Implementation of an Institution-Wide Rules-Based Automated CT Protocoling System

BACKGROUND. Examination protocoling is a noninterpretive task that increases radiologists' workload and can cause workflow inefficiencies. OBJECTIVE. The purpose of this study was to evaluate effects of an automated CT protocoling system on examination process times and protocol error rates. METHODS. This retrospective study included 317,597 CT examinations (mean age, 61.8 ± 18.1 [SD] years; male, 161,125; female, 156,447; unspecified sex, 25) from July 2020 to June 2022. A rules-based automated protocoling system was implemented institution-wide; the system evaluated all CT orders in the EHR and assigned a protocol or directed the order for manual radiologist protocoling. The study period comprised pilot (July 2020 to December 2020), implementation (January 2021 to December 2021), and postimplementation (January 2022 to June 2022) phases. Proportions of automatically protocoled examinations were summarized. Process times were recorded. Protocol error rates were assessed by counts of quality improvement (QI) reports and examination recalls and comparison with retrospectively assigned protocols in 450 randomly selected examinations. RESULTS. Frequency of automatic protocoling was 19,366/70,780 (27.4%), 68,875/163,068 (42.2%), and 54,045/83,749 (64.5%) in pilot, implementation, and postimplementation phases, respectively (p < .001). Mean (± SD) times from order entry to protocol assignment for automatically and manually protocoled examinations for emergency department examinations were 0.2 ± 18.2 and 2.1 ± 69.7 hours, respectively; mean inpatient examination times were 0.5 ± 50.0 and 3.5 ± 105.5 hours; and mean outpatient examination times were 361.7 ± 1165.5 and 1289.9 ± 2050.9 hours (all p < .001). Mean (± SD) times from order entry to examination completion for automatically and manually protocoled examinations for emergency department examinations were 2.6 ± 38.6 and 4.2 ± 73.0 hours, respectively (p < .001); for inpatient examinations were 6.3 ± 74.6 and 8.7 ± 109.3 hours (p = .001); and for outpatient examinations were 1367.2 ± 1795.8 and 1471.8 ± 2118.3 hours (p < .001). In the three phases, there were three, 19, and 25 QI reports and zero, one, and three recalls, respectively, for automatically protocoled examinations, versus nine, 19, and five QI reports and one, seven, and zero recalls for manually protocoled examinations. Retrospectively assigned protocols were concordant with 212/214 (99.1%) of automatically protocoled versus 233/236 (98.7%) of manually protocoled examinations. CONCLUSION. The automated protocoling system substantially reduced radiologists' protocoling workload and decreased times from order entry to protocol assignment and examination completion; protocol errors and recalls were infrequent. CLINICAL IMPACT. The system represents a solution for reducing radiologists' time spent performing noninterpretive tasks and improving care efficiency.

Addressing the Challenges of Implementing Artificial Intelligence Tools in Clinical Practice: Principles From Experience

The multitude of artificial intelligence (AI)-based solutions, vendors, and platforms poses a challenging proposition to an already complex clinical radiology practice. Apart from assessing and ensuring acceptable local performance and workflow fit to improve imaging services, AI tools require multiple stakeholders, including clinical, technical, and financial, who collaborate to move potential deployable applications to full clinical deployment in a structured and efficient manner. Postdeployment monitoring and surveillance of such tools require an infrastructure that ensures proper and safe use. Herein, the authors describe their experience and framework for implementing and supporting the use of AI applications in radiology workflow.

Validation of Delphi procedure consensus criteria for defining fetal growth restriction

OBJECTIVE

Recently, a Delphi procedure was used to establish new criteria for defining fetal growth restriction (FGR). These criteria require clinical validation. We sought to validate the Delphi consensus criteria by comparing their performance with that of our current definition (estimated fetal weight (EFW) < 10^th percentile) in predicting adverse neonatal outcome (ANO).

METHODS

This was a secondary analysis of data from a prospective cohort study of women referred for fetal growth assessment between 26 and 36 weeks' gestation. The current standard definition of FGR used in our clinical practice is EFW < 10^th percentile using Hadlock's fetal growth standard. The Delphi consensus criteria for FGR include either a very small fetus (abdominal circumference (AC) or EFW < 3^rd percentile) or a small fetus (AC or EFW < 10^th percentile) with additional abnormal Doppler findings or a decrease in AC or EFW by two quartiles or more. The primary outcome was the prediction of a composite of ANO including one or more of: admission to the neonatal intensive care unit, cord pH < 7.1, 5-min Apgar score < 7, respiratory distress syndrome, intraventricular hemorrhage, neonatal seizures or neonatal death. The discriminatory capacities of the two definitions of FGR for composite ANO and delivery of a small-for-gestational-age (SGA) neonate, defined as birth weight < 10^th percentile, were compared using area under the receiver-operating-characteristics curve (AUC). The sensitivity, specificity and predictive values of the methods were also compared.

RESULTS

Of 1055 pregnancies included in the study, composite ANO occurred in 139 (13.2%). There were only two cases of early FGR (before 32 weeks); therefore, the study focused on late FGR. Our current FGR diagnostic criterion of EFW < 10^th percentile was not associated significantly with composite ANO (relative risk (RR), 1.1 (95% CI, 0.6-1.8)), while the Delphi FGR criteria were (RR, 2.0 (95% CI, 1.2-3.3)). Our current definition of FGR showed higher discriminatory ability in the prediction of a SGA neonate (AUC, 0.69 (95% CI, 0.65-0.73)) than did the Delphi definition (AUC, 0.64 (95% CI, 0.60-0.67)) (P = 0.001). The AUCs of both definitions were poor for the prediction of composite ANO, despite slightly improved performance using the Delphi consensus definition of FGR (AUC, 0.53 (95% CI, 0.50-0.55)) compared with that of our current definition (AUC, 0.50 (95% CI, 0.48-0.53)) (P = 0.02).

CONCLUSION

The newly postulated criteria for defining FGR based on a Delphi procedure detects fewer cases of neonatal SGA than does our current definition of EFW < 10^th percentile, but is associated with a slight improvement in predicting ANO. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

A miniaturized device for the measurement of sheet-metal formability using digital image correlation

A laboratory-scale device to obtain forming-limit diagram data was designed to utilize the Marciniak and Kuczynski (MK) sample geometry. The design uses a high-resolution photographic camera, automatic trigger, and light-emitting diode (LED) lighting to record the time history of deformation calculated with the digital-image correlation technique. Because the testing device was miniaturized, it was possible to halt the forming experiments at intermediate strains and recrystallize the MK carrier blank. This permits large formability strains to be obtained without cracks developing at the carrier blank's central hole, an advantage over full-size specimens and conventional testing rates. A number of initial experiments were performed on a zinc alloy sheet (Zn-Cu-Ti) over the entire forming-limit range (-0.5 ≤ ε₂/ε₁ ≤ 1), and the strain fields reduced employing the Bragard criterion to obtain limit strains. These results are compared favorably to previous data of this material obtained with a hemispherical, Nakazima, punch and a circle-grid pattern.

Real-Time Electronic Dashboard Technology and Its Use to Improve Pediatric Radiology Workflow

The purpose of our study was to create a real-time electronic dashboard in the pediatric radiology reading room providing a visual display of updated information regarding scheduled and in-progress radiology examinations that could help radiologists to improve clinical workflow and efficiency. To accomplish this, a script was set up to automatically send real-time HL7 messages from the radiology information system (Epic Systems, Verona, WI) to an Iguana Interface engine, with relevant data regarding examinations stored in an SQL Server database for visual display on the dashboard. Implementation of an electronic dashboard in the reading room of a pediatric radiology academic practice has led to several improvements in clinical workflow, including decreasing the time interval for radiologist protocol entry for computed tomography or magnetic resonance imaging examinations as well as fewer telephone calls related to unprotocoled examinations. Other advantages include enhanced ability of radiologists to anticipate and attend to examinations requiring radiologist monitoring or scanning, as well as to work with technologists and operations managers to optimize scheduling in radiology resources. We foresee increased utilization of electronic dashboard technology in the future as a method to improve radiology workflow and quality of patient care.

Discrepancies in reporting the vertebral level of abnormality in MR of the spine

PURPOSE

The aim of this study was to assess discrepancies in the spinal levels of abnormalities stated in the findings or impression (or both) sections of radiology reports of magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Radiology reports from January 2006 through December 2007 (n = 2,097,966) were analyzed using an online radiology report search engine. Reports were searched for presence of the key words MR spine and addendum. The addended reports were then manually assessed for any discrepancies in the reported spinal levels between the body and impression sections; the addenda corrected these errors (identified errors). In addition, all reports with the search term MR spine from January 2006 (n = 1,183) and January 2007 (n = 1,354) were assessed manually to recognize unidentified errors in spinal locations of reported pathology. Two neuroradiologists independently graded the clinical significance of errors on a 5-point scale (1 = definitely not significant, 5 = definitely significant).

RESULTS

Of the 11,427 spinal MR reports analyzed in 2006, 7 had identified errors in the sites (levels of the spine) of the lesions. In 2007 (n = 11,785 spinal MR reports), 4 reports were detected with identified errors in spinal levels. In January 2006 and January 2007, 8 and 12 reports, respectively, had unidentified erroneous vertebral levels. Errors were related to discrepant vertebral regions (eg, cervical vs thoracic) in 16% of cases (5 of 31), the wrong number of vertebrae (eg, L2 instead of L3) in 68% of cases (21 of 31), and both in 16% of cases (5 of 31). The average time taken to issue an addendum was 5 +/- 7 days in 2006 and 11 +/- 13 days in 2007. Fifteen reports (48%) scored <3 on the scale of clinical significance, 1 report scored 3, and 15 scored >3.

CONCLUSIONS

Errors in lesion level on spinal MR do occur in radiology reports. The number of unidentified errors is substantially higher than that of identified errors. Care should be taken before signing off on radiology reports to identify erroneous mentions of the vertebral levels of abnormalities.

Comparison of the permeability properties and post-thaw motility of ejaculated and epididymal bovine spermatozoa

There are very few experimental reports on the comparative water transport (membrane permeability) characteristics of ejaculated and epididymal mammalian spermatozoa during freezing. In the present study, we report the effects of cooling ejaculated and epididymal bovine sperm from the same males with and without the presence of a cryoprotective agent, glycerol. Water transport data during freezing of ejaculated and epididymal bovine sperm suspensions were obtained at a cooling rate of 20 degrees C/min under two different conditions: (1) in the absence of any cryoprotective agents, CPAs and, (2) in the presence of 0.7 M glycerol. Using values published in the literature, we modeled the spermatozoa as a cylinder of length 39.8 microm and a radius of 0.4 microm with an osmotically inactive cell volume, V(b), of 0.61 V(o), where V(o) is the isotonic cell volume. The subzero water transport response is analyzed to determine the variables governing the rate of water loss during cooling of bovine spermatozoa, i.e. the membrane permeability parameters (reference membrane permeability, L(pg) and activation energy, E(Lp)). The predicted best-fit permeability parameters ranged from, L(pg)=0.021-0.038 microm/min-atm and E(Lp)=27.8-41.1 kcal/mol. The subzero water transport response and consequently the subzero water transport parameters are not significantly different between the ejaculated and epididymal bovine spermatozoa under corresponding cooling conditions. If this observation is found to be more generally valid for other mammalian species as well, then in the future the sperm extracted from the testes of a postmortem male could be optimally cryopreserved using procedures similar to those derived for ejaculated sperm.

Use of Radcube for extraction of finding trends in a large radiology practice

The purpose of our study was to demonstrate the use of Natural Language Processing (Leximer), along with Online Analytic Processing, (NLP-OLAP), for extraction of finding trends in a large radiology practice. Prior studies have validated the Natural Language Processing (NLP) program, Leximer for classifying unstructured radiology reports based on the presence of positive radiology findings (F (POS)) and negative radiology findings (F (NEG)). The F (POS) included new relevant radiology findings and any change in status from prior imaging. Electronic radiology reports from 1995-2002 and data from analysis of these reports with NLP-Leximer were saved in a data warehouse and exported to a multidimensional structure called the Radcube. Various relational queries on the data in the Radcube were performed using OLAP technique. Thus, NLP-OLAP was applied to determine trends of F (POS) in different radiology exams for different patient and examination attributes. Pivot tables were exported from NLP-OLAP interface to Microsoft Excel for statistical analysis. Radcube allowed rapid and comprehensive analysis of F (POS) and F (NEG) trends in a large radiology report database. Trends of F (POS) were extracted for different patient attributes such as age groups, gender, clinical indications, diseases with ICD codes, patient types (inpatient, ambulatory), imaging characteristics such as imaging modalities, referring physicians, radiology subspecialties, and body regions. Data analysis showed substantial differences between F (POS) rates for different imaging modalities ranging from 23.1% (mammography, 49,163/212,906) to 85.8% (nuclear medicine, 93,852/109,374; p < 0.0001). In conclusion, NLP-OLAP can help in analysis of yield of different radiology exams from a large radiology report database.

Further elucidation of mechanism of resistance to vincristine in myeloid cells: role of hypochlorous acid in degradation of vincristine by myeloperoxidase

Inherent resistance of myeloblasts to vincristine (VCR) has been related to the activity of myeloperoxidase (MPO) which can degrade VCR in the presence of hydrogen peroxide (H2O2). We investigated the relationship between VCR degradation and hypochlorous acid (HOCl) generation from the reaction of H2O2 with chlorine (Cl) as catalyzed by MPO. A cell-free system, three human leukemia cell lines (CEM/CCRF, HL-60, U937) and 15 bone marrow samples from children with acute myeloid leukemia (AML) were studied. VCR cytotoxicity was evaluated by MTT assay and by quantitative measurement of apoptosis. In vitro levels of VCR in cell-free systems were measured by high performance liquid chromatography (HPLC), and intracellular HOCl levels by oxidation of 5-thio-2-nitrobenzoic acid with the accompanying decrease in the absorbency at 412 nm. VCR was degraded by increasing concentrations of HOCl in cell-free systems and this activity was inhibited by taurine, which is known to block HOCl activity. This finding was confirmed by the VCR cytotoxicity studies on cell lines. The HOCl-producing myeloblasts from patients were resistant to VCR. In five samples out of eight HOCl was also detected extracellularly. These results suggest that oxidation by HOCl may be the final step in VCR degradation catalyzed by MPO through its action on intracellular H2O2 and Cl. Leukemia (2000) 14, 47-51.

Morbidity and mortality of intra-aortic balloon pumps placed through the aortic arch

Twenty-four patients required an intra-aortic balloon pump placed through the aortic arch during cardiac operations from 1985 to 1993. The operative procedures of the 24 patients requiring arch balloon pumps included aortocoronary bypass (14), redo aortocoronary bypass (3), valve replacement (3), aortocoronary bypass with concomitant ventricular septal defect repair (1), heart transplantation (2), and aortic to right ventricle fistula repair (1). Mortality was 54%. Morbidity included cerebral vascular accident (17%), acute renal failure (29%), left ventricular thrombus (4%), sternal wound infection (4%), and mediastinal exploration secondary to bleeding from the balloon pump site (4%). This review suggests that (1) mortality for patients requiring arch balloon is significant, (2) complications of cerebral vascular accident and renal failure may be increased, and (3) severe peripheral vascular disease is associated with arch balloon placement and subsequent increased morbidity and mortality.

Impact of Medicaid managed mental health care on delivery of services in a rural state: an AMI perspective

In March 1995 Iowa implemented a statewide mental health carve-out program under a Medicaid Section 1915b waiver. A goal was to provide equal access across counties for Medicaid recipients by introducing a statewide network of service providers. Problems have included the contractor's authorizing only services considered medically necessary for persons with serious mental illness, who also need community supports; contractor staff's lack of knowledge about regional resources and the limited availability of community-based services in most rural areas; clients' difficulty in gaining access to the new system; denial of inpatient hospitalization; untimely provider payments; and lack of education for providers, consumers, and families.

Heart and lung grafts harvested en bloc: operative technique, utilization, and results

Combined heart and lung transplantation has been shown to provide successful therapy for patients with end-stage heart and lung disease. The improved success of lung transplantation has resulted in increasing number of potential recipients and longer waiting times. Maximal utilization of all three thoracic organs is no longer a casual goal but of utmost necessity. We devised a new technique that improves operative visualization, decreases dissection time, and ensures excellent preservation of all three thoracic organs. Bench dissection after extraction of this heart-lung block allows the thoracic and cardiac surgeons to agree on precise dissection of the left atrium and adequate pulmonary venous and atrial cuff. This technique has been used in 48 of our last 50 harvests with excellent results. Utilization of heart and lungs has been 93% and 74%, respectively.

Genetic regulation of the quinic acid utilization (QUT) gene cluster in Aspergillus nidulans

A large number of quinic acid non-utilizing qut mutants of Aspergillus nidulans deficient in the induction of all three quinic acid specific enzymes have been analysed. One class the qutD mutants, are all recessive and are non-inducible at pH 6.5 due to inferred deficiency in a quinate ion permease. Two regulatory genes have been identified. The QUTA gene encodes an activator protein since most qutA mutants are recessive and non-inducible although a few fully dominant mutants have been found. The QUTR gene encodes a repressor protein since recessive mutations are constitutive for all three enzyme activities. Rare dominant non-inducible mutants which revert readily to yield a high proportion of constitutive strains are inferred to be qutR mutants defective in binding the inducer. The gene cluster has been mapped in the right arm of chromosome VIII in the order: centromere - greater than 50 map units - ornB - 12 map units - qutC (dehydratase)-0.8 map units-qutD (permease), qutB (dehydrogenase), qutE (dehydroquinase), qutA (activator)-4.4 map units - qutR (repressor)-20 map units - galG. This organization differs from that of the qa gene cluster in Neurospora crassa, particularly in the displacement of qutC and qutR.

Follicular fluid concentrations of thiopental and thiamylal during laparoscopy for oocyte retrieval

Because access into ovarian tissue of drugs used during anesthesia may be potentially harmful to the oocyte and/or follicular structure, we measured concentrations of thiopental (n = 15) and thiamylal (n = 9) in follicular fluid (FF) aspirates of 24 patients who underwent laparoscopic oocyte retrieval. In both groups, measurable amounts of the respective drug were found in all FF aspirates. Within individual patients, plasma concentrations of both drugs declined during the period of sampling between initial and final follicular aspiration. The mean plasma drug concentration was 7.99 +/- 3.97 micrograms/ml in the thiamylal group and 4.13 +/- 0.90 micrograms/ml in the thiopental group. Mean drug concentrations in FF were similar in both groups (thiopental 1.62 +/- 0.61 micrograms/ml; thiamylal 1.67 +/- 0.83 micrograms/ml). The mean FF/plasma concentration ratio during the sampling period was greater in the thiopental group (0.41 +/- 0.19) as compared with the thiamylal group (0.22 +/- 0.14). Several steps in the clinical management of these patients can be taken to reduce exposure of oocytes to drugs used during anesthesia.

Near-hanging injury

Near-hanging injury results in multisystem insult and injury. Acute or delayed respiratory complications can result in death. A survivor can suffer neuropsychiatric sequelae ranging from amnesia to a prolonged vegetative state. Treatment is directed toward ensuring cerebral oxygenation, lowering increased intracranial pressure, and treating respiratory distress. Psychiatric consultation will be necessary in long-term survivors. Patients should be observed for at least 24 hours after a near-hanging injury.

Single-sample diagnosis of recent rubella by fractionation of antibody on Sephadex G-200 column

To facilitate the diagnosis of recent rubella infection, rubella haemagglutination inhibiting antibody has been determined in four fractions obtained by Sephadex G-200 gel filtration of samples of serum. All the 21 samples collected at the convalescent stage of the disease had varying proportions of haemagglutination inhibiting antibody in fraction 1, representing the major portion of IgM antibody whereas all but three out of 22 sera from persons with no history of recent rubella had negative titres in this fraction. The haemagglutination inhibiting titres in the three positive sera in the second group was very low as compared to the other fractions. Fractionation of sera on a Sephadex G-200 column coupled with the rubella haemagglutination inhibition test can, therefore, be used to diagnose recent rubella infection.