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

Women who have ductal carcinoma in situ (DCIS) are more than three times as likely to die from breast cancer that are women in the general population, according to a new study.

 a research team from the University of Toronto determined women with DCIS have a 3.3-fold higher risk of dying from breast cancer than women the same age who do not have the disease. And, the risk is higher among young women and black women, they said.

“In the population studied, the risk of dying of breast cancer…suggests that our current treatment focus on preventing invasive recurrence is insufficient to eliminate all deaths from breast cancer after DCIS,” said the team led by Vasily Giannakeas, MPH, a doctoral candidate at the University of Toronto and Women’s College Research Institute.

While DCIS currently accounts for 30 percent of all cancers picked up in breast cancer screening, there is no consensus over whether it is an early-stage cancer that requires treatment before it progresses or if it should simply be monitored over time. It has also been suggested that searching for these cancers leads to overdiagnosis, and, therefore, unnecessary treatment. Giannakeas’s team contend their results support the argument for putting more emphasis on DCIS detection.

To determine the actual risk of death associated with DCIS, the team compared actual deaths with estimated deaths for women who received a DCIS diagnosis between 1995 and 2014. They pulled Surveillance, Epidemiology, and End Result data on 144,524 women treated surgically for DCIS. Women ranged in age from 25 to 79 at the time of diagnosis, and team tracked their outcomes either until they died, were lost to follow-up, reached 20 years post-diagnosis, or until the study ended in December of 2016.

 Pre-Operative Breast MRI Diagnoses More Cancers in Women with DCIS

The team calculated the standard mortality ratios (SMR) for these groups, leading them to postulate that 459 women from the entire study population would die from breast cancer if they had not developed DCIS. In actuality, 1,540 succumbed to the disease, resulting in a 3.36 SMR that indicates women with DCIS die three times as often as anticipated according to their year of diagnosis and age.

SMRs based on age and race also differed significantly, the team determined. Specifically, women under age 40 were 12 times more likely to die than the women in the healthy cohort, and black women were 7.6 times more likely. And, black women over age 50 fared worst with a 12.1 SMR.

Overall, the team said, the cohort had a 3.3 percent cumulative 20-year risk of breast cancer-specific mortality – a rate of risk that is too low to recommend chemotherapy across the board for women with DCIS. However, some subsets of women face higher cumulative risks, potentially making chemotherapy necessary. For example, black women over age 50 had a breast cancer-specific mortality risk of 8.1 percent.

Based on these results, the team recommended additional studies that could shed light on which patients with DCIS are at a higher mortality risk. Such investigations could improve treatment options.

“The current approach is to identify women with a high risk of local recurrence and treat them with radiotherapy initially and with chemotherapy at time of invasive cancer according to the clinical profile,” the team said. “It is challenging to identify patients with DCIS who are at high risk of dying; it might be possible to address this question using a case-controlled approach and compare pathological specimens and molecular expression and other demographic criteria for those who died and those who survived.”

Articles

Women treated with both surgery and radiotherapy for ductal carcinoma in situ fared best.

DCIS Carries Three-Fold Risk of Death

Recent articles that point to evidence of myocarditis found on cardiac MRI (CMR) in patients who have recovered from COVID-19 have included results from scans conducted on asymptomatic individuals. Using these findings as a basis for clinical practice could be leading the healthcare community down a questionable path, a group of experts have said.

 addressed to the American College of Radiology (ACR), the Radiological Society of North America (RSNA), the European Society of Radiology (ESR), and 15 other professional organizations, a cadre of 50 imaging, cardiology, and general medicine experts, specifically requested that these societies draft guidance that does not recommend CMR for asymptomatic patients.

Their Sept. 15 plea comes in response to recently published research in 

, as well as other studies, that suggest CMR can play a critical role in pinpointing signs of myocarditis in this patient population.

Cardiac MRI Reveals Myocarditis in Competitive Athletes Recovered from COVID-19

“We wish to emphasize that the prevalence, clinical significance, and long-term implications of CMR surrogates of myocardial injury on morbidity and mortality are unknown,” the group wrote. “Further, it is unclear if the elevated T1 and T2 flagged in these studies are clinically significant, particularly in isolation, if treatment is needed, and, if so, what the management should be. These important questions should inspire future prospective studies.”

They also raised concerns about media coverage of the findings, indicating that it has already led to inappropriate use of the study.

“We are aware that some individuals are seeking CMR testing despite the absence of cardiac symptoms,” they wrote. “We believe that, given the preliminary nature and limitations of the current evidence, testing asymptomatic members of the general public after COVID-19 is not indicated outside of carefully planned and approved research studies with appropriate control groups.

Consequently, the letter authors called on the ACR, RSNA, ESR, and other groups to use their influence to provide clarity and guidance on using this scan going forward.

“In light of your societies’ standing in the community and advocacy against low-yield testing and low-value medical care through your sponsorship of the Choosing Wisely, Image Wisely, and other similar campaigns,” they wrote, “we request that you offer clear guidance discouraging CMR screening for COVID-19-related heart abnormalities in asymptomatic members of the general public.”

A group of cardiologists, imaging specialists, and general medicine providers offer a warning about using CMR with asymptomatic patients and entreat professional societies from radiology and other specialties to craft guidance on proper usage.

Reconsider That Cardiac MRI for Some COVID-19 Patients: Healthcare Experts Express Concern and Caution

Close to 20 percent of COVID-19-positive patients present with abdominal symptoms alone. Consequently, a new article recommends, abdominal radiologists need to keep their eyes open so they can identify patients who might be infected.

Although fever, fatigue, cough, and respiratory difficulties are considered the hallmark signs of COVID-19 infection, approximately 18 percent of patients show up with complaints of appetite loss, nausea, vomiting, diarrhea, and abdominal gas. In fact, according to a team of investigators from the University of Alberta, 16 percent of patients present with only these abdominal symptoms.

They published the results of their literature review, including findings from published studies and case reports, in the Sept. 14 

“Gastrointestinal manifestations of COVID-19 have been increasingly recognized,” said the team led by Kevin Lui from the University of Alberta radiology and diagnostic imaging department, noting that the findings are rare, but varied.

Bowel Abnormalities Revealed with Abdominal Imaging in COVID-19 Patients

For their review, Lui’s team analyzed 36 published studies that examined how COVID-19 has manifested on abdominal imaging. The studies were published between March 31, 2020, and July 15, 2020.

According to their analysis, the most common findings included small and large bowel wall thickening, fluid-filled colon, pneumatosis intestinalis, pneumoperitoneum, intussusception, and ascites. In many cases, they said, radiologists will pick up on them in abdominal CT scans as incidental findings that show up in the base of the lungs.

In fact, some studies specifically recommended that radiologists pay careful attention to the lung bases to catch any possible COVID-19 cases. In addition, the team added, the features highlighted in this study can be used a cues for imaging experts to consider a COVID-19 diagnosis, particularly when the patient does not have typical symptoms associated with the virus.

“Identifying these features on abdominal imaging highlight the need to consider and evaluate for other manifestations of COVID-19, such as lung parenchymal findings,” the team said. “In the appropriate setting, COVID-19 can be raised as a consideration, particularly in patients presenting with atypical symptoms.”

Based on their findings, the team pointed to the need for future investigations into abdominal imaging abnormalities in COVID-19 cases that present with both respiratory and gastrointestinal symptoms. 

Nearly 20 percent of patients infected with the virus show up with gastrointestinal – but no respiratory – complaints.  

Abdominal Radiologists Stay Alert: Some COVID-19 Patients Present with GI Symptoms Only

Radiologists are still struggling in personal ways with the impacts of COVID-19. For many, this means not only are they having more trouble sleeping, but they are experiencing higher levels of anxiety and depression.

In a new study published in the Sept. 15 

 investigators from France highlighted the mental health challenges providers are facing, as well as the factors that are contributing the most to the problems. From what they discovered, working in a public hospital can protect radiologists, but limited educational opportunities, personal medical histories, and being in a high-density work environment pulls them in the other direction.

“Given that radiologists are a population at risk to develop stress at work, as has been demonstrated in several studies,” said the team led by Marin Florin, M.D., a radiologist with the Georges Pompidou European Hospital in Paris, “our findings would drive to implement protective measures.”

Radiologist Wellness and Burnout in the COVID-19 Era

Overall, the team determined that more than one-third of providers have struggled with these challenges. In particular, the team pointed out, private-practice radiologists with personal histories of respiratory problems who work in high COVID-19 areas and manage COVID-19-positive patients are at the greatest risk, and they should be monitored closely.

The researchers reached these conclusions by conducting an anonymous survey with 1,515 radiologists between April 10 and April 19 of this year. Participants were from five different radiological societies that represent residents and board-certified radiologists from both academic and non-academic public hospitals.

Based on respondent answers, 40.9 percent of radiologists reported experiencing insomnia, 35 percent had symptoms of anxiety, and 30.6 percent struggled with depression. Between approximately 12 percent and 15 percent of these cases were self-reported as being clinically significant.

And, although these problems affected providers in all working environments, those who work in private practices faced higher levels of insomnia and depression. It is possible, the team said, that these providers were more heavily impacted because they experienced the biggest drops in workload – more than 75 percent saw a drop in activity. Worries about potential practice closures could also fuel these challenges, the team added, along with several other concerns.

“This difference between radiologists in hospitals and private practices can also be explained by the insufficient equipment, lesser feeling of usefulness (though not statistically significant), and a feeling of isolation,” the team explained, noting that 43 percent of private practice radiologists had no contact with co-workers.

Conversely, the team noted, the protective effective of working in a public hospital could stem from those providers feeling a greater sense of usefulness to the patient population. Such a feeling can work as a mental health reward.

“The societal praise of care work provided by hospital workers appears as a possible short-term protective factor,” Florin’s team said. “Working in a public hospital may also have resulted in more frequent opportunities for radiologists to receive logistic support from their institution, as well as psychological support from their colleagues and/or dedicated services.”

It is important to note, the team added, that radiologists already struggle with high levels of burnout – the specialty most recently ranked as 7th for burnout in 2015. This underlying current of frustration and fatigue could be a significant contributing factor to these reported problems during the pandemic.

“One should, therefore, interpret psychological symptoms measured in the context of the COVID-19 in the light of these pre-existing levels of psychological symptoms,” the team explained.

Providers from all care environments report some level of mental health impact during the pandemic.


Insomnia, Depression, and Anxiety Plague One-Third of Radiologists During COVID-19

Women without dense breasts are less likely to be recalled for follow-up studies when their providers screen them with both digital breast tomosynthesis (DBT) and synthetic mammography (SM) rather than standard digital mammography (DM) alone, new research has revealed.

When radiologists pair the combined DBT+SM studies with automated breast density software, they bring fewer women with non-dense breasts back for supplemental imaging. A team from Norway also found that when these scans are used together, a woman’s relative risk of a screen-detected cancer increases alongside an increase in her breast density – but, the same is not true for DM.

According to the team, led by Natalia Moshina, M.D., Ph.D., from the radiology department at the Haukeland University Hospital, there are few very reports examining the differences between DBT+SM versus DM screening performance in reference to volumetric breast density. They postulated that DBT+SM would be superior, publishing their findings in the Sept. 15 

DBT Yields Lower Recall Rates, But Not for Every Radiologist

“Our results support the previous conclusion that DBT is more responsive to volumetric density, where tumors, benign lesions, and normal structures are better visualized compared with DM,” the team wrote “Our findings might also indicate that automated software for DBT+SM provides a tool for more discriminatory evaluation of the breast cancer risk and potential risk-stratified screening practices, as women with dense breasts might be recommended to undergo additional screening techniques and more frequent screening based on the results from DBT+SM.”

To determine which screening technique works best, the team selected 28,749 women to be in the To-Be Trial, a randomized controlled trial in the BreastScreen Norway program that is investigating early performance measures with tomosynthesis. Women, who had an average age of 59, were randomly assigned to protocols – 14,380 underwent DBT+SM, and 14,369 were screened only with DM. Results from the scans were used to assign Volpara Density Grades (VDG) of 1-to-4, with 4 being the most dense, to each participant.

Based on their analysis, the team saw differences in recall rates, false-positive results, and positive predictive values and screen-detected cancers.

Women who underwent DBT+SM had a lower recall rate than women receiving DM alone. For women with VDG 1 and VDG 2, they had better recall rates with DBT+SM than with DM – 2.1 percent versus 3.3 percent for VDG 1 and 3.2 percent versus 4.3 percent for VDG 2. There was no different for VDG3 and VDG 4 – 4.1 percent and 4.0 percent, respectively.

 For women with VDG 1, the false-positive result was 1.6 percent versus 2.8 percent for DBT+SM and DM. Those with VDG 2 saw a 2.4 percent versus 3.6 percent difference. Again, rates did not differ for women with VDG 3 and VDG 4.

Positive Predictive Value and Screen-Detected Cancer:

 Based on their analysis, positive predictive values of recalls and biopsies were higher for DBT+SM versus DM for VDG 2, and the adjusted relative risk of screen-detected cancer increased by VDG for DBT+SM.

Although the outcomes of DBT performance in this study have been confirmed by other investigations, highlighting its ability to increase cancer detection and lower recall rates, these same results also show that DBT still has not reached the level to be effective enough for all women, other experts said. In an accompanying 

, Ioannis Sechopoulos, Ph.D., associate professor from Radboud University Medical Center with an expertise is DBT, and Alexandra Athanasious, M.D., head of the breast imaging department at Mitera Hospital in Greece, pointed to DBT's performance differences across levels of breast density.

“While DBT can further avoid unnecessary recalls in low-density breasts, this is not the case for very dense breasts,” they pointed out. “DBT also results in a higher cancer detection rate for denser breasts, but this increase is similar to that found in DM screening.”

Still, those boosts in detection rates with both DBT and DM fall short of the expected cancer increases in those subgroups. Consequently, they added, some women will need supplemental screening even after DBT, such as dynamic contrast-enhanced breast MRI, contrast-enhanced spectral mammography, or contrast-enhanced DBT.

“These modalities could have the same or a larger impact on breast screening to solve the shortcomings of morphologic-only imaging that not event DBT can escape,” they said.

Combining DBT and synthetic mammography can mean less follow-up imaging for women with non-dense breasts – but not necessarily for women with dense tissue.


Pairing DBT with Automated Breast Density Measurements Leads to Fewer Recalls

It is sometimes hard to see the forest all around you when you are busy focusing on the trees directly ahead. Likewise, when combatting a growing public health crisis, such as the novel coronavirus, we may be spending more time dealing with the immediate situation, with little time and attention given to what we will be doing in the aftermath of this growing public health crisis.

Several months into the global pandemic responsible for causing rampant infections of COVID-19, members of the radiology community need to address the harsh realities of this disease. There are five main factors considering radiology’s future status to keep in mind.

These issues are related to reimbursement, regulations, human resources, ongoing education and learning, and the growing use of telemedicine.

Leaders of radiology practices should consider expanding the financial expertise under their own roof. With the pandemic underscoring the ramifications of financial uncertainty, you would be wise to build up financial reserves and make contact with your lenders.

Establishing better relationships with referrers could also help you get through the next public health emergency. It is crucial to openly discuss the changes and understand why they evolve.

Healthcare leaders should seek professional finance help. Preparing for a rainy day now will help you weather future storms more easily.

It would be in your practice’s best interest to forge stronger bonds with your insurers and the lawmakers who represent you and who preside over radiology industry regulatory affairs. You should naturally do this on a local level, as well as on the national stage. Practices with less clout and standing are advised to join professional societies as they make an effort to change policy about the business of radiology.

Meeting with the principals in these groups is a good idea overall, even when you are not trying to sort out regulatory affairs during a pandemic. You can anticipate coming changes to the healthcare industry, as well as make your opinions known to the legislators. If you aren’t involved in the decisions that go into making laws concerning radiology, you really would have no right to complain about adverse effects.

For example, the impending E&M changes may end up with the unintended consequence of shaving radiology reimbursement by 10 percent. This is a great opportunity for radiology practices to jump in and roll up their advocacy sleeves.

Many industries are evolving because of their growing use of artificial intelligence (AI) to scan through massive databases of information, detecting important patterns, as well as to make predictions and gain greater control over their business processes. With that in mind, how much attention has your organization been paying to the role of AI and algorithms used to examine scans in radiology?

It’s a distinct possibility that pressures from the novel coronavirus pandemic will cause more practices to start working with AI systems. AI and machine learning algorithms can be used to examine radiology scans automatically and at high speed, helping to remove some grunt work from radiologists’ duties.

It is possible that image interpretation will continue to be supervised by radiologists. However, practices will incorporate mid-level providers and machine learning tools to augment the productivity of their physicians.

If your organization has not looked into AI and machine analysis yet, now would be a good time to investigate its usage. It seems inevitable that more successful practices will start to look at using machine learning tools both clinically and on the business side. Otherwise, you run the risk of losing momentum, with other radiologists getting more work done with fewer resources.

While it may seem strange to participate in these events over a computer – and you will not get the same opportunities to bump into colleagues and compare notes – you will at least be assured that participation will be safer as compared to attending in person.

Even after society has therapeutic agents and vaccinations for COVID-19, we still have to take into account that another pandemic could arise with even greater lethality, meaning that distance learning may become a standard feature of conferences and continuing education.

We are interested in participating in remote/virtual conferences to stay up on our continuing education requirements. The recent RBMA virtual PaRADigm conference is a good example of things to come.

5. Telepresence and Medicine at a Distance

We can anticipate continuing protests and demonstrations with citizens concerned about police violence and other pressing issues, along with severe weather conditions and random outbreaks of COVID-19. Such occurrences indicate that radiology professionals will need to work remotely. As a result, we need to continue enhancing telemedicine for all physicians. This includes data security.

Indeed, your organization must verify it is following current best practices to safeguard patient information when conducting telepresence meetings. You don’t want sensitive information to wind up in the hands of enterprising computer criminals bent on identify theft and fraud. Hire a computer security expert to consult with your team if you have not already taken care of this vital task in the midst of this new era of telemedicine, and be sure that you havemore than adequate cyber-insurance in place.

Preparing Your Radiology Organization for Changes in a Post-COVID World

What are you planning on doing in your organization once we emerge from the worst of the coronavirus pandemic? It would be prudent to gather together with stakeholders soon so you can prepare for potential changes in how you handle layoffs and retirement contributions, for example, or to stay on top of new regulations. You may also need to devote some time and attention to the use of AI to lower the burden on staffers for image interpretation. Finally, it’s likely that your team will be using telemedicine systems more often to work from remote performing radiology duties.

All of the topics discussed are valuable conversations to engage in with like-minded radiology groups. There is significant value in the aggregation of independent radiology practices into management service organizations whilst still maintaining their independence. The exchange of information and scale-based savings applied to insurance costs, overhead costs, and billing costs cannot be ignored.

Getting Your Team Ready for the Future of Radiology in a Post-Pandemic World 

5 Things to Consider about Radiology Post-Pandemic

Radiology practices can cut the time it takes to conduct knee MRI scans by roughly half with a new protocol that does not create any negative impacts on image quality or diagnostic certainty.

By using Compressed SENSE (CS) to truncate 2D and 3D fat-saturated sequences of the knee, investigators from the University Hospital of Cologne in Germany succeeded in reducing exam times. Doing so can potentially help practices control their costs and improve their throughput. they said.

The team, led by Andra-Iza Iuga, a radiology resident doctor at the University Hospital, published their findings in the Sept. 10 

 Specifically, they reported that, when the technique was employed, scan times for 2D knee MRIs dropped by 34.39 percent, and 3D exam times fell by 54.17 percent.

New MRI Approach Helps Assess Knee Osteoarthritis Progression

These results clearly show, the team said, that using CS acceleration offers faster exams while leaving image quality and diagnostic certainty untouched. It also offers other benefits for the patient.

“Optimization of scan times not only increases patient’s comfort and decreases the vulnerability of motion artifact,” the team explained, “but it also represents a key factor for cost reduction of MRI exams as it reduces the fixed costs per examination.”

As a technique, CS takes less time because it gathers less sample data for each pixel. To determine how well the technique actually works, Iuga’s team recruited 20 healthy volunteers to test it with a 3T scanner. Each patient underwent a standard protocol MRI, as well as additional scans that used a variety of accelerating factors. Three independent readers examined and rated the images for signal-to-noise, contrast-to-noise, root-mean-square error, and structural similarity index.

According to their analysis, the team determined scan times decreased with an increasing CS factor. Based on their results, the 2D standard sequences was rated the best for diagnostic certainty and overall image impression.

While these findings point to CS efficacy, the team said, additional work is needed.

“Future investigations should consider larger samples sizes and use patients to analyze different knee pathologies and transferability to clinical routine,” they said.

The Compressed SENSE MRI technique can reduce scan time by more than half without impacting image quality or diagnostic certainty.

MRI Knee Protocol Halves Scan Time, Safeguards Imaging Quality

Patient understanding and informed consent is particularly important when dealing with ionizing radiation. But, how can we expect patients to understand the risks they are taking when 28 percent of surveyed physicians are not even aware that forms of imaging like mammography utilize ionizing radiation at all?

Patient education is largely influenced by patient-physician communication, it and plays a large role in a patient’s ability to provide informed consent. Additionally, effective communication and teaching is thought to enhance the patient-physician relationship and increase patient levels of trust and satisfaction with the experience. This piece investigates patients' perceptions of radiation from magnetic resonance imaging (MRI) and computed tomography (CT) imaging in the healthcare setting. This analysis further reviews recent work that quantified the degree to which effective patient and physician education is taking place and identify areas for improvement and growth.

According to a survey of emergency department patients, when asked to compare the perceived radiation dose of MRI, CT, and a conventional chest X-ray, approximately 30 percent of individuals answered that they all had equal amounts of radiation.

 In that study, when comparing each to a conventional chest X-ray, roughly 40 percent thought that CT was 10-to-100 times greater, while 28 percent thought MRI was 10-to-100 times greater.

Right away, we can see that at least one-third of patients are unaware that MRI emits no radiation at all. Even more shockingly, when asked to compare radiation exposure levels between CT, MRI, and a nuclear power plant disaster, less than 40 percent of participants were certain that CT scans involved less radiation exposure compared to just 20 percent with MRI.

When looking at patients’ understanding of lifetime cancer risks associated with various imaging methods, the numbers were varied. When asked, “Do 3-to-5 abdominal scans increase lifetime risk of cancer?,” less than 5 percent answered yes for MRI.2 The results look encouraging, however, when posed the same question about CT. Just over 5 percent answered yes.

Roughly 25 percent for both groups reported having no idea.

 These results are unsurprising given the limited information available to patients on lifetime risks and specifically the effects of a single scan. Furthermore, a survey of physicians found that 90 percent either did not know or severely underestimated the amount of radiation associated with CT.

In a specific example, only 65 percent of patients in a study receiving a mammogram reported being informed of the risks before the procedure.

 Discouragingly, 60 percent of informed patients still over-estimated the amount of radiation they had received.

 In another study, the number of patients reporting a lack of communication about the radiation associated with their scheduled tests were as high as 92 percent.

 It is in this same study that 28 percent of surveyed physicians stated they were unaware of mammography utilizing any ionizing radiation.

Effective patient-physician communication is key to ensuring informed consent is obtainable and has even been shown to have therapeutic effects for patients.

 However, with low percentages of patients reporting communication about radiologic testing and physicians self-reporting knowledge gaps in these areas, patient education is hindered. Evidence is supportive of the benefits of educational presentations for ordering providers’ understanding of radiation exposure and risk.

Radiologists, therefore, must be aware of and work to address the knowledge gaps reported by attending physicians. Whether through direct communication with patients about risks, hosting educational conferences for colleagues, or simply re-distributing pertinent information, radiologists have a responsibility to ensure patients are educated on the radiological tests they are undergoing.

Based on the results of these studies and surveys, it can be concluded that both patients and physicians have misconceptions and lack comprehensive knowledge about the risks and benefits of diagnostic and therapeutic imaging modalities.

 Physicians that undergo radiologist-designed educational training are more informed on these risks and, therefore, can better communicate radiation risks and benefits to their patients, thus increasing patient understanding and ability to provide informed consent.

 As an additional benefit, this increased communication positively affects patients’ feelings of trust and understanding towards their providers and future procedures.

 As of now, further work is needed to clarify misconceptions surrounding radiologic imaging and the associated risks of ionizing radiation.

1. Ricketts, M. L., Baerlocher, M. O., Asch, M. R., & Myers, A. (2013). Perception of radiation exposure and risk among patients, medical students, and referring physicians at a tertiary care community hospital. 

Canadian Association of Radiologists Journal

2. Repplinger, M. D., Li, A. J., Svenson, J. E., Ehlehbach, W. J., Westergaard, R. P., Reeder, S. B., & Jacobs, E. A. (2016). Emergency department patients’ perceptions of radiation from medical imaging. WMJ: 

official publication of the State Medical Society of Wisconsin

3. Renston, J. P., Connors, J. A., & DiMarco, A. F. (1996). Survey of physicians' attitudes about risks and benefits of chest computed tomography. 

4. Hollada, J., Speier, W., Oshiro, T., Marzan-McGill, R., Ruehm, S. G., Bassett, L. W., & Wells, C. (2015). Patients’ perceptions of radiation exposure associated with mammography. 

5. Travaline, J. M., Ruchinskas, R., & D'Alonzo Jr, G. E. (2005). Patient-physician communication: why and how. 

Journal of the American Osteopathic Association

, 105(1), 13.

6. Zener, R., Johnson, P., Wiseman, D., Pandey, S., & Mujoomdar, A. (2018). Informed consent for radiation in interventional radiology procedures. 

7. Hobbs, J. B., Goldstein, N., Lind, K. E., Elder, D., Dodd III, G. D., & Borgstede, J. P. (2018). Physician knowledge of radiation exposure and risk in medical imaging. 

Journal of the American College of Radiology

Improving patient communication not only augments patient understanding of their radiation exposure with imaging studies, but it bolsters trust in their healthcare providers, as well.

Patient Perceptions of Imaging Modalities and Ionizing Radiation

This is Episode 2 of The Reading Room, the Diagnostic Imaging podcast. To subscribe, click 

According to Matthew Michela, president and chief executive officer of medical image exchange company Life Image, the continued spread of COVID-19 has revealed to many radiology departments the importance of digital image exchange. Those that have not viewed it as a critical priority are nervous about the impact of handling physical media over the long term.

Michela, a 30-year healthcare industry veteran, joins 

 to discuss how data can improve our understanding of COVID-19, what we have learned from the pandemic, and what best practices facilities can implement to bolster their interoperability and accessibility. 

Podcasts

Matthew Michela, president and chief executive officer of Life Image, discusses the role of data interoperability and accessibility during the pandemic. 

The Reading Room: Data Interoperability's Role in the Pandemic

Throughout much of healthcare, radiology is frequently considered to be a cost center. But, as the concept of value-based care continues to grow – and as more institutions pivot toward pursuing this goal – there are several steps that radiology can take to boost its image as a value producer.

Several radiology experts shared and expounded upon this opinion in a Sept. 11 opinion piece published in 

 Not only did they outline several aspects the industry can highlight that can boost its value reputation, but they also presented multiple specific strategies that can help make those changes.

“Diagnostic radiology adds value in the clinical evaluation by refining differential diagnoses, decreasing the time required to initiate correct treatment, and ultimately contributing to reducing morbidity and mortality,” said the team of experts led by Adrian Brady, the second vice president on the European Society of Radiology’s (ESR) Board of Directors and chair of the ESR Quality, Safety, and Standards Committee. “By embracing the principles of value-based healthcare and striving to create value when possible, radiology can contribute to moving from a volume-drive system to a value-drive one, in which as many investigations or interventions as possible contribute positively to patient outcomes.”

How Value-Based Care is Affecting Radiology

But, to reach that goal – and minimize the cost-center reputation – Brady and his colleagues clearly outlined five ways the industry can bring about changes.

Guide referring providers to a better understanding of radiology’s contributions to patient management, population benefits, and the communication of vital information.

Radiology researchers must add to their investigative efforts, including a focus on the clinical impact of their findings.

Referring providers should be held accountable for their role in the use of diagnostic imaging and the costs incurred to ensure that imaging services are applied appropriately.

Radiologists must educate managers on the negative results that can come from underfunding imaging services, such as service bottlenecks and care delays.

Ensure imaging services are being used appropriately – be prepared to directly and actively consult with referring providers to assess their requests and provide education on scan appropriateness and necessity, if needed.

And, there are several ways radiologists can accomplish this last task, they said. To help referring providers the most, radiologist should consider these tactics:

Find out more about referring providers needs – turnaround time, subspecialty expertise, muti-disciplinary input – to develop stronger relationships.

Use evidence-based guidelines to help referring providers request appropriate imaging.

Implement consistent standards and eliminate silos to ensure radiology departments work cohesively.

Use structured reporting, clinical decision support, and artificial intelligence to optimize workflow, minimize wait times, and shorten hospital stays.

Talk directly with patients to answer questions and explain findings.

Use information technology tools to optimize information exchange.

Maintain consistent quality reporting and improvement.

Actively speak up when an ordered imaging study might be inappropriate or unnecessary.

Conduct research on higher-level contributions.

By implementing these suggestions, Brady's team said, the industry can make significant headway in improving the perception throughout healthcare that radiology adds more value than cost to clinical care.

“Radiology is a deeply embedded and essential part of modern patient care,” the team wrote. “Radiologists must take the principles underpinning value-based health care into account when planning, developing, and delivering services. This will require radiologists to participate in multi-specialty clinical decision making, and referring physicians to work with radiologists to ensure the most appropriate use of radiologic resources, services, and personnel.”

Industry experts offer advice on specific steps radiology can take to bolster the understanding it adds value to clinical care.


5 Steps to Improve Your Value-Added Reputation

Welcome to Diagnostic Imaging’s Weekly Scan. I’m senior editor, Whitney Palmer.

Before we get to our featured interview this week with Dr. Murray Rebner about the disadvantages African American women experience with breast cancer screening, here are the top stories of the week.

 published a study, revealing that 15 percent of competitive athletes had evidence of myocarditis on cardiac MRI scans after recovering from COVID-19. The news is certainly concerning and has pushed many in healthcare to investigate these findings further. But, the results of that study – which included asymptomatic patients – also caught the attention of a cadre of experts from cardiology, diagnostic imaging, and general medicine. And, they are worried the investigation’s outcome could lead clinicians down a questionable path. In an 

 to the American College of Radiology, the Radiological Society of North America, the European Society of Radiology and more than a dozen other professional organizations, this group requested those organizations craft and publish guidance that does not recommend the use of cardiac MRI in patients who are asymptomatic for COVID-19. Ohio State cardiologist, Dr. Matthew Tong who was involved with the 

 and he agreed these concerns are not unfounded and that there is a need for more data that enable direct comparisons. The important thing, he stressed, is to continue to investigate this problem.

In addition to cardiac imaging, abdominal radiologists should keep their eyes open for signs of COVID-19, too. That’s according to a study published this week in 

 According to investigators from the University of Alberta, 18 percent of patients who end up testing positive for the virus first present with complaints of appetite loss, nausea, vomiting, diarrhea, and abdominal gas – in fact, 16 percent of patients only show those symptoms. For their study, the researchers analyzed 36 articles published between March 31 and July 15 of this year. In that review, they identified the most common findings as small and large bowel wall thickening, fluid-filled colon, pneumatosis intestinalis, pneumoperitoneum, intussusception, and ascites. And, in most cases, radiologists only caught these as incidental findings in the base of the lungs that show up on abdominal CT scans. So, if you’re examining any abdominal scans, be on the look out for evidence that might help you diagnose a COVID-19-positive patient.

And, once again, this week, investigators turned their eyes to how the pandemic is continuing to affect you and your colleagues. In a study published in the 

 a team from France showed that many of you are still experiencing insomnia, anxiety, and depression brought on by the continued outbreak. Based on an anonymous survey conducted from April 10 to April 19 of this year with responses from 1,515 radiologists, the team found that more than one-third of providers are struggling with these issues. In particular, 40.9 percent reported having trouble sleeping, 35 percent said they had symptoms of anxiety, and 30.6 percent wrestled with depression. Between 12 percent and 15 percent self-report that these issues were clinically significant. Radiologists in all care environments said they experienced these problems to some degree, but those in private practice were most affected. It’s possible the team said that substantial drops in workload led to a reduced sense of usefulness, as well as worries about financial stability. It’s also important to note, the team said, that these added feelings of stress and anxiety have compounded the already heavy sense of burnout that many providers in radiology were already dealing with prior to the pandemic.

In non-COVID-19 news, lung cancer screening guidelines could be overlooking African American smokers who are at risk for developing the disease. This sounds an alarm bell because African Americans have a higher incidence of and worse outcomes with lung cancer. In a study published in the 

 researchers from Cook County Health and Northwestern University in Chicago shared evidence that the 30-pack-year threshold used to determine which patients should undergo low-dose CT screening could be too high. They found that while African Americans might smoke for the same number of years as their white counterparts, they aren’t actually smoking as many packs a day. So, they are closer to a 20-pack-year threshold. Based on their review of CT scans from 784 current and former smokers, the team determined African Americans had an incidence of lung cancer of 2.5 percent while their white counterparts experienced 1.9 percent. When looking at lung cancer diagnosis in the context of smoking, African American participants were the only race who received the cancer diagnoses when they had a pack-year history below 30. Specifically, 30-pack-year smokers had an incidence of 2.2 percent, but for those less than 30, it was 2.7 percent. Based on these results, the team recommended changing the lung cancer screening threshold from 30-pack-years to 20-pack-years.

 spoke with Dr. Murray Rebner, professor of diagnostic radiology and molecular imaging at Oakland University William Beaumont School of Medicine. He is also the director of the division of breast imaging at Beaumont Health System, as well as president of the Society of Breast Imaging. He spoke with us about his latest research published in the 

 that examines the many obstacles and disadvantages that African American women face when it comes to being properly screened for breast cancer in a timely manner. Here’s what he had to say.

Videos

Rethinking CMR during COVID-19; Abdominal Imaging and COVID-19; Mental Health Impacts of COVID-19; African American and Lung Cancer Screening; Plus, African American Women and Disadvantages in Breast Cancer Screening

Diagnostic Imaging Weekly Scan: Sept. 18, 2020

Ultrasound guidance makes carpal tunnel release surgery not only safer and less invasive than traditional open or endoscopic surgeries, but it also leads to quicker improvements in hand function and discomfort, according to newly published research.

Ultrasound-guided carpal tunnel release (UGCTR) uses smaller incisions and provides a quicker recovery, so researchers from Thomas Jefferson University Hospital investigated what the long-term implications of this technique might be. They found patients had sustained improvements at  approximately one year post-surgery.

They published their results in the Sept. 17 

“Our study demonstrates that ultrasound-guided carpal tunnel release can be performed safely, with high patient satisfaction and significant long-term relief of [carpal tunnel syndrome],” said the team led by Sarah I. Kamel, M.D., assistant professor of radiology. “The rapid post-operative recovery and longstanding relief of symptoms suggest that ultrasound-guided carpal tunnel release may be advantageous to traditional surgical methods of transverse carpal ligament transection.”

To determine how well UGCTR works, Kamel’s team retrospectively reviewed the results of the procedure performed on 46 patients (61 wrists total) that were referred to their clinic between July 2017 and April 2019. All surgeries were performed by the same provider, under local anesthesia in an outpatient setting, and using the same procedure equipment (SX-One MicroKnife®).

As a way to judge the outcomes, the team had patients fill out three questionnaires designed to assess their hand’s pain and function levels – the Quick-Disabilities of the Arm, Shoulder, and Hand (QDASH), the Boston Carpal Tunnel Syndrome Questionnaire symptom severity scale (BCTSQ-SS), and the BCTSQ functional status scale (BCTSQ-FS). The provided answers pre-procedure, two-weeks post-procedure, and after 1.7 years with higher score indicating greater discomfort.

According to their responses the median pre-procedure scores here 45.4 for QDASH, 3.2 for BCTSQ-SS, and 2.5 for BCTSQ-FS. After two weeks, scores had fallen to 22.5 for QDASH, 1.7 for BCTSQ-SS, and 1.9 for BCTSQ-FS. And, at the final check point, for the 90 percent of participants who could be contacted, scores had plummeted – 2.3 for QDASH, 1.2 for BCTSQ-SS, and 1.1 for BCTSQ-FS. Overall, 96 percent of wrists ultimately had lower QDASH scores, as did 98 percent for BCTSQ.

No patients experienced immediate complications, but two patients required follow-up surgery within 8-to-10 days after the first procedure. To avoid those outcomes in the future, the team made two adjustments. They now include more extensive pre-procedural cleaning that extends around the forearm prior to draping, and they perform two passes of the ligament transection to potentially decrease the risk of remnant tissue that may contribute to incomplete release.

These results, the team said, these results point to the efficacy of the UGCTR procedure, but future longitudinal investigations into follow-up and cost analysis are necessary.

“Ultrasound-guided carpal tunnel release quickly improves hand function and reduces hand discomfort, with persistent improvement at one year,” the team said. “Ultrasound-guided carpal tunnel release may be a safe, effective and less invasive alternative to traditional open or endoscopic surgery, particularly in patients for whom traditional surgery may be high-risk or contraindicated.”

Minimally invasive ultrasound-guided carpal tunnel release offers faster and longer-term relief from carpal tunnel syndrome.
