had BAV Sievers type 1, 10 type 0, and 7 type 2. The minimum diameter, perimeter, area, and area-derived diameter were significantly higher in systole than in diastole with a relative change of 13.7%, 4.8%, 13.7%, and 7.2% respectively (all p < 0.001). The AR was ≥ 1.1 in all phases, indicating an elliptic shape, with more pronounced flattening in diastole (p < 0.001). Different BAV types showed comparable dynamic changes., Conclusions: BAV annulus undergo significant changes in shape during the cardiac cycle with a wider area in systole and a more elliptic conformation in diastole regardless of valve type., Key Points: • A refined method for the identification of the annulus plane on CT scans of patients with bicuspid aortic valves, tailored for the specific anatomy of each valve type, is proposed. • The annulus of patients with bicuspid aortic valves undergoes significant changes during the cardiac cycle with a wider area and more circular shape in systole regardless of valve type. • As compared to previously published data, the bicuspid aortic valve annulus has physiological dynamics similar to that encountered in tricuspid valves but with overall larger dimensions., (© 2021. The Author(s).)

Backgrounds: Transcatheter-implanted aortic valve infective endocarditis (TAVI-IE) is difficult to diagnose when relying on the Duke Criteria. Our aim was to assess the additional diagnostic value of 18 F-fluorodeoxyglucose ( 18 F-FDG) positron emission/computed tomography (PET/CT) and cardiac computed tomography angiography (CTA) in suspected TAVI-IE., Methods: A multicenter retrospective analysis was performed in all patients who underwent 18 F-FDG-PET/CT and/or CTA with suspected TAVI-IE. Patients were first classified with Duke Criteria and after adding 18 F-FDG-PET/CT and CTA, they were classified with European Society of Cardiology (ESC) criteria. The final diagnosis was determined by our Endocarditis Team based on ESC guideline recommendations., Results: Thirty patients with suspected TAVI-IE were included. 18 F-FDG-PET/CT was performed in all patients and Cardiac CTA in 14/30. Using the Modified Duke Criteria, patients were classified as 3% rejected (1/30), 73% possible (22/30), and 23% definite (7/30) TAVI-IE. Adding 18 F-FDG-PET/CT and CTA supported the reclassification of 10 of the 22 possible cases as "definite TAVI-IE" (5/22) or "rejected TAVI-IE" (5/22). This changed the final diagnosis to 20% rejected (6/30), 40% possible (12/30), and 40% definite (12/30) TAVI-IE., Conclusions: Addition of 18 F-FDG-PET/CT and/or CTA changed the final diagnosis in 33% of patients and proved to be a valuable diagnostic tool in patients with suspected TAVI-IE., (© 2019. The Author(s).)

We present and evaluate a new insight into magnetic resonance imaging (MRI). It is based on the algebraic description of the magnetization during the transient response-including intrinsic magnetic resonance parameters such as longitudinal and transverse relaxation times (T 1 , T 2 ) and proton density (PD) and experimental conditions such as radiofrequency field (B 1 ) and constant/homogeneous magnetic field (B 0 ) from associated scanners. We exploit the correspondence among three different elements: the signal evolution as a result of a repetitive sequence of blocks of radiofrequency excitation pulses and encoding gradients, the continuous Bloch equations and the mathematical description of a sequence as a linear system. This approach simultaneously provides, in a single measurement, all quantitative parameters of interest as well as associated system imperfections. Finally, we demonstrate the in-vivo applicability of the new concept on a clinical MRI scanner., (© 2021. The Author(s).)

Due to the outbreak of Severe Acute Respiratory Syndrome coronavirus (SARS-Cov-2), an efficient COVID-19 screening strategy is required for patients undergoing cardiac surgery. The objective of this prospective observational study was to evaluate the role of preoperative computed tomography (CT) screening for COVID-19 in a population of COVID-19 asymptomatic patients scheduled for cardiac surgery. Between the 29th of March and the 26th of May 2020, patients asymptomatic for COVID-19 underwent a CT-scan the day before surgery, with reverse-transcriptase polymerase-chain reaction (RT-PCR) reserved for abnormal scan results. The primary endpoint was the prevalence of abnormal scans, which was evaluated using the CO-RADS score, a COVID-19 specific grading system. In a secondary analysis, the rate of abnormal scans was compared between the screening cohort and matched historical controls who underwent routine preoperative CT-screening prior to the SARS-Cov-2 outbreak. Of the 109 patients that underwent CT-screening, an abnormal scan result was observed in 7.3% (95% confidence interval: 3.2-14.0%). One patient, with a normal screening CT, was tested positive for COVID-19, with the first positive RT-PCR on the ninth day after surgery. A rate of preoperative CT-scan abnormalities of 8% (n = 8) was found in the unexposed historical controls (P > 0.999). In asymptomatic patients undergoing cardiac surgery, preoperative screening for COVID-19 using computed tomography will identify pulmonary abnormalities in a small percentage of patients that do not seem to have COVID-19. Depending on the prevalence of COVID-19, this results in an unfavorable positive predictive value of CT screening. Care should be taken when considering CT as a screening tool prior to cardiac surgery., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation., Methods, Findings and Interpretation: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To explore the association between baseline osteoarthritis (OA)-related magnetic resonance (MR) imaging features and pain reduction after genicular artery embolization (GAE) in patients with mild-to-moderate symptomatic knee OA resistant to conservative therapy., Materials and Methods: This was a retrospective analysis of patients with mild-to-moderate symptomatic knee OA treated with GAE using imipenem-cilastatin sodium. The clinical outcome was scored at baseline and 6 months after treatment using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). MR images were scored using the MR imaging osteoarthritis knee score. Linear regression was used to evaluate associations of before-treatment MR imaging scores with WOMAC pain and WOMAC total reduction after 6 months., Results: Fifty-four patients (22.2% male; median age, 69.4 years; median WOMAC pain at baseline, 12) were evaluated. Of all OA features scored, a higher cartilage full-thickness defect score showed the strongest association with less reduction of both WOMAC pain (B,-0.63 [95% confidence interval (CI), -0.91 to -0.34]; P < .001) and WOMAC total scores (B, -1.77 [95% CI, -2.87 to -0.67]; P < .001) following treatment. The presence of grade 2-3 effusion synovitis (B, -2.99 [95% CI, -5.39 to -0.60]) bone marrow lesions (B, -0.52 [95% CI, -0.86 to -0.19]), osteophytes (B, -0.21 [95% CI, -0.36 to -0.06]), and cartilage defect surface area score (B, -0.25 [95% CI -0.42 to -0.08]) all showed a significant association with less WOMAC pain reduction (all P < .05)., Conclusions: In patients with mild-to-moderate symptomatic knee OA treated with GAE, the presence and severity of full-thickness cartilage defects, effusion synovitis, bone marrow lesions, osteophytes, and cartilage surface area scores at baseline are associated with less favorable clinical outcomes at 6 months., (Copyright © 2020 SIR. Published by Elsevier Inc. All rights reserved.)

Background: To assess diagnostic accuracy of quantitative double-echo in steady-state (qDESS) MRI for detecting synovitis in knee osteoarthritis (OA)., Methods: Patients with different degrees of radiographic knee OA were included prospectively. All underwent MRI with both qDESS and contrast-enhanced T1-weighted magnetic resonance imaging (CE-MRI). A linear combination of the two qDESS images can be used to create an image that displays contrast between synovium and the synovial fluid. Synovitis on both qDESS and CE-MRI was assessed semi-quantitatively, using a whole-knee synovitis sum score, indicating no/equivocal, mild, moderate, and severe synovitis. The correlation between sum scores of qDESS and CE-MRI (reference standard) was determined using Spearman's rank correlation coefficient and intraclass correlation coefficient for absolute agreement. Receiver operating characteristic analysis was performed to assess the diagnostic performance of qDESS for detecting different degrees of synovitis, with CE-MRI as reference standard., Results: In the 31 patients included, very strong correlation was found between synovitis sum scores on qDESS and CE-MRI (ρ = 0.96, p < 0.001), with high absolute agreement (0.84 (95%CI 0.14-0.95)). Mean sum score (SD) values on qDESS 5.16 (3.75) were lower than on CE-MRI 7.13 (4.66), indicating systematically underestimated synovitis severity on qDESS. For detecting mild synovitis or higher, high sensitivity and specificity were found for qDESS (1.00 (95%CI 0.80-1.00) and 0.909 (0.571-1.00), respectively). For detecting moderate synovitis or higher, sensitivity and specificity were good (0.727 (95%CI 0.393-0.927) and 1.00 (0.800-1.00), respectively)., Conclusion: qDESS MRI is able to, however with an underestimation, detect synovitis in patients with knee OA.

Background: Patellofemoral pain (PFP) is a common knee condition and possible precursor of knee osteoarthritis (OA). Inflammation, leading to an increased perfusion, or increased volume of the infrapatellar fat pad (IPFP) may induce knee pain. The aim of the study was to compare quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameters, as imaging biomarkers of inflammation, and volume of the IPFP between patients with PFP and controls and between patients with and without IPFP edema or joint effusion., Methods: Patients with PFP and healthy controls were included and underwent non-fat suppressed 3D fast-spoiled gradient-echo (FSPGR) and DCE-MRI. Image registration was applied to correct for motion. The IPFP was delineated on FSPGR using Horos software. Volume was calculated and quantitative perfusion parameters were extracted by fitting extended Tofts' pharmacokinetic model. Differences in volume and DCE-MRI parameters between patients and controls were tested by linear regression analyses. IPFP edema and effusion were analyzed identically., Results: Forty-three controls and 35 PFP patients were included. Mean IPFP volume was 26.04 (4.18) mL in control subjects and 27.52 (5.37) mL in patients. Median K trans was 0.017 (0.016) min -1 in control subjects and 0.016 (0.020) min -1 in patients. None of the differences in volume and perfusion parameters were statistically significant. Knees with effusion showed a higher perfusion of the IPFP compared to knees without effusion in patients only., Conclusions: The IPFP has been implicated as source of knee pain, but higher DCE-MR blood perfusion, an imaging biomarker of inflammation, and larger volume are not associated with PFP. Patient's knees with effusion showed a higher perfusion, pointing towards inflammation., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/qims-20-441). EHGO serves as an unpaid Associate Editor of Quantitative Imaging in Medicine and Surgery. Dr. RA van der Heijden reports grants from European Society Skeletal Radiology, during the conduct of the study; Dr. M van Middelkoop reports grants from Erasmus University Rotterdam, during the conduct of the study; Dr. SMABZ reports grants from Dutch Artritis Foundation, during the conduct of the study; Dr. EHGO reports grants from RSNA, during the conduct of the study. The other authors have no conflicts of interest to declare., (2021 Quantitative Imaging in Medicine and Surgery. All rights reserved.)

Background: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation., Methods, Findings and Interpretation: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Purpose: To assess the diagnostic accuracy of grayscale (GSUS), power Doppler (PDUS) and contrast-enhanced ultrasound (CEUS) for detecting synovitis in knee osteoarthritis (OA)., Method: Patients with different degrees of radiographic knee OA were included prospectively. All underwent GSUS, PDUS, CEUS, and contrast-enhanced magnetic resonance imaging (CE-MRI), on which synovitis was assessed semi-quantitatively. Correlations of synovitis severity on ultrasound based techniques with CE-MRI were determined. Receiver operating characteristic (ROC) analysis was performed to assess diagnostic performance of GSUS, PDUS, and CEUS, for detecting synovitis, using CE-MRI as reference-standard., Results: In the 31 patients included, synovitis scoring on GSUS and CEUS was significantly correlated (ρ = 0.608, p < 0.001 and ρ = 0.391, p = 0.033) with CE-MRI. For detecting mild synovitis, the area under the curve (AUC) was 0.781 (95 %CI 0.609-0.953) for GSUS, 0.788 (0.622-0.954) for PDUS, and 0.653 (0.452-0.853) for CEUS. Sensitivity and specificity were 0.667 (0.431-0.845) and 0.700 (0.354-0.919) for GSUS, 0.905 (0.682-0.983) and 0.500 (0.201-0.799) for PDUS, and 0.550 (0.320-0.762) and 0.700 (0.354-0.919) for CEUS, respectively. The AUC of GSUS increased to 0.862 (0.735-0.989), 0.823 (0.666-0.979), and 0.885 (0.767-1.000), when combined with PDUS, CEUS, or both, respectively. For detecting moderate synovitis, the AUC of GSUS was higher (0.882 (0.750-1.000)) and no added value of PDUS and CEUS was observed., Conclusions: GSUS has limited overall accuracy for detecting synovitis in knee OA. When GSUS is combined with PDUS or CEUS, overall diagnostic performance improves for detecting mild synovitis, but not for moderate synovitis., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: To develop an automatic method for identification and segmentation of clinically significant prostate cancer in low-risk patients and to evaluate the performance in a routine clinical setting., Methods: A consecutive cohort (n = 292) from a prospective database of low-risk patients eligible for the active surveillance was selected. A 3-T multi-parametric MRI at 3 months after inclusion was performed. Histopathology from biopsies was used as reference standard. MRI positivity was defined as PI-RADS score ≥ 3, histopathology positivity was defined as ISUP grade ≥ 2. The selected cohort contained four patient groups: (1) MRI-positive targeted biopsy-positive (n = 116), (2) MRI-negative systematic biopsy-negative (n = 55), (3) MRI-positive targeted biopsy-negative (n = 113), (4) MRI-negative systematic biopsy-positive (n = 8). Group 1 was further divided into three sets and a 3D convolutional neural network was trained using different combinations of these sets. Two MRI sequences (T2w, b = 800 DWI) and the ADC map were used as separate input channels for the model. After training, the model was evaluated on the remaining group 1 patients together with the patients of groups 2 and 3 to identify and segment clinically significant prostate cancer., Results: The average sensitivity achieved was 82-92% at an average specificity of 43-76% with an area under the curve (AUC) of 0.65 to 0.89 for different lesion volumes ranging from > 0.03 to > 0.5 cc., Conclusions: The proposed deep learning computer-aided method yields promising results in identification and segmentation of clinically significant prostate cancer and in confirming low-risk cancer (ISUP grade ≤ 1) in patients on active surveillance., Key Points: • Clinically significant prostate cancer identification and segmentation on multi-parametric MRI is feasible in low-risk patients using a deep neural network. • The deep neural network for significant prostate cancer localization performs better for lesions with larger volumes sizes (> 0.5 cc) as compared to small lesions (> 0.03 cc). • For the evaluation of automatic prostate cancer segmentation methods in the active surveillance cohort, the large discordance group (MRI positive, targeted biopsy negative) should be included.

Objectives: (1) To determine the association between patellar tendon stiffness and the presence of patellar tendinopathy (PT). (2) To evaluate the reliability of shear-wave elastography (SWE)., Methods: Participants were consecutively enrolled between January 2017 and June 2019. PT was diagnosed clinically and confirmed by either grayscale US or power Doppler US, or both. Controls had no history of anterior knee pain and no clinical signs of PT. Patellar tendon stiffness (kilopascal, kPa) was assessed using SWE. Logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Reliability analyses included coefficients-of-variation (CV), coefficients-of-repeatability (CR), intraclass correlation coefficient (ICC) for intraobserver and interobserver reliability, and Bland-Altman analysis., Results: In total, 76 participants with PT (58 men, mean age 24.4 ± 3.8 years) and 35 asymptomatic controls (16 men, mean age 21.5 ± 3.8 years) were included. Univariate analyses (OR 1.094, 95% CI 1.061-1.128, p < .001) and adjusted multivariate analyses (OR 1.294, 95% CI 1.044-1.605, p = .018) showed that athletes with PT had significantly increased patellar tendon stiffness. ICC for intraobserver reliability was 0.95 (95% CI 0.92-0.97), CR (CV) 12 kPa (10%) and 0.79 (95% CI 0.65-0.88), CR (CV) 18 kPa (21%) for interobserver reliability. Mean differences from Bland-Altman analysis were 5.6 kPa (95% CI 3.1-8.1, p < .001) for intraobserver reliability and 4.6 kPa (95% CI 1.9-7.2, p < .001) for interobserver reliability., Conclusions: PT is associated with significantly higher patellar tendon stiffness. SWE measurements demonstrate excellent intraobserver reliability and good interobserver reliability. Therefore, SWE is a promising tool to implement in longitudinal studies and future studies should evaluate its prognostic value and utility as a monitoring tool in athletes with PT., Key Points: • Patellar tendon stiffness measured with shear-wave elastography (SWE) is higher in athletes with patellar tendinopathy than in healthy controls, also after adjusting for potential confounders. • Excellent intraobserver reliability and good interobserver reliability were found for the quantitative assessment of patellar tendon stiffness using SWE.

Aims: The aim of this study was to evaluate the possible value of dobutamine stress cardiac magnetic resonance imaging (CMR) to predict adverse outcome in Tetralogy of Fallot (TOF) patients., Methods and Results: In previous prospective multicentre studies, TOF patients underwent low-dose dobutamine stress CMR (7.5 µg/kg/min). Subsequently, during regular-care patient follow-up, patients were assessed for reaching the composite endpoint (cardiac death, arrhythmia-related hospitalization, or cardioversion/ablation, VO2 max ≤65% of predicted). A normal stress response was defined as a decrease in end-systolic volume (ESV) and increase in ejection fraction. The relative parameter change during stress was calculated as relative parameter change = [(parameterstress - parameterrest)/parameterrest] * 100. The predictive value of dobutamine stress CMR for the composite endpoint was determined using time-to-event analyses (Kaplan-Meier) and Cox proportional hazard analysis. We studied 100 patients [67 (67%) male, median age at baseline CMR 17.8 years (interquartile range 13.5-34.0), age at TOF repair 0.9 years (0.6-2.1)]. After a median follow-up of 8.6 years (6.7-14.1), 10 patients reached the composite endpoint. An abnormal stress response (30% vs. 4.4%, P = 0.021) was more frequently observed in composite endpoint patients. Also in endpoint patients, the relative decrease in right ventricular ESV decreased less during stress compared with the patients without an endpoint (-17 ± 15 vs. -26 ± 13 %, P = 0.045). Multivariable analyses identified an abnormal stress response (hazard ratio 10.4; 95% confidence interval 2.5-43.7; P = 0.001) as predictor for the composite endpoint., Conclusion: An abnormal ventricular response to dobutamine stress is associated with adverse outcome in patients with repaired TOF., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Quantitative MRI of patellar tendinopathy (PT) can be challenging due to spatial variation of T 2 * relaxation times., Purpose: 1) To compare T 2 * quantification using a standard approach with analysis in specific tissue compartments of the patellar tendon. 2) To evaluate test-retest reliability of different methods for fitting ultrashort echo time (UTE)-relaxometry data., Study Type: Prospective., Subjects: Sixty-five athletes with PT., Field Strength/sequence: 3D UTE scans covering the patellar tendon were acquired using a 3.0T scanner and a 16-channel surface coil., Assessment: Voxelwise median T 2 * was quantified with monoexponential, fractional-order, and biexponential fitting. We applied two methods for T 2 * analysis: first, a standard approach by analyzing all voxels covering the proximal patellar tendon. Second, within subregions of the patellar tendon, by using thresholds on biexponential fitting parameter percentage short T 2 * (0-30% for mostly long T 2 *, 30-60% for mixed T 2 *, and 60-100% for mostly short T 2 *)., Statistical Tests: Average test-retest reliability was assessed in three athletes using coefficients-of-variation (CV) and coefficients-of-repeatability (CR)., Results: With standard image analysis, we found a median [interquartile range, IQR] monoexponential T 2 * of 6.43 msec [4.32-8.55] and fractional order T 2 * 4.39 msec [3.06-5.78]. The percentage of short T 2 * components was 52.9% [35.5-69.6]. Subregional monoexponential T 2 * was 13.78 msec [12.11-16.46], 7.65 msec [6.49-8.61], and 3.05 msec [2.52-3.60] and fractional order T 2 * 11.82 msec [10.09-14.44], 5.14 msec [4.25-5.96], and 2.19 msec [1.82-2.64] for 0-30%, 30-60%, and 60-100% short T 2 *, respectively. Biexponential component short T 2 * was 1.693 msec [1.417-2.003] for tissue with mostly short T 2 * and long T 2 * of 15.79 msec [13.47-18.61] for mostly long T 2 *. The average CR (CV) was 2 msec (15%), 2 msec (19%) and 10% (22%) for monoexponential, fractional order and percentage short T 2 *, respectively., Data Conclusion: Patellar tendinopathy is characterized by regional variability in binding states of water. Quantitative multicompartment T 2 * analysis in PT can be facilitated using a voxel selection method based on using biexponential fitting parameters., Level of Evidence: 1 TECHNICAL EFFICACY STAGE: 1 J. Magn. Reson. Imaging 2020;52:420-430., (© 2020 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.)

Objectives: To investigate whether serial prostate magnetic resonance imaging (MRI) may guide the utility of repeat targeted (TBx) and systematic biopsy (SBx) when monitoring men with low-risk prostate cancer (PCa) at 1-year of active surveillance (AS)., Patients and Methods: We retrospectively included 111 consecutive men with low-risk (International Society of Urological Pathology [ISUP] Grade 1) PCa, who received protocolled repeat MRI with or without TBx and repeat SBx at 1-year of AS. TBx was performed in Prostate Imaging-Reporting and Data System (PI-RADS) score ≥3 lesions (MRI-positive men). Upgrading defined as ISUP Grade ≥2 PCa (I), Grade ≥2 with cribriform growth/intraductal carcinoma PCa (II), and Grade ≥3 PCa (III) was investigated. Upgrading detected by TBx only (not by SBx) and SBx only (not by TBx) was investigated in MRI-positive and -negative men, and related to radiological progression on MRI (Prostate Cancer Radiological Estimation of Change in Sequential Evaluation [PRECISE] score)., Results: Overall upgrading (I) was 32% (35/111). Upgrading in MRI-positive and -negative men was 48% (30/63) and 10% (5/48) (P < 0.001), respectively. In MRI-positive men, there was upgrading in 23% (seven of 30) by TBx only and in 33% (10/30) by SBx only. Radiological progression (PRECISE score 4-5) in MRI-positive men was seen in 27% (17/63). Upgrading (I) occurred in 41% (seven of 17) of these MRI-positive men, while this was 50% (23/46) in MRI-positive men without radiological progression (PRECISE score 1-3) (P = 0.534). Overall upgrading (II) was 15% (17/111). Upgrading in MRI-positive and -negative men was 22% (14/63) and 6% (three of 48) (P = 0.021), respectively. In MRI-positive men, there was upgrading in three of 14 by TBx only and in seven of 14 by SBx only. Overall upgrading (III) occurred in 5% (five of 111). Upgrading in MRI-positive and -negative men was 6% (four of 63) and 2% (one of 48) (P = 0.283), respectively. In MRI-positive men, there was upgrading in one of four by TBx only and in two of four by SBx only., Conclusion: Upgrading is significantly lower in MRI-negative compared to MRI-positive men with low-risk PCa at 1-year of AS. In serial MRI-negative men, the added value of repeat SBx at 1-year surveillance is limited and should be balanced individually against the harms. In serial MRI-positive men, the added value of repeat SBx is substantial. Based on this cohort, SBx is recommended to be performed in combination with TBx in all MRI-positive men at 1-year of AS, also when there is no radiological progression., (© 2020 The Authors BJU International Published by John Wiley & Sons Ltd on behalf of BJU International.)

Objective: Infrapatellar fat pad (IPFP) fat-suppressed T2 (T2 FS ) hyperintense regions on MRI are an important imaging feature of knee osteoarthritis (OA) and are thought to represent inflammation. These regions are also common in non-OA subjects, and may not always be linked to inflammation. Our aim was to evaluate quantitative blood perfusion parameters, as surrogate measure of inflammation, within T2 FS -hyperintense regions in patients with OA, with patellofemoral pain (PFP) (supposed OA precursor), and control subjects., Methods: Twenty-two knee OA patients, 35 PFP patients and 43 healthy controls were included and underwent MRI, comprising T2 and DCE-MRI sequences. T2 FS -hyperintense IPFP regions were delineated and a reference region was drawn in adjacent IPFP tissue with normal signal intensity. After fitting the extended Tofts pharmacokinetic model, quantitative DCE-MRI perfusion parameters were compared between the two regions within subjects in each subgroup, using a paired Wilcoxon signed-rank test., Results: T2 FS -hyperintense IPFP regions were present in 16 of 22 (73%) OA patients, 13 of 35 (37%) PFP patients, and 14 of 43 (33%) controls. DCE-MRI perfusion parameters were significantly different between regions with and without a T2 FS -hyperintense signal in OA patients, demonstrating higher Ktrans compared to normal IFPF tissue (0.039 min -1 versus 0.025 min -1 , p = 0.017) and higher Ve (0.157 versus 0.119, p = 0.010). For PFP patients and controls no significant differences were found., Conclusions: IPFP T2 FS -hyperintense regions are associated with higher perfusion in knee OA patients in contrast to identically appearing regions in PFP patients and controls, pointing towards an inflammatory pathogenesis in OA only., Key Points: • Morphologically identical appearing T2 FS -hyperintense infrapatellar fat pad regions show different perfusion in healthy subjects, subjects with patellofemoral pain, and subjects with knee osteoarthritis. • Elevated DCE-MRI perfusion parameters within T2 FS -hyperintense infrapatellar fat pad regions in patients with osteoarthritis suggest an inflammatory pathogenesis in osteoarthritis, but not in patellofemoral pain and healthy subjects.

The etiology of chest pain in hypertrophic cardiomyopathy (HC) is diverse and includes coronary artery disease (CAD) as well as HC-specific causes. Myocardial bridging (MB) has been associated with HC, chest pain, and accelerated atherosclerosis. We compared HC patients with age-, gender- and CAD pre-test probability-matched outpatients presenting with chest pain to investigate differences in the presence of MB and CAD using coronary computed tomography angiography (CCTA). We studied 84 HC patients who underwent CCTA and compared these with 168 matched controls (age 54 ± 11 years, 70% men, pre-test probability 12% [5% to 32%]). MB, calcium score, plaque morphology and presence and extent of CAD were assessed for each patient. Linear mixed models were used to assess differences between cases and controls. MB was more often seen in HC patients (50% vs 25%, p <0.001). Calcium score and the presence of obstructive CAD were similar in both groups (9 [0 to 225] vs 4 [0 to 82] and 18% vs 19%; p = 0.22 and p = 0.82). In the HC group, MB was associated with pathogenic DNA variants (p = 0.04), but not with the presence of chest pain (74% vs 76%, p = 0.8), nor with worse outcome (log-rank p = 0.30). In conclusion, the prevalence and extent of CAD was equal among patients with and without HC, demonstrating that pre-test risk prediction using the CAD Consortium clinical risk score performs well in HC patients. MB was twice as prevalent in the HC group compared with matched controls, but was not associated with chest pain or decreased event-free survival in these patients., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Subchondral bone changes, characterized by increased bone turnover and vascularity, are believed to stimulate progression and pain in knee osteoarthritis (OA). The objective of this study was to evaluate the bone perfusion in knee OA using quantitative dynamic contrast enhanced MRI (DCE-MRI)., Design: Unicompartmental knee OA patients were included and underwent 3 Tesla DCE-MRI and T2-weighted MRI. Quantitative DCE-MRI analysis of Ktrans and Kep, representing perfusion parameters, was performed to evaluate differences between the most and least affected knee compartment. First, DCE-MRI parameter differences between epimetaphyseal and subchondral bone in both femur and tibia were assessed. Second, DCE-MRI parameters in subchondral bone marrow lesions (BMLs) were compared to surrounding subchondral bone without BMLs., Results: Twenty-three patients were analyzed. Median Ktrans and Kep in epimetaphyseal bone were significantly higher (p < 0.05) in the most affected (Ktrans: 0.014; Kep: 0.054 min -1 ) compared to least affected (Ktrans: 0.010; Kep: 0.016 min -1 ) compartment. For subchondral bone, DCE-MRI parameters were significantly higher (p < 0.05) in the most affected (Ktrans: 0.019; Kep: 0.091 min -1 ) compared to least affected (Ktrans: 0.014; Kep: 0.058 min -1 ) compartment as well. Subchondral BMLs detected on fat-saturated T2-weighted images were present in all patients. Median Ktrans (0.091 vs 0.000 min -1 ) and Kep (0.258 vs 0.000 min -1 ) were significantly higher within subchondral BMLs compared to surrounding subchondral bone without BMLs (p < 0.001)., Conclusions: Increased perfusion parameters in epimetaphyseal bone, subchondral bone and BMLs are observed in unicompartmental knee OA. BMLs likely account for most of the effect of the higher bone perfusion in knee OA., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Perioperative stroke in cardiac surgery is most often embolic in origin. Preoperative chest X-ray (CXR) is routinely used amongst others to screen for relevant aortic calcification, a potential source of embolic stroke. We performed a nested matched case-control study to examine the relationship between aortic calcifications on CXR and the occurrence of embolic stroke., Methods: Among all consecutive patients undergoing cardiac surgery in our hospital between January 2014 and July 2017, we selected all patients with perioperative embolic stroke (cases). Controls, all patients without perioperative stroke, were matched on age, sex and type of surgery. All preoperative CXRs were scored for aortic calcifications (none, mild, severe) in the ascending aorta, arch, aortic knob and descending aorta., Results: Out of the 3038 eligible patients, 27 cases were detected and 78 controls were selected. In the stroke group, mild-to-severe calcifications were found least often in the ascending aorta [9% of patients, 95% confidence interval (CI) 1-29%] and most frequently in the aortic knob (63% of patients, 95% CI 44-78%). The distribution of aortic calcification was comparable in cases versus controls., Conclusions: Calcification burden was comparable between the cases and their matched controls. In our study population, CXR findings on aortic calcification were not related to the risk of embolic stroke. In these patients, the correlation between findings on the preoperative CXR and the risk of stroke might, therefore, be too weak to use the CXR directly for the assessment of the safety of manipulating the ascending aorta during surgery., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Women in Focus: Be Inspired was a unique programme held at the 2019 European Congress of Radiology that was structured to address a range of topics related to gender and healthcare, including leadership, mentoring and the generational progression of women in medicine. In most countries, women constitute substantially fewer than half of radiologists in academia or private practice despite frequently accounting for at least half of medical school enrolees. Furthermore, the proportion of women decreases at higher academic ranks and levels of leadership, a phenomenon which has been referred to as a "leaky pipeline". Gender diversity in the radiologic workplace, including in academic and leadership positions, is important for the present and future success of the field. It is a tool for excellence that helps to optimize patient care and research; moreover, it is essential to overcome the current shortage of radiologists. This article reviews the current state of gender diversity in academic and leadership positions in radiology internationally and explores a wide range of potential reasons for gender disparities, including the lack of role models and mentorship, unconscious bias and generational changes in attitudes about the desirability of leadership positions. Strategies for both individuals and institutions to proactively increase the representation of women in academic and leadership positions are suggested. KEY POINTS: • Gender-diverse teams perform better. Thus, gender diversity throughout the radiologic workplace, including in leadership positions, is important for the current and future success of the field. • Though women now make up roughly half of medical students, they remain underrepresented among radiology trainees, faculty and leaders. • Factors leading to the gender gap in academia and leadership positions in Radiology include a lack of role models and mentors, unconscious biases, other societal barriers and generational changes.

Background: Identifying persons at risk for cognitive decline may aid in early detection of persons at risk of dementia and to select those that would benefit most from therapeutic or preventive measures for dementia., Objective: In this study we aimed to validate whether cognitive decline in the general population can be predicted with multivariate data using a previously proposed supervised classification method: Disease State Index (DSI)., Methods: We included 2,542 participants, non-demented and without mild cognitive impairment at baseline, from the population-based Rotterdam Study (mean age 60.9 ± 9.1 years). Participants with significant global cognitive decline were defined as the 5% of participants with the largest cognitive decline per year. We trained DSI to predict occurrence of significant global cognitive decline using a large variety of baseline features, including magnetic resonance imaging (MRI) features, cardiovascular risk factors, APOE-ε4 allele carriership, gait features, education, and baseline cognitive function as predictors. The prediction performance was assessed as area under the receiver operating characteristic curve (AUC), using 500 repetitions of 2-fold cross-validation experiments, in which (a randomly selected) half of the data was used for training and the other half for testing., Results: A mean AUC (95% confidence interval) for DSI prediction was 0.78 (0.77-0.79) using only age as input feature. When using all available features, a mean AUC of 0.77 (0.75-0.78) was obtained. Without age, and with age-corrected features and feature selection on MRI features, a mean AUC of 0.70 (0.63-0.76) was obtained, showing the potential of other features besides age., Conclusion: The best performance in the prediction of global cognitive decline in the general population by DSI was obtained using only age as input feature. Other features showed potential, but did not improve prediction. Future studies should evaluate whether the performance could be improved by new features, e.g., longitudinal features, and other prediction methods., (Copyright © 2020 Cremers, Huizinga, Niessen, Krestin, Poot, Ikram, Lötjönen, Klein and Vernooij.)

Objective: We aimed to assess whether individuals with type 2 diabetes (T2D) have increased risk of vertebral fractures (VFs) and to estimate nonvertebral fracture and mortality risk among individuals with both prevalent T2D and VFs., Research Design and Methods: A systematic PubMed search was performed to identify studies that investigated the relationship between T2D and VFs. Cohorts providing individual participant data (IPD) were also included. Estimates from published summary data and IPD cohorts were pooled in a random-effects meta-analysis. Multivariate Cox regression models were used to estimate nonvertebral fracture and mortality risk among individuals with T2D and VFs., Results: Across 15 studies comprising 852,705 men and women, individuals with T2D had lower risk of prevalent (odds ratio [OR] 0.84 [95% CI 0.74-0.95]; I 2 = 0.0%; P het = 0.54) but increased risk of incident VFs (OR 1.35 [95% CI 1.27-1.44]; I 2 = 0.6%; P het = 0.43). In the IPD cohorts ( N = 19,820), risk of nonvertebral fractures was higher in those with both T2D and VFs compared with those without T2D or VFs (hazard ratio [HR] 2.42 [95% CI 1.86-3.15]) or with VFs (HR 1.73 [95% CI 1.32-2.27]) or T2D (HR 1.94 [95% CI 1.46-2.59]) alone. Individuals with both T2D and VFs had increased mortality compared with individuals without T2D and VFs (HR 2.11 [95% CI 1.72-2.59]) or with VFs alone (HR 1.84 [95% CI 1.49-2.28]) and borderline increased compared with individuals with T2D alone (HR 1.23 [95% CI 0.99-1.52])., Conclusions: Based on our findings, individuals with T2D should be systematically assessed for presence of VFs, and, as in individuals without T2D, their presence constitutes an indication to start osteoporosis treatment for the prevention of future fractures., (© 2019 by the American Diabetes Association.)

Imaging in Oncology is rapidly moving from the detection and size measurement of a lesion to the quantitative assessment of metabolic processes and cellular and molecular interactions. Increasing insights into cancer as a complex disease with involvement of the tumor stroma in tumor pathobiological processes have made it clear that for successful control of cancer, treatment strategies should not only be directed at the cancer cells but should also take aspects of the tumor microenvironment into account. This requires an understanding of the complex molecular and cellular interactions in cancer tissue. Recent developments in imaging technology have increased the possibility to image various pathobiological processes in cancer development and response to treatment. For computed tomography (CT) and magnetic resonance imaging (MRI) various improvements in hardware, software, and imaging probes have lifted these modalities from classical anatomical imaging techniques to techniques suitable to image and quantify various physiological processes and molecular and cellular interactions. Next to a more general overview of possible imaging targets in oncology, this chapter provides an overview of the various developments in CT and MRI technology and some specific applications.

Purpose: High-resolution three-dimensional (3D) structural MRI is useful for delineating complex or small structures of the body. However, it requires long acquisition times and high SAR, limiting its clinical use. The purpose of this work is to accelerate the acquisition of high-resolution images by combining compressed sensing and parallel imaging (CSPI) on a 3D-GRASE sequence and to compare it with a (CS)PI 3D-FSE sequence. Several sampling patterns were investigated to assess their influence on image quality., Methods: The proposed k-space sampling patterns are based on two undersampled k-space grids, variable density (VD) Poisson-disc, and VD pseudo-random Gaussian, and five different trajectories described in the literature. Bloch simulations are performed to obtain the transform point spread function and evaluate the coherence of each sampling pattern. Image resolution was assessed by the full-width at half-maximum (FWHM). Prospective CSPI 3D-GRASE phantom and in vivo experiments in knee and brain are carried out to assess image quality, SNR, SAR, and acquisition time compared to PI 3D-GRASE, PI 3D-FSE, and CSPI 3D-FSE acquisitions., Results: Sampling patterns with VD Poisson-disc obtain the lowest coherence for both PD-weighted and T 2 -weighted acquisitions. VD pseudo-random Gaussian obtains lower FWHM, but higher sidelobes than VD Poisson-disc. CSPI 3D-GRASE reduces acquisition time (43% for PD-weighted and 40% for T 2 -weighted) and SAR (∼45% for PD-weighted and T 2 -weighted) compared to CSPI 3D-FSE., Conclusions: CSPI 3D-GRASE reduces acquisition time compared to a CSPI 3DFSE acquisition, preserving image quality. The design of the sampling pattern is crucial for image quality in CSPI 3D-GRASE image acquisitions., (© 2019 The Authors. Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.)