Publications

2021
Shainker SA, Coleman B, Timor-Tritsch IE, Bhide A, Bromley B, Cahill AG, et al. Special Report of the Society for Maternal-Fetal Medicine Placenta Accreta Spectrum Ultrasound Marker Task Force: Consensus on definition of markers and approach to the ultrasound examination in pregnancies at risk for placenta accreta spectrum. Am J Obstet Gynecol. 2021;224 (1) :B2-B14. Abstract
Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.
2020
AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 Weeks 0 Days and 13 Weeks 6 Days. J Ultrasound Med. 2020;
Niu BT, Nicolaou S, Levine D, Sanelli PC, Abujudeh H, Siddiqi J, et al. Trends in Gender and Racial Profiles of US Academic Radiology Faculty. J Am Coll Radiol. 2020;17 (10) :1337-1343. Abstract
OBJECTIVE: To evaluate gender and racial profiles of US academic radiology faculty. MATERIALS AND METHODS: This is a retrospective analysis of the American Association of Medical College database of radiology faculty members from 2006 to 2017 by academic rank, chair position, race or ethnicity, and gender. The data were described with annual proportions and average annual counts and fit to a Poisson regression model. Comparison data were taken from American Association of Medical College on matriculants at US medical schools and from ACGME on radiology residents. RESULTS: Women increased significantly in the ranks of professor by 4.5%, associate professor by 4.8%, and assistant professor by 4.8% (P < .05). Asian and multiple race non-Hispanic radiologists increased in the rank of professor by 5.9% and 3.1%, respectively (P < .05). Among department chairs, only women and Asian faculty increased by 6.4% and 7.5%, respectively (P < .05). The proportion of women chairs increased from 10.0% (19 of 191) in 2006 to 17.4% (39 of 224) in 2017. Black and Hispanic chairs collectively represented less than 10% of the total chairs every year. DISCUSSION: The significant percent annual increase in women faculty in academic ranks and chair positions suggests that the radiology faculty is becoming more diverse. However, the decreasing proportion of women with increasing academic ranks within each year of the study period suggests attrition or lack of promotion of women radiology faculty. The disparity in black and Hispanic faculty members and chairs suggests that emphasis should continue to be placed on tailored recruitment.
2019
Frank RA, Sharifabadi AD, Salameh J-P, McGrath TA, Kraaijpoel N, Dang W, et al. Citation bias in imaging research: are studies with higher diagnostic accuracy estimates cited more often?. Eur Radiol. 2019;29 (4) :1657-1664. Abstract
OBJECTIVES: To assess the risk of citation bias in imaging diagnostic accuracy research by evaluating whether studies with higher accuracy estimates are cited more frequently than those with lower accuracy estimates. METHODS: We searched Medline for diagnostic accuracy meta-analyses published in imaging journals from January 2005 to April 2016. Primary studies from the meta-analyses were screened; those assessing the diagnostic accuracy of an imaging test and reporting sensitivity and specificity were eligible for inclusion. Studies not indexed in Web of Science, duplicates, and inaccessible articles were excluded. Topic (modality/subspecialty), study design, sample size, journal impact factor, publication date, times cited, sensitivity, and specificity were extracted for each study. Negative binomial regression was performed to evaluate the association of citation rate (times cited per month since publication) with Youden's index (sensitivity + specificity -1), highest sensitivity, and highest specificity, controlling for the potential confounding effects of modality, subspecialty, impact factor, study design, sample size, and source meta-analysis. RESULTS: There were 1016 primary studies included. A positive association between Youden's index and citation rate was present, with a regression coefficient of 0.33 (p = 0.016). The regression coefficient for sensitivity was 0.41 (p = 0.034), and for specificity, 0.32 (p = 0.15). CONCLUSION: A positive association exists between diagnostic accuracy estimates and citation rates, indicating that there is evidence of citation bias in imaging diagnostic accuracy literature. Overestimation of imaging test accuracy may contribute to patient harm from incorrect interpretation of test results. KEY POINTS: • Studies with higher accuracy estimates may be cited more frequently than those with lower accuracy estimates. • This citation bias could lead clinicians, reviews, and clinical practice guidelines to overestimate the accuracy of imaging tests, contributing to patient harm from incorrect interpretation of test results.
Ludwin A, Coelho Neto MA, Ludwin I, Nastri CO, Costa W, Acién M, et al. Congenital Uterine Malformation by Experts (CUME): T-shaped uterus. Ultrasound Obstet Gynecol. 2019;Abstract
OBJECTIVES: To assess whether is there any uterine measurement that is reliable and accurate to distinguish between T-shaped and normal/arcuate uterus considering the most voted option by 15 experts as the reference standard. METHODS: This was a prospectively designed multi-rater reliability/agreement study with elements of diagnostic accuracy study performed between Nov-2017 and Dec-2018 in a sample of 100 3D datasets of different uteri acquired in consecutive women with the presence of lateral uterine cavity indentations between 2014-2016. Fifteen blinded representative experts (5 clinicians, 5 surgeons, and 5 imaging specialists) provided their independent opinion whether that the uterus was T-shaped or not regarding anonymized images of the coronal plane of each uterus. Two other blinded experienced observers performed 15 measurements using the originally acquired 3D data-sets. The agreement between experts was assessed by kappa and percent agreement. The inter-observer reliability of measurements was assessed using the concordance correlation coefficient (CCC). The diagnostic test accuracy was assessed using the area under ROC curve (AUROC) and the best cut-off value was assessed using Youden's index, using the most voted option by the 15 experts as the reference standard. Sensitivity, specificity, negative and positive-likelihood ratio (LR- and LR+) and post-test probability were calculated. RESULTS: There were 20 T-shaped and 80 normal/arcuate uteri using CUME as reference standard (at least 8 votes). Single experts recognized from 5 to 35 (median = 19) T-shaped uteri by subjective judgments. The agreement among experts was 82% with kappa = 0.43. We identified three measurements with good diagnostic test accuracy considering CUME as reference standard: lateral indentation angle (AUROC=0.95), lateral indentation depth (AUROC=0.92), and T-angle (AUROC=0.87). From these three measurements, T-angle was the one with the best inter-observer reproducibility: CCC = 0.87 vs 0.82 vs. 0.62 (T-angle, lateral indentation depth and angle respectively). The best cut-offs values for these measurements were: lateral indentation angle ≤ 130° (sensitivity = 75%, specificity = 96%, LR- = 0.21, LR+ = 21, positive post-test probability = 83%), lateral indentation depth ≥ 7 mm (sensitivity = 85%, specificity = 78%, LR- = 0.06, LR+ = 4.2, positive post-test probability = 49%), and T-angle ≤ 40° (sensitivity = 65%, specificity = 91%, LR- = 0.23, LR+ = 6.4, positive post-test probability = 64%). We suggest considering as borderline T-shaped when only 2 of these 3 criteria (PPV = 50%) are present and definitely T-shaped uterus when meeting all the three criteria (PPV = 93%), with 75% and 93% post-test probability for the definitions, respectively. CONCLUSIONS: The diagnostic of T-shaped uterus is not easy and the agreement among top-experts is only moderate, and single expert judgment is commonly insufficient for accurate diagnosis. The study has identified three measurements with cut-offs that had good diagnostic test accuracy and fair to moderate reliability (lateral indentation depth ≥ 7 mm, lateral indentation angle ≤ 130° and T-angle ≤ 40°), and when applicated together they have provided high post-test probability of this condition. Based on the CUME criteria of T-shaped uterus, the prevalence, clinical implication and the management, as well as assessment of post-surgical morphologic outcomes of this condition may be determined with enough accuracy, reliability and with a known probability of disease after negative and positive test results. The CUME definition of T-shape uterus may help on the development of interventional randomized controlled trials, observational studies, and diagnostics of uterine morphology in every day practice, and therefore could be adopted by guidelines on uterine anomalies to enrich their classification systems. This article is protected by copyright. All rights reserved.
Levine D. Evaluating an Asymptomatic Adnexal Cyst Found on Pelvic Ultrasonography. JAMA Intern Med. 2019;179 (1) :78-79.
Levine D, Duszak R. Evolving Priorities for Imaging Utilization Research: From Outputs to Outcomes. JAMA. 2019;322 (9) :819-821.
Dewey M, Levine D, Bossuyt PM, Kressel HY. Impact and perceived value of journal reporting guidelines among Radiology authors and reviewers. Eur Radiol. 2019;29 (8) :3986-3995. Abstract
OBJECTIVES: To analyse the author-perceived impact on the final manuscript and perceived value of journal reporting guidelines among Radiology authors and reviewers. METHODS: This survey was conducted among all corresponding authors of original research submissions to Radiology. Separately, we surveyed active Radiology reviewers. Results were analysed using logistic multivariate regression. RESULTS: Overall, 60% of authors (831/1391) completed the survey. Only 15% (120/821) had used the guideline and checklist when designing the study, significantly more so for PRISMA (55%, 16/29) compared with STARD and STROBE users (17%, 52/310; p < 0.001 and 10%, 46/443; p < 0.001). For 23% of the surveyed manuscripts (189/821), authors used the guidelines when writing the manuscript; these authors more often reported an impact on the final manuscript (i.e. changes in the content, 57%, 107/189) compared to those who used the guideline when submitting the manuscript (35%, 95/272; p < 0.001; OR 0.433, 95% confidence interval [CI] 0.288-0.648, p < 0.001) or when the checklist was requested by the editorial office (17%, 41/240; p < 0.001; OR 0.156, CI 0.097-0.247, p < 0.001). The perceived value of the reporting guideline was rated significantly higher the earlier the authors used the guideline in the research process (p < 0.001). The checklist was used by 77% of reviewers (200/259) some or all of the time; 60% (119/199) said it affected their reviews. CONCLUSION: Reporting guidelines had more author-perceived impact on the final manuscript and higher perceived value the earlier they were used, suggesting that there is a need for enhanced education on the use of these guidelines. KEY POINTS: • Only 15% of authors had used the respective reporting guideline and checklist when designing the study. • Almost 4 out of 5 Radiology authors and half of reviewers judged the guideline checklists to be useful or very useful. • Reporting guidelines had more author-perceived impact on manuscripts, i.e. changes that were made in the final manuscript, the earlier authors used them in the research process.
Agarwal PP, Balasubramanian S, Levine D, Kazerooni EA, Oates EM. Letter to the Editor: Women Representation on Radiology Journal Editorial Boards. Acad Radiol. 2019;26 (1) :144-145.
Levine D, Patel MD, Suh-Burgmann EJ, Andreotti RF, Benacerraf BR, Benson CB, et al. Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting. Radiology. 2019;293 (2) :359-371. Abstract
This multidisciplinary consensus update aligns prior Society of Radiologists in Ultrasound (SRU) guidelines on simple adnexal cysts with recent large studies showing exceptionally low risk of cancer associated with simple adnexal cysts. Most small simple cysts do not require follow-up. For larger simple cysts or less well-characterized cysts, follow-up or second opinion US help to ensure that solid elements are not missed and are also useful for assessing growth of benign tumors. In postmenopausal women, reporting of simple cysts greater than 1 cm should be done to document their presence in the medical record, but such findings are common and follow-up is recommended only for simple cysts greater than 3-5 cm, with the higher 5-cm threshold reserved for simple cysts with excellent imaging characterization and documentation. For simple cysts in premenopausal women, these thresholds are 3 cm for reporting and greater than 5-7 cm for follow-up imaging. If a cyst is at least 10%-15% smaller at any time, then further follow-up is unnecessary. Stable simple cysts at initial follow-up may benefit from a follow-up at 2 years due to measurement variability that could mask growth. Simple cysts that grow are likely cystadenomas. If a previously suspected simple cyst demonstrates papillary projections or solid areas at follow-up, then the cyst should be described by using standardized terminology. These updated SRU consensus recommendations apply to asymptomatic patients and to those whose symptoms are not clearly attributable to the cyst. These recommendations can reassure physicians and patients regarding the benign nature of simple adnexal cysts after a diagnostic-quality US examination that allows for confident diagnosis of a simple cyst. Patients will benefit from less costly follow-up, less anxiety related to these simple cysts, and less surgery for benign lesions.
2018
Frank RA, McInnes MDF, Levine D, Kressel HY, Jesurum JS, Petrcich W, et al. Are Study and Journal Characteristics Reliable Indicators of "Truth" in Imaging Research?. Radiology. 2018;287 (1) :215-223. Abstract
Purpose To evaluate whether journal-level variables (impact factor, cited half-life, and Standards for Reporting of Diagnostic Accuracy Studies [STARD] endorsement) and study-level variables (citation rate, timing of publication, and order of publication) are associated with the distance between primary study results and summary estimates from meta-analyses. Materials and Methods MEDLINE was searched for meta-analyses of imaging diagnostic accuracy studies, published from January 2005 to April 2016. Data on journal-level and primary-study variables were extracted for each meta-analysis. Primary studies were dichotomized by variable as first versus subsequent publication, publication before versus after STARD introduction, STARD endorsement, or by median split. The mean absolute deviation of primary study estimates from the corresponding summary estimates for sensitivity and specificity was compared between groups. Means and confidence intervals were obtained by using bootstrap resampling; P values were calculated by using a t test. Results Ninety-eight meta-analyses summarizing 1458 primary studies met the inclusion criteria. There was substantial variability, but no significant differences, in deviations from the summary estimate between paired groups (P > .0041 in all comparisons). The largest difference found was in mean deviation for sensitivity, which was observed for publication timing, where studies published first on a topic demonstrated a mean deviation that was 2.5 percentage points smaller than subsequently published studies (P = .005). For journal-level factors, the greatest difference found (1.8 percentage points; P = .088) was in mean deviation for sensitivity in journals with impact factors above the median compared with those below the median. Conclusion Journal- and study-level variables considered important when evaluating diagnostic accuracy information to guide clinical decisions are not systematically associated with distance from the truth; critical appraisal of individual articles is recommended. RSNA, 2017 Online supplemental material is available for this article.
Levine D. Can Coregistered Photoacoustic Tomography and US Be Used in Screening for Ovarian Cancer?. Radiology. 2018;289 (3) :748-749.
Levine D. Can Ultrasound Be Used to Reassure Pregnant Women Infected by Zika Virus?. JAMA Netw Open. 2018;1 (8) :e186537.
Ludwin A, Martins WP, Nastri CO, Ludwin I, Coelho Neto MA, Leitão VM, et al. Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus?. Ultrasound Obstet Gynecol. 2018;51 (1) :101-109. Abstract
OBJECTIVES: To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three-dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)). METHODS: Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and provided to 15 experts (five clinicians, five surgeons and five sonologists). They were instructed to indicate whether they believed the uterus to be normal/arcuate (defined as normal uterine morphology or not clinically relevant degree of distortion caused by internal indentation) or septate (clinically relevant degree of distortion caused by internal indentation). Two other observers independently measured indentation depth, indentation angle and indentation-to-wall-thickness (I:WT) ratio. The agreement between experts was assessed using kappa, the interobserver reliability was assessed using the concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) and the best cut-off value was assessed using Youden's index, considering as the reference standard the choice made most often by the experts (CUME). RESULTS: There was good agreement between all experts (kappa, 0.62). There were 18 septate and 82 normal/arcuate uteri according to CUME; European Society of Human Reproduction and Embryology (ESHRE)-European Society for Gynaecological Endoscopy (ESGE) criteria (I:WT ratio > 50%) defined 80 septate and 20 normal/arcuate uteri, while American Society for Reproductive Medicine (ASRM) criteria defined five septate (depth > 15 mm and angle < 90°), 82 normal/arcuate (depth < 10 mm and angle > 90°) and 13 uteri that could not be classified (referred to as the gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa, 0.1); the agreement between ASRM criteria and CUME for septate was 87% (kappa, 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa, 0.93). Among the three measurements, the interobserver reproducibility of indentation depth (CCC, 0.99; 95% CI, 0.98-0.99) was better than both indentation angle (CCC, 0.96; 95% CI, 0.94-0.97) and I:WT ratio (CCC, 0.92; 95% CI, 0.90-0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good, with AUC between 0.96 and 1.00. The best cut-off values for these measurements to define septate uterus were: indentation depth ≥ 10 mm, indentation angle < 140° and I:WT ratio > 110% . CONCLUSIONS: The suggested ESHRE-ESGE cut-off value overestimates the prevalence of septate uterus while that of ASRM underestimates this prevalence, leaving in the gray-zone most of the uteri that experts considered as septate. We recommend considering indentation depth ≥ 10 mm as septate, since the measurement is simple and reliable and this criterion is in agreement with expert opinion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
McDonald RJ, Levine D, Weinreb J, Kanal E, Davenport MS, Ellis JH, et al. Gadolinium Retention: A Research Roadmap from the 2018 NIH/ACR/RSNA Workshop on Gadolinium Chelates. Radiology. 2018;289 (2) :517-534. Abstract
Gadolinium-based contrast agents (GBCAs) have revolutionized MRI, enabling physicians to obtain crucial life-saving medical information that often cannot be obtained with other imaging modalities. Since initial approval in 1988, over 450 million intravenous GBCA doses have been administered worldwide, with an extremely favorable pharmacologic safety profile; however, recent information has raised new concerns over the safety of GBCAs. Mounting evidence has shown there is long-term retention of gadolinium in human tissues. Further, a small subset of patients have attributed a constellation of symptoms to GBCA exposure, although the association of these symptoms with GBCA administration or gadolinium retention has not been proven by scientific investigation. Despite evidence that macrocyclic GBCAs show less gadolinium retention than linear GBCAs, the safety implications of gadolinium retention are unknown. The mechanism and chemical forms of gadolinium retention, as well as the biologic activity and clinical importance of these retained gadolinium species, remain poorly understood and underscore the need for additional research. In February 2018, an international meeting was held in Bethesda, Md, at the National Institutes of Health to discuss the current literature and knowledge gaps about gadolinium retention, to prioritize future research initiatives to better understand this phenomenon, and to foster collaborative standardized studies. The greatest priorities are to determine (a) if gadolinium retention adversely affects the function of human tissues, (b) if retention is causally associated with short- or long-term clinical manifestations of disease, and (c) if vulnerable populations, such as children, are at greater risk for experiencing clinical disease. The purpose of the research roadmap is to highlight important information that is not known and to identify and prioritize needed research. ©RSNA, 2018 Online supplemental material is available for this article .
Levine D, McDonald RJ, Kressel HY. Gadolinium Retention After Contrast-Enhanced MRI. JAMA. 2018;320 (18) :1853-1854.
Hobbins JC, Platt LD, Copel JA, Euser AG, Afshar Y, Irani RA, et al. Gottesfeld-Hohler Memorial Foundation Zika Virus Think Tank Summary. Obstet Gynecol. 2018;131 (4) :661-665. Abstract
At a think tank bringing together experts on fetal neuroimaging, obstetric infectious diseases, and public health, we discussed trends in all of these areas for Zika virus. There is a wide variety of imaging findings in affected fetuses, influenced by timing of infection and probably host factors. The resources for diagnosis and interventions also vary by location with the hardest hit areas often having the fewest resources. We identified potential areas for both research and clinical collaboration as the Zika virus epidemic continues to evolve.
Boos J, Brook OR, Fang J, Brook A, Levine D. Ovarian Cancer: Prevalence in Incidental Simple Adnexal Cysts Initially Identified in CT Examinations of the Abdomen and Pelvis. Radiology. 2018;286 (1) :196-204. Abstract
Purpose To evaluate the rate of malignancy in incidentally detected simple adnexal cysts at computed tomography (CT) to determine if simple-appearing cysts require follow-up. Materials and Methods In this HIPAA-compliant, institutional review board-approved retrospective cohort study, an institutional database was searched for abdominal and pelvic CT studies performed between June 2003 and December 2010 in women reported to have adnexal cysts. Adnexal cyst characterization was determined by prospective report description as well as image review by a research fellow and by a fellowship-trained abdominal radiologist for examinations with disagreement between the original report and the research fellow's assessment. Patients with known ovarian cysts or ovarian cancer at time of the index CT examination were excluded. Clinical outcome was assessed by using follow-up imaging studies, medical records, and the state cancer registry. Benign outcome was determined by benign findings at surgery, a decrease in size or resolution of a simple-appearing cyst at follow-up imaging, or stability of the cyst for at least 1 year. Descriptive statistics and 95% confidence intervals (CIs) were calculated. Results Among 42 111 women who underwent abdominal and pelvic CT examinations in the study period, 2763 (6.6%; 95% CI: 6.3%, 6.8%) (mean age, 48.1 years ± 18.1; range, 15-102 years) had a newly detected finding of ovarian cyst described in the body or impression section of the report. Median cyst size was 3.1 cm (range, 0.8-20.0 cm). Eighteen (0.7%; 95% CI: 0.4%, 1.0%) of 2763 patients were found to have ovarian cancer after an average follow-up of 5.1 years ± 3.8 (range, 0-12.8 years). None (95% CI: 0%, 0.4%) of 1031 women with simple-appearing cysts were given a diagnosis of ovarian cancer. This included none (95% CI: 0%, 0.4%) of 904 women with simple-appearing cysts with an adequate reference standard for benign outcome. Conclusion The prevalence of previously unknown adnexal cysts at CT was 6.6%, with an ovarian cancer rate of 0.7% (95% CI: 0.4%, 1.0%). All simple-appearing cysts were benign (95% CI: 99.6%, 100%). RSNA, 2017 Online supplemental material is available for this article.
Kruskal J, Patel A, Levine D, Canon C, Macura K, Allen BJ, et al. Fostering Diversity and Inclusion: A Summary of the 2017 Intersociety Summer Conference. JACR. 2018;
Levine D. Dynamic ultrasound of hernias of the groin and anterior abdominal wall. In: Diagnostic Ultrasound, 5th edition, Rumack and Levine editors, Elsevier. 2018.

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