Dr. Laurence Klotz discusses micro-ultrasound as a faster, less invasive, more cost-effective screening strategy compared to mpMRI in this podcast. 

Reading Room Podcast: Micro-Ultrasound for Easier Prostate Cancer Screening

Cardiac ultrasound can reveal how COVID-19 damages the heart, not only potentially helping doctors identify patients who are at risk faster, but also guiding future therapies.

Journal of the American College of Cardiology, 

investigators from the Icahn School of Medicine and Mount Sinai Hospital revealed that cardiac ultrasound (echocardiograms) can identify different types of post-cardiac injury structural damage that can occur in COVID-19 patients. These injuries can be linked to several deadly conditions associated with higher mortality risks in hospitalized patients, such as heart attack, pulmonary embolism, heart failure, and myocarditis.

“Early detection of structural abnormalities may dictate more appropriate treatments, including anti-coagulation and other approaches for hospitalized and post-hospitalized patients,” said study author Valentin Fuster, M.D., Ph.D., director of Mount Sinai Heart and physician-in-chief of The Mount Sinai Hospital.”

Echocardiograms are particularly suited for providing this type of information, the team said, because it is the only modality that can be safely used at the beside for patients who are on ventilators.

This new retrospective study, the team said, builds on Mount Sinai’s existing body of research into troponin levels that shows heart damage is common in COVID-19 hospitalized patients. This investigation focuses on elevated cardiac troponin levels that are present alongside echocardiographic abnormalities. Based on their analysis, the team determined this combination was linked to a worse prognosis and mortality for the patient than having an elevated troponin level by itself.

“We found that among COVID-19 patients who underwent transthoracic echocardiography, these cardiac structural abnormalities were diverse and present in nearly two-thirds of patients,” said first and corresponding author Gennaro Giustino, M.D, cardiology fellow at The Mount Sinai Hospital, noting this is one of the first studies to generate detailed echocardiographic and electrocardiographic data in hospitalized COVID-19 patients who have lab evidence of myocardial injury.

To gather this data, the team analyzed transthoracic echocardiographic (TTE) and electrocardiographic (ECG) scans from 305 adult, COVID-19-positive patients who were admitted to four New York City hospitals in the Mount Sinai system, as well as one hospital in Queens and two hospitals in Milan, Italy, between March 2020 and May 2020. The average patient age was 63, and 67.2 percent of participants were men.

Evidence of myocardial injury was present in 190 individuals – 62.6 percent of the study population. Heart damage was present in 118 of them when they were admitted to the hospital, and 72 developed a myocardial injury during their hospitalization. Those patients with injuries had more electrocardiographic abnormalities, higher inflammatory biomarkers, and an increased prevalence of TTE abnormalities than patients without heart injury.

According to their analysis, the identified abnormalities were diverse, and some patients had multiple abnormalities. For example, 26.3 percent had right ventricular dysfunction, an abnormality that can be linked to pulmonary embolism and severe respiratory failure, and 23.7 percent had regional left ventricular wall motion abnormalities that can be associated with heart attacks. In addition, diffuse left ventricular dysfunction – an abnormality associated with heart failure and myocarditis – was present in 18.4 percent, and 13.2 percent of patients had grade II or III diastolic dysfunction, a condition that can lead to stiffer cardiac chambers. Lastly, 7.2 percent had pericardial effusions that can cause abnormal heart pumping.

The team also went further to examine in-hospital morality and troponin elevation, adjusting for major COVID-19 complications, including shock, acute respiratory distress syndrome, and renal failure. Their findings revealed troponin elevation was 5.2 percent in patients without heart injury and 18.6 percent in whose who did have myocardial injury without echocardiographic abnormalities. The elevation was 31.7 percent in patients with heart injury and echocardiographic abnormalities.

Overall, the team said, cardiac ultrasound can play a significant role in managing COVID-19 patients and determining their course of treatment.

“Our study shows that an echocardiogram performed with appropriate personal protection considerations is a useful and important tool in early identification of patients at greater risk for COVID-19 related cardiac injury, who may benefit from a more aggressive therapeutic approach earlier in their hospitalization,” said Martin Goldman, M.D., cardiology professor at Ichan. “Additionally, because this is a new disease with lingering symptoms, we plan on following these patients closely using imaging to evaluate the evolution and, hopefully, resolution of these cardiac issues.”

For more coverage based on industry expert insights and research, subscribe to the Diagnostic Imaging e-Newsletter

Articles

The modality is the only one that can be safely conducted at the bedside with patients on a ventilator.

Ultrasound Reveals Cardiac Injury Caused By COVID-19

It was one of those workweeks: I spent much of each day behind the 8-ball.

That metaphor will mean different things to different rads. Heck, it has meant different things to me over the course of the four jobs I’ve held since finishing fellowship.

First was in a group of outpatient imaging centers which routinely maintained a backlog of unread cases in each location. Freshly graduated from hospitals where all the work got done each day, I could see that this was a very different mess. Attempting to get everything done here would be tilting at windmills. But, that didn’t stop me from striving to make a visible dent as I tried to prove myself to the practice.

At some point, the practice rotated me to one of its saner locations, where I was actually able to get everything done and up-to-date. This was noticed – one of the other rads was also young and hard-working, and the group responded by exclusively assigning one or the other of us to that office. It was only for half a day at a time, though, so we wouldn’t be able to 

 get everything done. Still, it would be far better than their other locations, to which we’d get rotated for the other half of each day.

For more coverage based on industry expert insights and research, subscribe to the Diagnostic Imaging e-Newsletter 

Lesson learned: Getting out from behind the 8-ball would result in either you or the ball being moved squarely back in place – and, with no recognition for your efforts. The group’s offer for me to stay on with them after that year was laughably bad, so I moved on to another local group, also exclusively outpatient imaging. (The other young rad was married to the managing partner’s daughter, thus less able to extract himself.)

My second group also had a routine backlog of work, albeit far less egregious. It probably had something to do with fewer sites generating cases, and fewer rads necessary to stay on top of it all. Here, it was far more possible to get everything done every day, and while they were initially pleasantly surprised to see me empty the bin of case files, they soon came to expect it.

I didn’t mind such expectations, since I was, theoretically, in a partnership track and happy to have a chance to prove myself. It also felt nice and refreshing to be able to, once again, get all the work done each day. Even when a larger volume of cases was made available for me to draw from, I took it on. The only real sense of being “behind the 8-ball” here was when other tasks got in my way and allowed more unread cases to accumulate at certain times of day than usual, and I thought I might not actually get everything done before it was time to leave.

You might be noticing that being behind the 8-ball, for me, tends to be a self-imposed sense of productivity below what I’d like to maintain. Most of the causative factors are beyond my control, but often I’ll have a sense that I can compensate for those from my side of things. Adapt and overcome.

So, it was that I approached my third gig, in vRad, with optimism. Here was a massive business with a proven model of giving you all the work you could possibly want, and a bunch of tools to get it done efficiently. I would no longer be held back by the quirks and limited resources of my previous, comparatively tiny rad groups. Gone also, however, would be the days when all the work was done and “caught up.” Indeed, if that ever happened, it would be vRad’s failure not having anything for its pay-per-case rads to do.

It turned out there were still some things which could hold me back. When vRad’s system went down, or they simply chose to do software updates in the middle of my shift, their model didn’t have any mechanisms to compensate for the loss of productivity.

Even without such outside interference, I found that I had my own internalized 8-ball to get stuck behind. After being in the radiological world for a few years, I had developed a sense of how much work I was capable of doing—not only in a current environment, but in an ideal setting. If, in a typical day, my hourly pace was behind what I knew it could be, I’d get that “gotta make up for lost time” feeling. I’d even get that sensation when I’d had an unusual preponderance of low-value studies on my list, XR instead of MR, and my “work-unit” tally was falling behind its norm.

Coming back to the present day, I’m considerably less productive than I was at vRad. There are more than a few ways that could be changed—again, mostly beyond my control, but I adapt when and how I can. It’s no longer that every gained (or lost) case impacts my bottom line. Rather, I just want to give a good accounting of myself.

This past week, for instance, software issues were interfering with the transmission of cases to the group’s telerad system, such that I spent substantial chunks of each day with nothing available on my worklist. I could have shrugged and sat back, reassuring myself that whoever tracks productivity in my group would know the telerads were hamstrung and should not be regarded harshly if their daily numbers took a hit…

…but my 8-ball instincts wouldn’t allow for that. Instead, I watched, rather hawk-like, with each “refresh” of the RIS screen, that I might grab whatever new case had managed to trickle through the system. I knew that not all of the other telerads might be doing the same, but if even one was, darn it, I would be the faster gunslinger and click first.

There is, without question, added stress in maintaining an awareness of being behind the 8-ball, let alone carrying one around in my mind. I find that the adaptive value outweighs any excess anxiety it might bring: It gives me an extra edge as I play “catch-up,” focusing on tasks at hand and ignoring distractions.

Also, the sooner my 8-ball alarm starts going off, the earlier I can figure out what set it off and get to work fixing things. Sometimes, that includes identifying what caused the situation – and learning how to avoid or even prevent it in the future.

Follow Diagnostic Imaging Editorial Board member Dr. Eric Postal on Twitter: @EricPostal_MD

When a self-imposed expectation of productivity is a driving force.

Behind the 8-Ball

Senior Fellow and Director of the Center for Medical Economics and Innovation at the Pacific Research Institute

Life expectancy in the U.S. has markedly improved over the last century. At the turn of the 20th century, it was 

. By 2017, life expectancy at birth reached nearly 

. Advances in medical innovations are often cited as “one of the greatest contributors” to this progress.

These long-term trends provide important perspective for Congress as it considers re-authorizing the Medical Device User Fee and Modernization Act of 2002 – the next authorization is referred to as MDUFA V.

All new medical devices – the wide range of products that are used to diagnose, treat, monitor, or prevent diseases and conditions – must obtain U.S. Food & Drug Administration (FDA) authorization before the products can be marketed and sold in the United States. Prior to MDUFA, FDA’s review process was widely viewed as inefficient, time consuming, and the FDA rarely met the required deadlines.

As a result of these inefficiencies, patients’ access to potentially lifesaving or life-enhancing medical devices were unnecessarily delayed, harming health outcomes. From the companies’ perspectives, the delays created uncertainties that made marketing their products more difficult and complicated the process of conducting follow-up studies.

MDUFA is a win-win-win policy that reduces these problems.

How Industry-FDA Cooperation Removed Medical Imaging Device Delivery Delays

For the FDA, MDUFA ensures that the agency has access to the necessary resources to improve its efficiencies. Consider that the 

 for devices that are “substantially equivalent” to a device already on the market (510(k) applications) has fallen from 154 days in 2010 (including the time spent by the FDA and time spent by the applicant responding to the FDAs requests) to 124 days in 2019. The decision time for novel medical devices (PMAs) has been more volatile, but still fell from 467 days in 2013 to 217 days in 2019. Thanks to the resources provided by MDUFA, the FDA is largely meeting is required efficiency goals.

For the manufacturers, the improved speed and predictability of the approval process improves manufacturers’ efficiencies and planning processes. Perhaps most importantly, the expedited review process provides patients with faster access to new medical devices. 

, these new devices include better heart valves, devices that enable minimally invasive spinal correction, and better glucose monitors.

These results strongly support the argument that MDUFA V should be authorized by Congress. The terms of that reauthorization are a bit more controversial.

MDUFA’s benefits are enabled by the act’s user fee structure. There are, undoubtedly, strong arguments in favor of funding the FDA’s review process by levying user fees on the manufacturers submitting devices for approval. There are equally strong arguments that user fees should only partially fund the review process and general tax revenues should also fund a substantial portion of these costs.

It is commonly accepted that government agencies 

 when a limited number of people or businesses benefit from the public service. Taxes, on the other hand, are appropriate when the general population benefits from the public service.

The benefits from the FDA’s medical device review process contain both of these elements. Medical device manufacturers benefit greatly from an efficient review process, but so does the broad patient population. The current blended revenue structure that funds the review process with both MDUFA user fees and general tax revenues balances both types of benefits.

Over time, the revenue structure has been tilting toward an excessive 

 rather than general tax revenues. When first implemented, user fees accounted for approximately one-fifth of total program revenues. The implementation of new fees and increases in rates has caused user fee revenues to grow at double-digit rates and now account for around 44 percent of total revenues.

This excessive growth in user fees is becoming an excessive tax on manufacturers that, if not appropriately managed, will reduce their efficiencies and incent wasteful expenditures on programs that do not enhance the FDA’s mission of performing a comprehensive and timely safety review process of new medical devices. The consequence will be a higher-cost, less efficient, FDA.

It is imperative that Congress recognize these considerations in its upcoming MDUFA reauthorization process. While reauthorizing MDUFA is an important public health policy, the user fee authority should not be used as a slush fund to authorize ancillary programs that do not enhance the agency’s prime directive.

Wayne Winegarden, Ph.D. is a Senior fellow and Director of the Center for Medical Economics and Innovation at the Pacific Research Institute

Re-authorize MDUFA without raising user fees to fund unrelated programs.

 Medical Device Legislation Should Be Re-Authorized, But Without User Fee Changes

In this week’s preview, here are some highlights of what you can expect to see coming soon on 

Breast Cancer Awareness month will soon be coming to a close, but that does not mean radiology practices and breast imaging centers should relax the attention they pay to patients who come in for breast cancer screening. This week, 

 spoke with breast imaging technologist Stephanie Johnston from Solis Mammography in Texas about what is most important to women when they come in for annual screening, as well as what practices can do to ensure women have the best counters possible.

For additional insights on patient experience, 

Stroke remains the leading cause of disability in the United States, as well as a leading cause of death. Given their skill set, radiologists are uniquely positioned for stroke prevention. In a column this week, 

Editorial Board member Mina Makary, M.D., an interventional radiologist from The Ohio State University Wexner Medical Center, shared insights on alternative training models for interventional neuroradiology.

To read our previous coverage of neuroimaging, 

Research efforts are continuing to help providers better understand the development of dementia in patients. This week, we will share investigation results from two institutions that shed light on how this disease affects the brain. Look for this coverage as the week progresses.

Here's what to expect this week on Diagnostic Imaging.

Diagnostic Imaging's A Look Ahead: Oct. 26, 2020, to Nov. 1, 2020

Women of Indian and Pakistani decent are more often diagnosed – at a younger age -- with more aggressive forms of breast cancer, and they could benefit from more culturally targeted screening and prevention strategies, experts have said.

Finding ways to reach these women successfully is critical, according to investigators from Rutgers University because the South Asian population is the fastest-growing group in the United States – and breast cancer rates among these women are increasing. To date, research has provided little data about the disease and this unique population.

To offer more clarity, Rutgers researchers looked at the characteristics of breast cancers in women of Indian and Pakistani descent and compared those findings to results from non-Hispanic white women in the United States. They published their findings Oct. 25 in the 

“Our results provide an insight into breast cancer in Indian and Pakistani women, suggesting several hypotheses to guide future scientific studies to better understand the risk factors influencing disease etiology and prognosis,” said Jaya M. Satagopan, Ph.D., professor of biostatistics and epidemiology and director of the Center for South Asian Quantitative Health and Education at Rutger’s School of Public Health.

Q&A: Breast Cancer Screening Shortfalls for African American Women

To draw these comparisons, Satagopan’s team examined data from the National Cancer Institute’s Surveillance, Epidemiology and End Results Program. They analyzed incidence data from women of Indian and Pakistani descent gathered from 1990 to 2014, as well as disease characteristics, treatment, and survival data captured between 2000 and 2016 for 4,900 women in these groups. In additional, they examined the same data from 482,250 non-Hispanic white women who had breast cancer.

Based on their analysis, they determined that, while breast cancer occurrence was lower in women of Indian and Pakistani descent, the number of diagnosed cancers increased throughout the years studied. Additionally, women in these groups were more likely to be diagnosed with a more advanced-stage disease at a younger age.

As a result, the team said, women of Indian and Pakistani descent received more subcutaneous or total mastectomies than non-Hispanic white women. And, even though they had lower breast cancer mortality than their white counterparts, their health outcomes were tracked for less time.

Historically, Satagopan said, fewer women of Indian and Pakistani descent have participated in scientific research, and many delay seeking necessary health services due to sociocultural factors. Specifically, diminished family support, transportation difficulties, modesty, fear, and beliefs about cancer being a divine punishment for past misdeeds have all factored into poor mammogram screening rates in this group. This is particularly true for women who have lived in the United States less than a decade, have low English proficiency, and do not have confidence in the U.S. healthcare system, she said.

Consequently, the team determined, the industry must devise strategies than can specifically engage women of Indian and Pakistani descent into breast cancer studies, potentially improving their experiences and interactions with healthcare providers. Identifying the sociocultural factors that come into play with their screening and healthcare use decisions is paramount, they said.

“As the South Asian population in the United States grows, it is imperative that we work to promote health equity in cancer prevention, screening, early diagnosis, and treatment through community engagement and a team science approach, said Anita Kinney, Ph.D., RN, director of the Center for Cancer Health Equity at Rutgers School of Public Health and Rutgers Cancer Institute of New Jersey.

Ultimately, the team said, their study findings point to the existence of important differences within this population that support further study. Future research should focus on findings ways to better understand the biological, sociocultural, and system-level factors that impact breast cancer screening patterns and diagnosis, as well as risk and survival rates in women of Indian and Pakistani descent.

More culturally relevant screening strategies could improve preventive healthcare in these groups.

Younger Indian and Pakistani Women Diagnosed with Aggressive Breast Cancer

Despite recent evidence that physician extenders can streamline radiology workflow and reduce turnaround times, radiologists should rely more on artificial intelligence (AI) for assistance than non-physician providers (NPP), a group of industry experts has said.

Journal of the American College of Radiology

a team of experts, led by Daniel Ortiz, M.D., with Summit Radiology in Georgia, pointed to the several benefits of AI – not only do the tools save money and streamline workflow, but they will not encroach on a radiologist’s responsibilities.

For these reasons, they said, radiologists should forego giving physician extenders – the nurse practitioners, physician assistants, and other providers who take on some of a provider’s duties – full practice authority.

“Although labor costs have been reduced and radiologists can focus more on complex imaging studies and interventional procedures, there are unintended consequences of non-physician practitioners in practice that could diminish physician’s role as healthcare providers,” the group wrote. “Therefore, we encourage radiologists to consider an alternative to non-physician practitioners in radiology: the incorporation of rapidly evolving artificial intelligence algorithms into daily practice.”

Radiology Extenders Outperform Radiology Residents with Chest X-ray Interpretations

Their concern was spawned by a recently passed Georgia law that allows advanced practice registered nurses to order CR, MRI, and other imaging exams under certain circumstances. Some pockets of support in healthcare have heralded the measure as a way to both decrease labor costs and take less complicated studies off of the radiologist’s work list, leaving him or her available for more complex exams.

But, according to Ortiz and his colleagues, radiology must be careful before proceeding down this path.

“If one year, we agreed upon a catalog of procedures to be relegated, do we really believe it will stop at those procedures deemed ‘simple’ by radiologists?” they asked. “Radiology, particularly interventional radiology, already finds itself in ever-growing struggles with other physicians for access to procedures, such as cardiac imaging or vascular interventions.”

Instead, in their editorial, they outlined their reasons why radiologists should lean more heavily on AI for support.

First, they pointed out that the push behind greater autonomy for NPPs is rooted in their ability to complete non-complex tasks, such as placing a nasogastric tube, successfully. However, radiology’s interpretation responsibilities are largely more complicated.

“The fallacy of this logic is highlighted by the idea that radiologists are not only responsible for answering the question at hand, but are responsible for the ‘whole image,’” they explained. “Although one could train an NPP to identify tips of lines, tubes, and otherwise, this does not rescind the liability for finding the unexpected.”

Even if radiology does cede control of simpler tasks to NPPs – but remains responsible for signing off on the work completed – the specialty runs the risk of creating a “culture of rubber-stamping” without review.

Second, the Center for Medicare & Medicaid Services recently granted its first approval to AI software, allowing for payment for the use of these tools. Consequently, many in the industry see this as an encouragement to additional AI vendors to continue development and clinical trials.

“Unlike humans with a narrow scope of practice, narrow AI algorithms can easily be integrated into existing workflow and amalgamated into a platform for use by radiologists,” the group said, noting there is little support for autonomously operating, unsupervised AI. “Many of the gains touted by proponents for the use of preserving the radiologist’s role, supplemented by AI.”

Ultimately, said Ortiz and his colleagues, expanding the use of NPPs will have unforeseen consequences for radiology’s future. Rather than opting to delegate radiology work to others, providers should be focused on strategies that can empower radiologists to stay in control of the imaging care that benefits patients.

“Empowered by AI,” the group said, “radiologists can achieve their wish of being as ubiquitous as water and remain heralded as diamonds.”

Industry experts advocate for radiologists to opt for relying on artificial intelligence – rather than non-physician providers – for help with workflow and cost reduction.

In a Choice Between AI and a Radiology Extender, Choose AI

A substantial international effort, bringing together experts from a variety of specialties, is now in motion with the goal of augmenting the use of MRI to better determine the long-term impacts of traumatic brain injury.

Dubbed ENIGMA, this initiative based at the University of Southern California and conducted in conjunction with the Norwegian University of Science and Technology (NTNU), is designed to collect, combine, and analyze large brain imaging data sets from around the world, searching for connections that cannot be identified on single studies.

The team shared the specifics of this initiative in 

“A major challenge in the research is to figure out which injury characteristics and which changes in the brain caused by the injury can predict how patients will recover and what follow-up they need,” said Alexander Olsen, Ph.D., associate professor of psychology and head of the Clinical Neuroscience Laboratory at NTNU. “A big part of the challenge is that individual patients are so different.”

The Value of MRI After Traumatic Brain Injury

Progress into understanding how the brain responds after a traumatic brain injury has been stymied, largely because most previous studies were small and they had no standard way for sharing and analyzing data across institutions because patient populations are heterogenous. The hope now, according to this group comprised of 170 researchers from 13 countries, is that investigations into newer and more advanced MRI methods will provide some clinical benefit.

“By pooling our resources, in terms of data, computational power and intellectual expertise,” said Emily Dennis, Ph.D., co-principal investigator for ENIGMA’s main group on brain injuries, “we’ll be able to tackle some of the big unanswered questions in our field, such as how sex impacts outcome, whether there are subtypes within the broader patient population, or how to handle lesions in neuroimaging data.”

While MRI images can reveal the size and type of injury, Olsen’s group will work with research-based MRI methods that use advanced algorithms and statistics. They intend to apply those methods to MRI data that has already been collected from investigators across the globe, including the United States, Europe, Australia, the Middle East, South Africa, and South America.

“We’re working to develop better and more standardized ways of summarizing and making sense of the MRI data.” Olsen said, noting that only an international collaboration can handle data of this magnitude. “We hope to contribute to breakthroughs in research that will benefit patients.”

Worldwide effort will amass large datasets from institutions  that can be used to identify long-term traumatic brain injury and augment therapies. 

Global MRI Initiative Looks to Improve Brain Injury Treatment

The radiation oncology (RO) payment model from the Centers for Medicare & Medicaid Services (CMS) has been pushed back from its original Jan. 1 start date.

In a statement released Thursday, Oct. 21, via Twitter, the CMS Administrator Seema Verma said the agency would postpone the payment model launch until July 2021. The decision was made based on the response from the RO community that indicated they needed more time to prepare.

The move earned gratitude from the RO community. The leadership of the American Society of Radiation Oncology published a comment, expressing their appreciation that CMS paid heed to their requests, joining the American College of Radiology in resisting the initial Jan. 1 start date. In particular, they said, COVID-19 has presented significant challenges to the specialist community.

“We are hopeful that the delay represents the first step toward full, open engagement with ASTRO on ways to ensure that the RO Model achieves our shared goals on higher quality, lower-cost cancer care,” said Theodore L. DeWeese M.D., the chair of ASTRO’s Board of Directors. “We remain seriously concerned with excessive payment cuts in the model that will cause significant financial strain on practices and risk patient access to radiation treatments.”

Once implemented, the RO model will bundle payments for a 90-day episode-of-care to radiotherapy provides who treat patients with one of 16 different types of cancers. Over five years, the anticipation is that it will save approximately $230 million.

CMS pushes launch from January 2021 to July 2021.



Radiation Oncology Payment Model Start Date Delayed

’s Weekly Scan. I’m senior editor, Whitney Palmer.

Before we get to our featured interview with Drs. Rich Heller and Nina Kottler from Radiology Partners about corporatization in radiology practices, here are the top stories of the week.

Think back for a moment to being a medical student – what one tool was always at your side. No doubt, you immediately thought of your stethoscope. Well, there’s a potential paradigm shift underway in medical education that could have point-of-care ultrasound taking over that coveted spot. Together in partnership, ultrasound manufacturer Vave Health and the College of Osteopathic Medicine at Touro University in Nevada have launched a new ultrasound curriculum that weaves image acquisition and interpretation instruction into nearly all levels of didactic training. At the same time students will be learning about anatomy and disease presentation, they will also be using hand-held ultrasound probes for visualization. In addition, students are getting a Vave EduPlus Membership that will give them access not only to ultrasound experts, but also to in-app content that can both help them prepare for medical exams and provide clinical context. The goal, according to Vave Health leaders, is to make the program available to other institutions who can then customize the curriculum to meet their program needs.

Throughout this year, there has been a lot of news emerging around pre-operative MRI and in what situations and for which women it works best. In an multi-institutional study published in 

investigators determined that this scan performs best in women who have dense breasts who have undergone digital breast tomosynthesis rather than digital mammography alone. In these situations, pre-operative MRI is able to identify more overlooked malignant lesions. To make this determination, researchers conducted a retrospective study of 388 consecutive breast MRIs captured for newly diagnosed breast cancers between Oct. 1, 2013, to July 31, 2015. Based on their results, the team discovered MRI detected additional malignant lesions in 57 percent of all women with dense breasts included in their study. Specifically, pre-operative MRI identified 50 additional malignancies, more of which were in women with dense breasts who had undergone digital breast tomosynthesis. These findings are clinically important, the researchers pointed out, because 43 percent of women in the United States between the ages of 40 and 74 have dense breasts, and evidence continues to mount that they could benefit from supplemental screening.

Since the beginning of the pandemic, the American College of Radiology and other industry professional organizations have recommended against using CT to diagnose COVID-19. But, research published by a team of France this week in the 

showed that spectral CT with electron density imaging can make it easier for providers to assess the extent of lung lesions in patients who have early-stage disease. The team used a small group of four case studies from patients diagnosed and treated in their hospital to show that electron density imaging improves the visualization of ground-glass opacities compared to conventional CT scans. The team reconstructed the spectral CT images using the same standard soft kernel (filter B) and a similar iterative method that is used to capture conventional CT images. Then, they compared initial conventional CT images with follow-up scans. They found that all 45 ground-glass opacities identified in the four patients showed up better on the electron density imaging, and the lesion extent was much easier to determine. Overall, they said, these results show that it is possible to gather greater detail for earlier assessment of ground-glass opacities, potentially impacting treatment for COVID-19.

 spoke with Drs. Rich Heller and Nina Kottler from Radiology Partners about the growing trend of corporatization in the industry. They shared with us not only their experiences within Radiology Partners, but the impact that corporatization is having on radiology at the local level and as a specialty overall. Here’s what they had to say.

Videos

Ultrasound as the New Stethoscope; Pre-Operative MRI and Dense Breasts; Spectral CT and COVID-19; Corporatization in Radiology

Diagnostic Imaging's Weekly Scan: Oct. 23, 2020

Protecting ultrasound providers during the COVID-19 pandemic requires going a step further than simply disinfecting surfaces – the air in ultrasound departments should be disinfected, too.

That’s the recommendation from a group of ultrasound experts from China. Representatives from four medical organizations collaborated this year to produce the first recommendation about air sanitation during the outbreak. They published their guidance in the Oct. 12 

“Given that patients undergoing ultrasound examination might be virus carrying or infected, or suspicious for infection (symptomatic or asymptomatic), it is of great importance to have good protection for the healthcare staff (including doctors, nurses, medical assistants, and technicians) during work,” said the team led by Luo Yukun, Ph.D., professor in the diagnostic ultrasound department at Chinese People’s Liberation Army General Hospital in Beijing. “Since in the department of ultrasound the healthcare workers are close contacted with patients who might be infected or virus carrying, it is extremely important to offer protection to them.”

This new advice underscores how what the industry knows about the COVID-19 virus continues to grow and change.

Lung Ultrasound Reveals COVID-19 Duration and Disease Severity

The team divided their suggestions into two main categories – designated spaces for healthcare providers and patients and personal protective equipment (PPE). They based their recommendations on existing hygiene standards, practitioner experience, and existing literature.

Most importantly, the team said departments must designate certain individual areas to be strictly used by patients or providers. For example, they said, each group should be relegated to separate hallways. In addition, some areas should be off-limits except to providers, and departments should create two buffer zones where providers can put on and take off PPE.

Following these measures is critical, they said because it will help keep track of what resources have been used and contaminated and strengthen the efforts to minimize exposure and transmission. The team also recommends disinfecting all surfaces, such as door handles, keyboards, floors, and ultrasound probes and machines. Using probe and plastic machine covers when it is feasible – especially with patients suspected of infection – could also be beneficial.

The team also offered clarity around the recommendations for greater air disinfection. Rooms reserved for patients without known or suspected COVID-19 infection should be ventilated for at least 30 minutes in both the morning and evening, and ultraviolet light should be added after all patients have been seen for the day, as well.

However, rooms used for patients who are suspected of infection must undergo a more stringent protocol. Alongside the daily ventilation measures, the team also said departments should also use a 3-percent hydrogen peroxide spray or a UV lamp for 60 minutes after each patient. Putting a plasma air disinfection machine in the COVID-19 rooms could also help combat exposure and transmission.

In addition, the authors reiterated existing PPE guidelines, advocating that everyone in the department – not just providers working directly with the ultrasound equipment – wear work coats, latex gloves, surgical masks, and disposable hairnets. These PPE should be changed every 4-to-6 hours, they said. But, they went a step further, recommending that providers wear isolation gowns with patients who have known infection and full-face respirators and other tertiary PPE for the riskiest procedures, ultrasound-guided aerosol-generating procedures.

To dispose of or process this equipment, the team offered this guidance:

Dispose of medical waste items in dedicated trash cans.

Soak anti-fog goggles in electrolyzed-oxidizing disinfectant for 5 minutes or chlorine-containing 1,000 mg/L disinfectant for 30 minutes.

Wipe face shield with 75-percent medical alcohol.

Change working coat every day or put under UV light in dressing room for 30 minutes.

Disinfect work shoes with UV light when necessary.

Despite not being a popular screening method in China, the team said, handheld ultrasound has proven beneficial with COVID-19 patients in other countries in a variety of healthcare settings.

“Ultrasound examination, having the advantages of convenience, quickness, non-invasiveness, radiation free, bedside available,” they said, “is a cost-effective, real-time technique which was reported to be an important role in the diagnosis and treatment of COVID-19.”

Researchers from China recommend disinfecting the air, alongside, sanitizing surfaces, to reduce exposures and transmission.



Don’t Stop with Disinfecting Surfaces – Clean the Air to Decrease COVID-19

Integrating advanced PET into imaging for patients who have recurrent prostate cancer can not only impact treatment plans, but it can also improve their disease-free survival rates, according to new research presented Monday.

During the American Society for Radiation Oncology annual meeting, investigators from the Winship Cancer Institute of Emory University shared the results of their EMPIRE-1 (Emory Molecular Prostate Imaging for Radiotherapy Enhancement) trial that determined adding the PET radiotracer fluciclovine to conventional imaging significantly benefits patients.

Overall, the team determined that among patients whose prostate cancer returned after prostatectomy, more than 75 percent of those who used the PET molecular to help guide their treatment were still disease-free three years later. This increased survival rate was sustained for four years, the team said.

Additional PET/CT Tracer to Detect Prostate Cancer

“The decision to offer post-prostatectomy radiation therapy is complex, because conventional imaging can leave unanswered questions on the best approach to treatment planning,” said co-principal investigator Ashesh B. Jani, M.D., radiation oncology professor in the Winship Cancer Institute. “What this research has found is that integrating advanced molecular imaging into the treatment planning process allow us to do a better job of selecting patients for radiation therapy, guiding radiation treatment decisions and planning and ultimately, keeping patients’ cancer under control.”

With one in nine men developing prostate cancer during their lives, this disease is the leading cause of cancer death among American men. Even after radical prostatectomy, between 20 percent and 40 percent of men can experience a recurrence, signaling that they have an aggressive form of the disease. In these cases, providers typically use conventional imaging techniques, including CT and MRI, to guide radiation therapy decisions, but MRI with PET has been shown to more accurately detect the presence and location of developing tumors.

African American Men with Prostate Cancer Have Less Access to Cutting-Edge PET Care

To determine the impact on fluciclovine (

F), a radiotracer that received U.S. Food & Drug Administration approval halfway through a trial in 2016, the team, also led by David M. Schuster, M.D., a nuclear radiology specialist and professor at Emory, enrolled 165 patients who had undergone radical prostatectomies in their EMPIRE-1 trial. All patients, who had abnormal prostate specific antigen (PSA) levels had CT and MRI for initial treatment planning. The team, then, divided participants into two groups – one that received radiation therapy based on conventional imaging alone and a second group that underwent 

F PET scans and received treatment guided by those additional findings.

Based on a three-year follow-up, the team determined that patients who had advanced imaging-guided radiation therapy had a higher disease-free survival rate than those with therapy guided by conventional imaging along – 75.5 percent versus 51 percent, respectively. There were no significant differences in provider-reported severe genitourinary or gastrointestinal side effects reported in either treatment group.

“At three years, the group getting treatment guided by PET fluciclovine had a 12-percent better cancer control rate, and this persisted at four years, as well, with a 24 percent-improvement,” Jani said. “We think the improvement was seen because the novel PET allowed for better selection of patients for radiation, better treatment decisions, and better radiation target design.”

F, which had not been widely integrated into prostate cancer treatment planning, should be integrated into therapeutic planning. And, it is possible that an even more effective radiotracer could be around the corner, they said.

“Fluciclovine PET has become the best available test,” Schuster said. “But, now there’s an even newer kid on the block. In EMPIRE-2, we’re building on the results of EMPIRE-1 by comparing PSMA with fluciclovine to see which one of these radiotracers improves cancer control better.”

Adding the 18F radiotracer to MRI scans provides more detail, leading to better treatment planning and better disease-free survival rates in men with recurrent prostate cancer.

PET-Enhanced MRI is “Best Available Test” to Guide Recurrent Prostate Cancer Treatment

Siemens Healthineers announced Monday it has secured 510(k) clearance from the U.S. Food & Drug Administration for its ceiling-mounted radiography system.

Dubbed YSIO X.pree, this system uses the MyExam Companion intelligent user interface and comes with a new 3D camera that can help technologists with patient positioning and advanced collimation. Together, with a new smart image processing engine, company officials said, the system can augment patient and user experience, as well as optimize clinical operations.

“The YSIO X.pree ceiling-mounted radiography system represents a dramatic leap forward in intelligent X-ray imaging,” said Niral Patel, vice president of X-ray products, “providing our customers with an unprecedented level of intuitive operation for consistent X-ray images and potential faster workflow.”

For consistency, according to a company statement, the new image processing database allows technologists to set preferred image contrasts, and it removes image noise. In addition, it allows for low-dose settings, can limit the need for additional patient exposure, and produce cropped images with artificial intelligence-based cropping.

This is Siemens’ first X-ray system armed with MyExam Companion. While this interface can help technologists of any experience level work through an X-ray procedure, said company representatives, it also brings together available demographic patient data with other machine-observable, patient-specific details that can lead to optimal acquisition and reconstruction parameters.

The system’s 3D camera offers several features that can streamline and accelerate workflow:

Virtual Collimation: Allows technologists to adjust, via a touchscreen monitor, the size and shape of the X-ray beam to reduce the volume of tissue exposed to radiation.

Smart Virtual Ortho: Shortens preparation times for multi-image orthopedic acquisitions by adjusting exposure parameters based on individual patients, making it easier to capture long-leg and full-spine images.

Auto Thorax Collimation: Uses automated, AI-based body part detection and collimation to analyze the patient’s body contour and make half-second collimator blade adjustments, speeding up the workflow associated with thorax studies.

Ceiling-mounted system offers intelligent interface to guide technologists through exam.

FDA Clears Siemens Healthineers Intelligent Radiography System

A new mapping tool used with MRI can help radiologists pick up on the early signs of dementia with more than 70 percent accuracy, a new study has revealed.

Currently, providers rely on a “trained eye” to distinguish white matter lesions – hyperintensities – that can point to the beginning stages of cognitive decline. But, in an article published Oct. 27 in 

a team of investigators from New York University (NYU) Grossman School of Medicine share the results of their new tool that can analyze tissue damage seen on MRI brain scans.

“Our new calculator for properly sizing white matter hyperintensities, which we call bilateral distancing, offers radiologists and other clinicians an additional standardized test for assessing these lesions in the brain, well before severe dementia or stroke damage,” said study senior investigator Yulin Ge, M.D. professor of radiology at NYU Langone.

Patients who have more and larger white matter lesions on the gray matter of their brain are more likely to experience memory loss and emotional problems, especially as they get older, the team said. If these spots appear at the center of the brain, they can also indicate worsening dementia or other conditions, such as stroke or depression, that can damage the brain.

Instead of relying on the existing three-point scale method where providers use their best judgement to stage disease, this team set out to create a more standardized, objective method that could accurately measure lesion volume and location. Providers can access the tool 

To do so, they randomly selected 72 MRI scans from the Alzheimer’s Disease Neuroimaging Initiative. Most patients were over age 70, and an equal number of men and women were included. Their cognitive abilities ranged from normal brain function to mild cognitive decline to severe dementia.

Once the brain was mapped with the most up-to-date MRI techniques, the team applied computer software to calculate the exact location and volume, in liters, for all white matter lesions that could be seen. They determined a lesion’s volume based on its distance from both side surfaces of the brain with normal ranges between 0 milliliters, indicating no lesions seen, and 60 milliliters, referring to some lesions. Any volume over 100 milliliters, they said, indicated severe disease.

Based on their calculations, which they crossed-checked, the team determined that 7 out of 10 – roughly 70 percent – of their measurements matched with the patient’s actual diagnosis.

Employing this tracking tool can be useful clinically, said study lead investigator Jingyun “Josh” Chen, Ph.D., research assistant professor of neurology at NYU Langone. With a tracking and measurement tool that is standardized, clinicians will be able to monitor whether – and how – white matter lesions grow in a patient’s brain relative to other tau and beta-amyloid proteins that are believed to be involved in the development of dementia and Alzheimer’s disease.

But, providers should proceed with caution, he noted. White matter lesion measurements are not enough on their own to validate an early dementia diagnosis. Providers should still take other factors, such as a history of brain injury, memory loss, and hypertension, into consideration as they are verified features of cognitive decline or other brain and blood vessel diseases.

Work with this tool is still ongoing, the team said. They are now testing it further with an additional 1,495 brain scans that will include a more diverse patient population.

A tool that objectively measures the volume of white matter lesions can accurately pinpoint evidence of early dementia.

PET-Enhanced MRI is “Best Available Test” to Guide Recurrent Prostate Cancer Treatment

FDA Clears Siemens Healthineers Intelligent Radiography System

New Tool Used with MRI Better Detects White Matter Lesions