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 On barium swallow with stomach demonstrated inadequate distension of the stomach with increased rigidity associated with a narrow lumen. The normal mucosal gastric fold pattern is no longer seen and in this case, completely absent.

 Linitis plastica is a condition referring to the appearance of the stomach resembling an “old leather bottle.” There is typically diffuse submucosal infiltration by an adenocarcinoma with thickening and loss of distensibility of the stomach. The mucosal gastric fold pattern is can be absent, thickened, or distorted.

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Image IQ Quiz: Patient Presents with Inadequate Stomach Distension

Whitney J. Palmer has been with Diagnostic Imaging since 2011, serving as the Senior Editor since November 2019. She has 20 years experience in healthcare and academic medicine reporting.

One of the first things to be side-lined during the early days of the pandemic was the screening mammogram. Delays, re-scheduling, and outright appointment cancellations have been common for the past 18 months-plus. It would make sense that all women have been affected equally – but that’s not the case.

As with many other healthcare disparities, new research shows that women who are older and those from under-served groups missed their screening mammogram appointments more often.

a team of investigators from Brigham & Women’s Hospital attempted to identify whether the women who missed their screening mammograms had any shared characteristics.

Based on their research, the team led by Nita Amornsiripanitch, M.D., a radiologist with Brigham & Women’s, determined that, once breast imaging centers began to re-open, older age, Medicare insurance coverage, and minority race and ethnicity were all independently associated with a missed screening. Their findings are in contrast with previous cancellation rates – prior to the pandemic, younger women were more likely to cancel their appointments.

“The effect on ethnic/racial minorities is exacerbated given lower screening mammogram utilization at baseline, tendency to present with later stage disease, and disproportionate number of COVID-19 infection in this subgroup,” the team said. “Amplification of our efforts to reschedule missed screening and strategic allocation of resources combined with approaches tailored to the underserved may be steps toward addressing longstanding inequity.”

To identify any similarities, the team took a look at the screening mammogram appointments from their hospital, focusing on three time periods during the pandemic: March 2020 to June 2020 (the state-wide shut-down), June 2020 to August 2020 (when services resumed), and June 2019 to August 2019 (a control time-period).

Based on their comparison, the team determined that overall cancellation rates were highest during the re-opening period – 46 percent compared with 37 percent during the shutdown. They found that being older and having Medicare insurance increased cancellation risk, as did being a member of a racial or ethnic minority group.

But, there was some good news in their analysis. The re-scheduling rate was 17 percent higher during the shutdown period than it had been before the pandemic was even identified – 78 percent versus 61 percent, respectively. The team postulated that this higher rate was a result of more concerted efforts to bring women back in for their annual screening mammograms.

“Possibly due to this focused effort, overall rescheduling rate during state-mandated shutdown exceeded that of pre-COVID-19 period for all patients, including minorities, those with Medicaid, and those with chronic disease,” the team said. “Although we do not currently have data to confirm that all re-scheduled exams were performed, a more rigorous endeavor to reschedule missed exams may be a small step towards increasing adherence to screening mammogram guidelines.”

Age, race, and insurance all factor in to whether women got their annual exams.







Women Who Canceled Pandemic-Era Screening Mammograms Share Similarities

I haven’t gone on vacation since before COVID. It’s been about a year and a half, but I’m finally getting away for a bit.

That’s not to say I haven’t taken any days off. Relating to holidays, for instance, to facilitate familial or social meet-ups. Still, far fewer than I’m allowed by my contract…and that’s been my state of affairs since long before the pandemic. I just don’t take much vacay.

I used to. Back in my pre-teleradiology days, when I was salaried and the vacation-deal was “use it or lose it.” I would size up my calendar for a forthcoming year and, having squared away any must-be-free dates like weddings, I’d put in for every single day I had coming to me.

I had a standard approach, beginning with the rationale that my time off should be evenly spaced around the year; thus, I wouldn’t have any disproportionately-longer stretches of work between breaks. If, say, I had 6 weeks coming to me, I should use one every couple of months…

…except summertime was great right where I lived, and I could thoroughly enjoy every single weekend, right there. No need to take any time off between June and September. Suddenly, my calendar only had 8 months for those six weeks…and the notion of planning a getaway almost one week out of every month seemed unpleasantly hectic. It boggled my mind when I heard about rads who had 10-to-12 weeks off.

If I’d stayed in such a position, I probably would have gotten more sophisticated about it by now: Used some of my time to scatter some extended weekends around the year, etc. Instead, I moved on to vRad, where fulltime work necessitated at least a week-on, week-off schedule. Which, technically, gives 26 weeks of “vacation,” but I’ve described in other columns why it doesn’t really work out that way for most rads (one of the reasons I left vR).

Even after that, I’ve found that working via telerad changes the way I think about vacation. When you work from home, there’s less of a perceived 

 to vacate. Unless you don’t particularly like your home and want to get away from it. Heck, people take vacations to stay at home so commonly that the word “staycation” got invented.

The other thing that changed in my post-vRad tele-life was a different approach to comp in my current group, one I think isn’t as widely used as it should be. The group’s approach isn’t salaried or per-click, but rather based on how many hours one works. “Vacation” is just a certain number of weeks per year that one is allowed to not work…but when you’re not working, you’re not earning.

“Unpaid time off?!” came the cries of dismay from some folks in my life when I originally told them about it. As if it was some sort of crime against humanity. I tried explaining that it was just a matter of perspective; if it really matters to you, just divide your annual income by 52 weeks and consider your off-weeks paid at that rate. Some of them “got it,” then. Others still seemed to think I was being cheated and failing to recognize it.

The neat thing about this was that my vacay was no longer a “use it or lose it” affair. Gone was the annual almost-chore of figuring out how to allocate my time around the calendar to properly slice the intervals I’d be driving into an office. Now, I could just use the time I genuinely wanted/needed, and leave the rest over to feed my bank account a little more.

Any time I didn’t use as vacay just stayed on the schedule as “extra” time I’d be working at my normal hourly rate. If, during the year, I came up with some occasion that could use a day or two off, I had enough slack in my system to take those, too…rather than having to cannibalize a vacation week I’d scheduled months earlier.

Not only does that work for a telerad like myself (and probably more than a few onsite-working rads), it’s gravy for the rad group. They’re getting more of a return-on-investment for the rads they hired, and they’ve got that much more redundancy in their coverage.

Might there be too much of this good thing? Money-hungry rads taking less time off than their mental health needs, or consuming more RVUs that other rads were counting on to meet their productivity goals? Groups concerned about that might institute a hybrid system: 50 percent of your available vacation-time is “use it or lose it,” and the other half can be worked pro rata. Details of course can be played with: Make it 75 percent-25 percent, or 25-75 if that fits better.

I do think that some degree of unavoidable downtime is good for everyone involved. “All work and no play,” as the saying goes. Again, I took no formal vacations during the past 1.5 years, and felt fine with it…but maybe other rads or ancillary staff in my group noticed undesirable changes in my attitude. Or maybe some quiet disgruntlement has been bubbling up inside of me, stuff I won’t notice till it’s close to boiling over. Maybe I 

 need some of the vacation I haven’t been taking.

And that doesn’t just go for full-time work. If one or more readers perceived that this column had some less-than chapters relative to years gone by, it wouldn’t be unreasonable to suggest that maybe I’d have done better if I’d had an occasional week away in which I didn’t have a chance to do any writing.

It would be sufficiently reasonable, in fact, that you’ll next hear from me in two weeks.

Finding time away for rads can be complicated – but, it’s necessary.

Vacating

Volpara Health announced Friday it has received 510(k) clearance from the U.S. Food & Drug Administration for the latest version of Volpara Imaging Software.

This version – VIS 3.2 – incorporates learnings from artificial intelligence to augment the robustness of the breast density assessment algorithm. In addition, this clearance approves VIS 3.2 for use on other mammography machines, including those from Giotto and Siemens.

The new version offers improved imaging processing security through the Open Virtual Appliance architecture, and it also makes it easier for Volpara to monitor, services, and update software, company officials said.

“These new innovations improve the overall security, scalability, robustness, and breadth of our breast health offering,” said Ralph Highnam, Ph.D., Volpara’s Group chief executive officer. “Our objective with each enhancement is the pursuit of our mission – to eliminate advanced-stage breast cancer and save more families from cancer.”

With this approval, Volpara marks its fifth clearance since launching Volpara Imaging Software in 2010. It is a key science algorithm that supports the Volpara Breast Health Platform, a product suite designed to improve early breast cancer detection through augmented mammography quality and workflow, volumetric breast density assessment, and personalized breast care.

Software improves on breast density assessment algorithm with artificial intelligence.

Volpara Receives FDA Clearance for Breast Density Algorithm

Warming iodinated CT contrast media to body temperature prior to injection may not be necessary, according to newly published research.

a team of investigators from Valleywise Health in Phoenix revealed that warming contrast agents to body temperature does not necessarily lower the number of adverse reactions in patients.

“The data suggest that maintaining iohexol 350 at room temperature is non-inferior to warming the agent to body temperature before injection,” said first investigator Noor Basharat from Valleywise Health’s radiology department.

Typically, iodinated CT contrast media is warmed to body temperature as a way to reduce viscosity and injection pressure. But, without data that support the overall benefit of warming, hospitals could change their protocols around iohexol 350 prior to injection, they said.

“If warming contrast media were shown to not be advantageous, then institutions would potentially no longer need to expend resources on warming, as well as no longer need to maintain a daily temperature log or provide evidence of device maintenance,” the team said.

Currently, the American College of Radiology has not provided conclusive guidance on warming iodine-based contrast media. But, they do suggest it under certain circumstances, including high-rate power injections, injections with viscous contrast material, arterial injections through small-caliber catheters, or arterial studies where timing and peak enhancement are critical.

To date, though, there has been little investigation into the relationship between contrast media temperature and adverse events. In order to get a better idea, the team conducted a retrospective study of adult patients who underwent CT exams using intravenous iohexol 350 that was either warmed or at room temperature.

Adverse Event Categories

Overall, they enrolled 3,939 patients who had scans with warmed contrast media and 3,933 patients who receive it at room temperature. The average patient age was 48, and the group was roughly half male and half female. Based on the team’s analysis, they saw both study groups showed no significant difference in the overall adverse event rate, extravasation rate, or allergic/allergic-like reaction rate.

“Our findings question the utility of pre-warming contrast media, which can be a resource-intensive process,” they said.

Specifically, they determined that the body temperature group experienced 11 adverse events – all extravasations. The group saw a 0-percent allergic or allergic-like reaction rate. Among the room temperature group, there were 17 adverse events – 13 extravasations and four allergic/allergic-like reactions. Their analysis identified an excess of 0.27 adverse events per 100 patients with the room temperature group – a rate below the 0.6-percent non-inferiority margin.

Based on their findings, the team concluded that expending the resources needed to pre-warm iohexol 350 prior to injection may not be warranted.

Warming media to body temperature does not decrease rate of adverse events. 

Warming CT Contrast Media May Not Be Necessary

When it comes to treating patients suspected of stroke, CT angiography (CTA) and perfusion CT have become integral parts of assessment and triage. But, should they be done with every patient?

Despite the benefits of these scans, the answer isn’t clear cut. In a point-counterpoint series published in the 

experts from the University of Wisconsin School of Medicine and Public Health and University of Pennsylvania Perelman School of Medicine debated the merits of routine use of both scans.

“CTA and perfusion CT have become crucial imaging techniques for making an appropriate diagnosis and triaging these patients to the best therapy,” said Howard A. Rowley, M.D., professor of radiology, neurology, and neurosurgery, as well as chief of neurological MRI, at Wisconsin. “Although the value of the information from these studies has been established, the clinical implementation and application of these studies remain varied.”

To support more consistent CTA use, Rowley and his colleague Anthony D. Kuner, M.D., a radiologist at Wisconsin, pointed to its reliability in identifying large-vessel occlusion for faster triage to mechanical thrombectomy or aspiration and its ability to pinpoint a potential cause of hemorrhage and assess active bleeding.

In fact, they said, Wisconsin providers perform CTA for all emergent stroke evaluations.

“This uninterrupted approach that does not rely on interpretation of head CT yields rapid image acquisition that facilitates faster treatment decisions,” they said.

They also advocated for using perfusion CT at any time during the stroke window because it offers several benefits. Alongside identifying and characterizing stroke mimics, including migraine, tumor, infection, and seizures, it may also be the only imaging technique to capture abnormal findings in as many as 25 percent of cases.

“Recognizing early parenchymal changes on CT and localizing thrombi may be difficult in the charged setting of acute stroke triage,” they said. “Even normal perfusion imaging findings remain helpful because they provide greater confidence in interpretation of negative examination findings, as well as confident disposition.”

Routine use can also streamline workflow and create a predictable, coordinated stroke team approach, reducing delays, indecisions, wrong decisions, and incomplete examinations. Doing these exams more frequently can also make providers more proficient with interpretation.

But, there are other considerations with CTA and perfusion CT, said Linda J. Bagley, M.D., associate program director of the Perelman neuroradiology fellowship, and her colleague Laurie A. Loevner, M.D., division chief of neuroradiology. Using these techniques incorrectly is associated with risk.

It is possible, when perfusion CT is conducted with CTA of the cervical and intracranial vasculature, that patients can experience radiation doses between two and 10 times greater than with a heat CT alone, they said.

In addition, employing these strategies prompts a stroke alert that can divert needed resources from other patients – those with sepsis, pulmonary embolism, or trauma – potentially leading to worse outcomes. It is better, they said, if CTA and perfusion CT are reserved for patients who are actual candidates for mechanical thrombectomy. In fact, they said, implementing an automated post-processing platform has resulted in a 1,500-percent increase in their use of CTA and perfusion CT, corresponding to a 150-to-200-percent increase in thrombectomies – half of which were for patients with stroke mimicking conditions.

Providers should also keep in mind that perfusion CT is inherently limited by a poor signal-to-noise ratio and can be subject to multiple artifacts, such as patient motion and sub-optimal bolus timing. Existing data also shows, they said, that the benefit of perfusion CT patient selection is questionable for patients who present within six hours of symptom onset or those whose symptoms are localized to posterior circulation.

“[Perfusion] CT studies are of questionable reliability, and CTA/perfusion CT may subject patients to an increased radiation dose and possibly divert resources from other critically ill patients, thereby delaying their care,” they said. “More importantly, [perfusion] CT studies often serve as a means to exclude patients from thrombectomy, a relatively low-risk procedure that is cost effective and of benefit to most patients who present within 24 hours of symptom onset with a confirmed large-vessel occlusion.”

Still, said Kuner and Rowley, routine incorporation of CTA and perfusion CT is a best practice for both early and late windows of triage because it give providers the most opportunity for assessment that can guide treatment decisions.

“Stroke triage is ‘like a box of chocolates,” they said, quoting the movie 

 “’You never know what you’re gonna get.’ CTA and [perfusion] CT help reveal the hidden.”

Implementing routine use of these techniques could offer the most opportunity for assessment, but there are risks to doing so.

To CTA and Perfusion CT or Not – What’s Best for Stroke Triage?

Diagnostic Imaging's Weekly Scan: The Top 5

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Diagnostic Imaging's Weekly Scan: July 26, 2021, to July 30, 2021

Creating a hotline and “HOT” sites for radiology procedures during the COVID-19 pandemic has been an effective strategy for processing patients and minimizing viral transmission.

a team of investigators from Yale University School of Medicine and Yale New Haven Hospital shared their experience that streamlined radiology services while protecting staff and patients.

“This project provides efficient and reassuring radiology operations during an emergency situation by providing a single reliable point of contact and a source of truth for all facets of radiology,” said the team led by Jay K. Pahade, M.D., associate professor of radiology and biomedical imaging. “In doing so, we facilitate high quality patient centered care while protecting the health of our patients and staff.”

In March 2020, the team launched their hotline, staffed by radiologic technologists, scheduling staff, and two assistant chief radiologic technologists, to answer all radiology COVID-19-related questions and help schedule appointments. All X-rays were scheduled through the hotline to ensure proper screening, and any COVID-19-positive patient was seen at a “HOT” site.

Initially, the hotline was open 24-hours-a-day, 7-days-a week. It has since been scaled back to a regular weekday schedule. During the first seven weeks, the hotline fielded 2,548 calls. Scheduling calls accounted for 92 percent, and radiology operation questions made up 6 percent. There were 371 “HOT” site visits, and 72 patients (19 percent) were positive for the virus at the time of scanning.

Although the model became operational at the beginning of the pandemic, it is a blueprint for similar efforts that may be needed during the resurgence of the virus. A plan now exists to encompass four different radiology practices and seven hospital sites across two states, the team said.

“We report the creation of a system wide centralized radiology call center and dedicated COVID-19 outpatient ‘HOT’ sites to effectively schedule, image, and answer radiology operational issues during the COVID-19 healthcare crisis,” the team said. “We facilitate high quality patient centered care while protecting the health of our patients and staff.”

Model created by Yale effectively provides imaging services while protecting patients and staff. 

A Hotline and HOT Site – A Centralized Approach to Imaging During COVID-19

If you’ve been a radiologist long enough, you’ve seen a patient have a reaction to contrast media. Depending on the severity, it can be scary for both you and the patient, and the possibility of these events has led to steroid pre-medication in high-risk patients.

That protocol could change for patients who have had previous acute allergic reactions.

a team of investigators, led by Robert J. McDonald, M.D., Ph.D., assistant professor of radiology at the Mayo Clinic, share their findings that point to the potential inefficacy of giving patients corticosteroids prior to contrast-enhanced CT exams.

“In this cohort, using iodinated contrast media (ICM) substitutions was more effective for preventing repeat allergic-like reactions than using steroid pre-medication and the same ICM that caused the previous reaction,” the team wrote.

Contrast-enhanced CTs are common in the United States. In 2019 alone, there were 70 million ICM-enhanced scans completed. And, to date, there have been 1 billion doses administered worldwide. One standard pre-medication procedure involves administering oral methylprednisolone at 12-hours and 2-hours before the procedure.

Acute allergic reactions are rare – occurring at a rate of 0.6 percent – but they’re still common enough that they happen daily at major medical centers.

Determining the efficacy of steroid pre-medication is important, the team said, because once a patient has an acute allergic-like reaction to contrast media, they’re at a higher risk for experiencing the same problem again. They investigated whether using iohexol with patients instead of iopromide made any difference.

For their retrospective study, they identified 1,973 adult and pediatric patients who were high-risk for an allergic reaction who had a contrast-enhanced CT scan at their institution between June 1, 2009, and May, 9, 2017. Among the group, they identified 4,360 ICM-enhanced scan that resulted in 280 allergic reactions (6 percent) in 224 patients (11.2 percent). Overall, 9 percent of the reactions were severe.

Hives, itching, and rash accounted for 74 percent of reactions, followed by wheezing and shortness-of-breath (11 percent), and nasal and eye symptoms (7 percent).

After adjusting, the team determined that patients who received a different ICM with or without steroid pre-medication had a significantly lower rate of repeated reaction than did patients who received the same pre-medication (80 out of 423 exams – 19 percent). When patients received a different ICM, but no steroid pre-medication, the reaction rate was 10 out of 322 – 3 percent. It was also 3 percent for patients who received a different ICM with steroid pre-medication (5 out of 166).

Focusing on first scans only, the reaction rate was the same between those receiving pre-medication and those who did not, 26 percent and 25 percent, respectively.

These results, they said, do not fall in line with current procedures.

“The study findings do not support the efficacy of steroid pre-medication (oral methylprednisolone at 12 and 2 hours) for preventing repeat allergic-like reactions in high-risk patients,” they concluded.

Patients who switch contrast media prior to a CT scan have fewer allergic reactions than do those treated with steroid pre-medication. 

Switching Contrast Media Reduces Allergic Reactions Better Than Steroid Pre-Medication

There’s new guidance available for percutaneous lung ablation from the Society of Interventional Radiology (SIR).

Journal of Vascular and Interventional Radiology,

 experts shared recommendations for patient selection, treatment, and follow-up, as well as a patient safety quality-improvement guide.

Image-directed percutaneous ablation is widely used to treat various types of lung cancer in minimally invasive ways.

“Minimally invasive, image-guided thermal ablation offers patients with early stage, non-small-cell lung cancer, recurring lung cancer, and metastatic disease a safe and effective treatment option,” said statement author Mark Baerlocher, M.D., SIR’s standards division councilor and interventional radiologist at Royal Victoria Hospital in Ontario. “The two publications provide physicians with guidance [to]...[ensure] high-quality care that improves patients’ lives.”

Creation of the position statement was supported by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Radiology. The statement itself was drafted by a team of interventional radiologists, oncologists, thoracic surgeons, and radiation oncologists.

Based on a literature review of 63 studies, the new recommendations are grounded in current evidence that points to the appropriateness of radiofrequency ablation, cryoablation, and microwave ablation as image-guided tools that can be used to treat primary and secondary lung cancer. They noted that lesion characteristics and risk mitigation should be used to choose which ablation method to use.

According to SIR President Mathew S. Johnson, M.D., FSIR, Gary J. Becker Professor of Radiology Research at Indiana University School of Medicine, publishing this evidence-based position statement is critical to improving patient outcomes. But, additional comparative studies on thermal ablation use in treating lung cancer will further strengthen guidance in the future.

Position statement supports radiofrequency ablation, cryoablation, and microwave ablation as appropriate image-guided treatment options. 



A Hotline and HOT Site – A Centralized Approach to Imaging During COVID-19

Switching Contrast Media Reduces Allergic Reactions Better Than Steroid Pre-Medication

New Guidance for Percutaneous Lung Ablation