Chest CT scans can provide a volumetric analysis of lung consolidation in COVID-19-positive patients, helping providers with care management and better enabling them to pinpoint which patients could die in the hospital from the virus.

investigators from Michigan State University examined whether the percentage of lung involvement on initial chest CT is directly related to the likelihood of a patient with the virus dying while admitted.

They used radiation therapy planning software to evaluate the impact of lung involvement and discovered that the risk of in-hospital mortality increased with each unit percentage of lung involvement by consolidations. In addition, these patients face a higher likelihood of experiencing major adverse hospital events.

The team was led by Lucas G. Sapienza, M.D., a resident at Baylor College of Medicine during his internship at Ascension Providence Hospital associated with Michigan State University College of Human Medicine.

“Among patients hospitalized with COVID-19, more lung consolidation on chest CT increases the risk of in-hospital death,” the team wrote. “Therefore, this study provides evidence that chest CT is a potential tool in guiding escalation or de-escalation of care in the hospital setting.”

Based on their evaluations, they anticipated by proportionally reflecting lung parenchyma impairment that the number of opacities relative to the total lung volume could be used to predict which patients would need more intense medical management, as well as survival.

Sapienza’s team tested their hypothesis by using radiotherapy planning software to run a volumetric analysis of the lung opacities on chest CT scans from 154 patients who had laboratory confirmed COVID-19 pneumonia between February 2020 and April 2020. According to their analysis, the median relative lung involvement was 28.8 percent with 26.3 percent of patients being intubated. Of these patients, 16.2 percent – 25 patients – died.

After adjusting for significant clinical factors, the team said, there was a 3.6-percent increase in the chance of dying in the hospital and a 2.5-percert increase in experiencing a major adverse hospital even for every percentage unit of lung involvement. Advanced age at the time of hospital admission, having a do-not-resuscitate (DNR) or do-not-intubate (DNI) order, and a history of smoking increased the likelihood of a patient dying in the hospital, they found, and older men had the highest risk of adverse events.

Use Lung Ultrasound to Predict COVID-19 Outcome

These findings can offer important details that can guide clinical management, the team said.

“For example, a patient who is more than 65 years of age and has a history of smoking has a 15 percent risk of dying during hospitalization if 10 percent of the lung is involved at the initial assessment,” they noted. “That risk would escalate to 50 percent for a similar patient with 60 percent of lung involvement.”

In addition, patients with a DNR or DNI had a 20 times higher chance of in-hospital mortality.

Providers may be able to use these results to better focus their efforts as the pandemic continues, the team said.

“In this scenario, tools to predict outcomes would be important to better triage patients who require more intensive support,” they said. “On the other hand, patients who had a limited risk of developing major adverse events could be managed in a lower complexity facility or from home.”

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

Articles

A volumetric analysis of lung consolidation can help providers make care management decisions and, potentially, pinpoint which patients are most likely to die in the hospital.

COVID-19 Lung Involvement Captured on CT Can Help Predict Mortality Risk

African American Medical recipients are nearly one-third less likely than their white counterparts to undergo advanced imaging – CT or MRI studies – in the emergency department (ED) setting, according to a new study.

In an article published online Dec. 23 in the 

a multi-institutional team led by Tarek N. Hanna, M.D., an associate professor of diagnostic imaging with expertise in emergency and trauma imaging at Emory University Midtown Hospital, revealed a variety of imaging inequities across the country.

“We believe that [our] observations have broad health care and health care equity implications, particularly because ED visits among the Medicare fee-for-service population are rising, as is the associated ED imaging of this population,” the team wrote.

study, more and more Medicare beneficiaries are relying on the ED for their healthcare needs. In fact, annually, this group accounts for nearly 22 million ED visits, so pinpointing what inequalities exist and identifying ways to rectify those differences could have a significant impact on patient outcomes, the team said.

RSNA 2020: Addressing Healthcare Disparities and Access to Care

Overall, the team hypothesized that advanced imaging utilization in the ED would differ according to hospital location, hospital status, and patient race and postulated learning more could lead to creating targeted interventions and shed light on how expanded coverage through Medicare-for-All insurance could affect these disparities.

For their study, the team retrospectively reviewed the records from 86,976 ED encounters from Medicare beneficiaries, focusing on CT and MRI. Of the population, nearly 61 percent were encounters for women, 29 percent were from rural hospitals, and approximately 16 percent occurred in critical access hospitals. Their review unveiled several inequalities in advanced imaging utilization.

Based on a fully adjusted multivariate logistic regression analysis, Hanna’s team determined that African American patients were 31.6 percent less likely than white patients to receive advanced imaging. In addition, rural patients – both African American and white – and those in critical care access hospitals were 6.9 percent and 18 percent, respectively, less likely than urban and those in non-critical care access facilities to receive these types of imaging. However, only white and patients who were categorized as Asian, Hispanic, Native American, other, or unknown were less likely to be imaged in a critical care hospital.

Gender also played a role, the team said, but only among African American patients. African American men were 15.9 percent less likely to received advanced imaging in the ED than were African American women. Geography was also a factor. Patients in critical access hospitals had lower odds of receiving advanced imaging in the Midwest and West; men were less likely in the Northeast; and African Americans were less likely in all regions.

Overall, they said, these results show that even routine courses of action in the ED have not been able to erase the presence of inequities in medical imaging.

“In EDs, one might expect that defined evidence-based imaging protocols would minimize health care disparities,” they said. “However, the persistence of these disparities for different populations (particularly with similar Medicare fee-for-service insurance coverage) is consistent with the complex nature of this problem, importantly, both unconscious bias and conscious bias may play a role in health care inequity.”

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

In fact, they said, standardizing ED imaging utilization and documenting guideline compliance could be an effective tactic for reducing these disparities. But, still, they asserted, further research is necessary to explain why the disparities exist, to examine the implications for patient outcomes, and to assess proposed interventions

Research shows African Americans and rural residents undergo fewer CT and MRI scans.

African American Patients One-Third Less Likely to Receive Advanced Imaging in Emergency Department

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

Healthcare disparities and inequities are known to exist in diagnostic imaging. Research published in the 

 takes a look at imaging utilization across Medicare beneficiaries in emergency departments nationwide. Results indicate that African American patients are nearly one-third less likely to receive advanced imaging that their white counterparts. Look for more in-depth coverage this week.

In the meantime, you can find additional health disparities coverage 

Providers cannot rely on the initial severity of a patient’s case of COVID-19 to determine whether he or she will have long-term respiratory complications. This week, findings published in the 

outline, based in part on CT and X-ray images, that common complications that linger after COVID-19 infection appear to be unrelated to how severe the patient’s case is. Keep your eyes open for more details this week.

For additional COVID-19 complications coverage, click 

It’s January, and the Radiological Society of North America (RSNA) is starting the year with a new president, Mary C. Mahoney, M.D., Benjamin Felson Endowed Chair and Professor of Radiology at the University of Cincinnati (UC) College of Medicine. This week 

 spoke with her about her priorities for RSNA over the coming year, as well as what she sees as the challenges and opportunities for the industry going forward. Watch for our interview with her in the coming days.

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

Diagnostic Imaging's A Look Ahead: Jan. 11, 2021, to Jan. 14, 2021

I’ve mentioned in this column that I’m not a handy kind of guy. Putting things together, fixing or otherwise tinkering with them, you name it.

That goes for anything hands-on, hardware and wetware alike. I knew very early on in my healthcare-days that I had no business in specialties that required manual tasks, such as surgery. Unsurprising, then, that rotations in interventional radiology (IR) saw me at far from my best.

Still, I did learn a few things. One of my more enduring recollections from the angio suites was a fundamental rule taught by the section-head: When you are feeding in a catheter or guidewire and meet resistance, do 

I’ll refrain from describing all the bad things that might result from ignoring that bit of guidance; suffice to say that a lot of damage can be done.

While my post-residency life has included not a single IR procedure in which I might have directly applied teachings from that attending, I’ve remembered that particular lesson well…and, a decent chunk of the time, abided by it.

Not purely in a physical sense—it’s actually served me well in a more philosophical way. That is, if I find myself in a situation where I’m trying to get something done, and my initial approach doesn’t work, I usually refrain from more forcefully trying the exact same thing again.

That’s easier said than done. I’ve mentioned in recent columns that our brains are efficient/lazy things, strongly biased towards whatever requires the least energy from them. If we’ve sized up a situation and decided on a course of action, we tend to cling to that decision, even if that action doesn’t yield desired results. More so when the situation is emotionally charged (for instance, we’re getting frustrated by our failed attempts, we’re pressured for time, or we’ve got other things demanding our attention).

Applying the “don’t just push harder” lesson came most readily to me with manual tasks, since they had the most in common with my fumbling efforts in the angio suites. As unhandy as I know myself to be, I’m pretty capable of breaking things when trying to force them to physically work: opening items that resist being opened, closing items that don’t want to be closed, etc. Learning to substitute “This isn’t working, I’d better try harder” with “This isn’t working, is there something else I can try” led to fewer broken items.

A good example of a less-physical application in my recent work: I stumbled across a glitch in the voice-recognition software used for dictating rad reports. On certain occasions, the software gets derailed by something I said. As a favorite aunt of mine likes to say, the program will “lose its mind,” freeze up, and close. Adding to the fun, when restarted, the software fails to accept 

 dictation; turning on the microphone and saying anything makes it crash again.

As mentioned earlier, my brain wants me to “just push harder.” The software 

 work. Even if it crashes, I should be able to restart it, hit the dictation-button, and resume work with nary a delay. Every time, the temptation is there to just fire it right back up and hit the button again, maybe getting righteously angry in the process. But that doesn’t work, and even if it occasionally did, it wouldn’t make the underlying problem go away.

So, after this had happened more than a few times, I reached out to Support so I could describe the issue to them, even demonstrate it with them remoted into my workstation. It made sense that they should gather all of the info they could so as to root out the problem, even though (thus far) I was the only rad having the issue. Ultimately they had no idea for a fix, but were presumably armed with data to present to the software-developers so they could figure things out.

At some point during all of this I found a workaround: After the first software crash, if I relaunched but 

 turn on the microphone, instead manually typing the next line or two in my report, I could then resume dictating without a problem.

Since the glitch still happens a few times each week, I can now circumvent the issue with my little workaround, instead of “pushing harder” by insisting on trying to dictate the normal way. At this point, I would even consider ringing up Support (“It’s happening again, do you have any updates on a fix? Want to remote in and gather more data? This is impairing our efficiency, you know”) to be pushing harder on an already-failed strategy.

Because my main purpose is not to be a software-tester and troubleshooter. I’m there to productively read cases. My workaround, irksome as it is that I have to use it, gets me back on-mission most quickly and effectively…whereas getting ahold of Support means that I sit idle until they get back to me, watch me demo the issue, try fixes, get screenshots, etc.

An even higher-level application of the “don’t push harder” philosophy I’ve learned is in dealing with other people or organizations, when there’s a difference of opinion or some other interaction where everyone isn’t on the same page.

It frankly amazes me how some people seem to think that the best way to debate is to repeat the same argument over and over, as if saying it enough times will somehow “get through” to the other side. Sometimes punctuated by talking more loudly, aggressively, even insultingly or threateningly. Instead of A) offering other lines of reasoning, or B) gathering additional information to better understand the other side.

I will close by with an incident from one of my later IR rotations, where a catheter or wire met resistance, and we paused while the attending came to the suite to feel things out for himself. A bit of fiddling with his more-expert hands, and he regarded us for a moment before saying, “Good, you’ve learned not to just push harder. Now you’re ready for the advanced lesson: Sometimes, if you’ve had enough experience, you can tell when it’s time to push harder.” Then, he successfully advanced the device.

Follow Editorial Board member Eric Postal, M.D., on Twitter -- 

Sometimes taking a step back can help you find the path to keep moving forward.

Don’t Just Push Harder

In a contradiction of research results published this past summer, cardiac MRI shows that heart muscle inflammation in athletes who have recovered from COVID-19 is not as common as previously believed.

In a study published by the American Heart Association, Vanderbilt University Medical Center researchers found that only a small number of athletes among the 59 evaluated suffered lingering cardiac effects. The results will be published in the February 

“The degree of myocarditis found by cardiac MRI in Vanderbilt athletes was only 3 percent, which is really good news,” said first author Dan Clark, M.D., MPH, a cardiovascular medicine instructor at Vanderbilt. “Since our first evaluation, we have screened almost double that number and the same findings are holding true.”

, published in September 2020, reported as many as 15 percent of athletes who recovered from the virus experienced myocarditis.

In this study – the COVID-19 Myocardial Pathology Evaluation in AthleTEs with Cardiac Magnetic Resonance (COMPETE CMR) – Clark’s team compared COVID-19-positive athletes with 60 healthy controls. It is the first study to include healthy controls to assess athletes post-COVID-19.

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

And, the outcome of the study shows the degree of myocarditis present in recovered athletes was much lower than earlier reports.

“The differences in the findings are extremely important,” he said. “The whole world paused after seeing the alarmingly high rates of myocardial inflammation and edema initially published.”

But, while this is a bright spot of news because the cardiovascular impacts of COVID-19 have been well documented, the study did present some negative results. None of the screening tests evaluated were effective in pinpointing which athletes had myocarditis – and none of those athletes had exhibited any symptoms of the virus.

It was a let-down, Clark explained, because he and his team were hopeful that standard screening tests would be definitive, limiting the need for cardiac MRI to the most necessary instances.

“However, their blood work, clinical exams, EKG, echocardiograms, and other cardiovascular screening were normal,” he said. “All of those traditional screening results would have led us to agree to allow some athletes to participate in a sporting event or practice, while the MRI told a different story.”

Cardiac MRI Reveals Post-Recovery Heart Damage in 78 Percent of COVID-19 Patients

Alongside the myocarditis findings, the team also found a higher level of scarring in healthy heart muscle than they anticipated. After comparing the cardiac MRI scans with those from healthy controls, however, they found a relatively similar level of scarring – 24 percent of COVID-19-positive athletes and 27 percent of health controls. The benign scarring, Clark said, is a result of athletic remodeling that is common among athletes.

“This particular piece of information is very important to share – myocarditis after COVID-19 tends to be in a similar spot,” he said. “Without the knowledge that this area of scarring is common in healthy athletes, clinicians could attribute the scarring to consequence from COVID-19. Those assumptions might unnecessarily restrict some athletes from competition.”

Consequently, he said, adding cardiac MRI into the mix as an assessment tool can make it easier to draft safe return-to-play guidelines.

“Myocarditis among recovering COVID-19 athletes is less common than previously reported,” Clark said. “We also want to highlight that the comparison to healthy athletic control group without COVID is critically important to show that many changes on a cardiac MRI are related to athleticism and not COVID-19. However, despite the lower incidence of myocarditis than expected, cardiac MRI remains a very useful tool for evaluating competitive athletes prior to a return to sports.”

New study, comparing recovered athletes to healthy controls, reveals a lower level of myocarditis that previously published research, but cardiac MRI is still important for safe return-to-play decisions.

Cardiac MRI Shows Less Myocarditis in Athletes Post-COVID-19 Than Previously Reported

Focused ultrasound may be able to help relieve symptoms for patients who are more affected by Parkinson’s disease on one side of the body than the other, according to new research out of the University of Virginia Health System.

For patients who do not respond well to medication, but who do not wish to undergo traditional brain surgery, focused ultrasound, which creates therapeutic lesions in deep-brain structures, can be a good option by targeting the subthalamic nucleus, the preferred deep-brain stimulation target for treating the characteristic motor features associated with Parkinson’s.

“This small brain region, the subthalamic nucleus, had a very strong and potent effect on parkinsonian symptoms when we targeted it with precise, focused ultrasound energy,” said researcher Jeff Elias, M.D., a neurosurgeon at UVA Health. “The key for the ultimate adoption of this new procedure will be further refinements of the technology to ensure reliability and safety.”

He and his team published the results of their investigation into the efficacy of focused ultrasound in the Dec. 24 

To test how well the technology and procedure works, Elias’s team enrolled 40 patients who had distinctly asymmetric Parkinson’s disease that was not fully controlled by medication and who were ineligible for deep-brain stimulation surgery in their study. They randomly assigned the group – at a 2-to-1 ratio – to either undergo focused ultrasound subthalamotomy on the side opposite from their main motor signs or a sham procedure – 27 underwent focused ultrasound and 13 received the sham surgery.

After the procedure, the team compared the Movement Disorder Society—Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) motor score at baseline and after four months for both groups. The scores, which ranged from 0-to-44 with higher scores indicating worse disease, focused on the differences between the more affected side of the body when the patient was not taking medication.

Based on their assessment, among those patients who received focused ultrasound, their MDS-UPDRS scores dropped from 19.9 at baseline to 9.9 after 4 months. The control group saw a much smaller change, only decreasing from 18.7 to 17.1. The overall difference between the groups was 8.1, the team said.

Alongside the score improvement, some patients did experience adverse events, including impairment of voluntary movements, weakness on the treated side, speech disturbance, facial weakness, and gait disturbance. Most of these cases dissipated over time.

Even with these improvements, said Binit Shah, M.D., assistant professor of neurology at UVA, more research is needed with a large group of patients over a longer period of time.

“Parkinson’s disease affects patients in more way than just tremor,” he said. “The current FDA approval for focused ultrasound in Parkinson’s disease treats only tremor. Targeting this new area allows us to improve tremor but also get more overall benefit for our patients that we previously were able to achieve.”

By targeting the subthalamus, providers can help alleviate symptoms for patients whose Parkinson’s is not controlled with medication and who are not candidates for traditional brain surgery.

Focused Ultrasound Can Reduce Parkinson’s Symptoms

X-ray technologists could soon experience fewer work-related injuries thanks to new technology released for sale recently by Shimadzu Medical Systems USA.

Throughout the industry, shoulder injuries top the list for the most common injuries these imaging professionals experience, followed closely by back and wrist problems. Most of these issues are due to the physical exertion needed for a technologist to maneuver the X-ray equipment that is mounted in the ceiling.

To prevent such injuries and potentially shorten exam times, Shimadzu announced the North American sales release of its RADspeed Pro style edition with GLIDE Technology™ that is designed to reduce the physical burden on technologists. Specifically called POWER GLIDE™, the tool can instantly sense the force exerted by a technologist, calculate how much assist-force is needed, and activate the motor in real-time. Consequently, company representatives said, the experience is individualized for both large movements and detailed positioning adjustments.

According to company information, the GLIDE VIEW ™ technology is available in mobile X-ray systems and GLIDE ASSIST™ can be found in patient-side R/F systems.

GLIDE Technology ™ is designed to provide individualized, motorized assistance to X-ray technologists, potentially reducing injuries and shortening exam time.



Shimadzu Medical Systems USA Releases X-ray Assist Technology

 Weekly Scan for 2021. I’m senior editor, Whitney Palmer, and we’re looking forward to an exciting New Year with you.

Before we get to our featured full interview this week with Dr. David Larson from Stanford University Medical Center about the ethics of using artificial intelligence in medical imaging, here are the top stories from this week.

It’s well understood now that COVID-19 can cause neurological problems that accompany the characteristic pulmonary damage. But, researchers from the National Institutes of Health published a story in the 

 this week that revealed the blood vessel damage and inflammation in the brain that happens with COVID-19-positive patients can occur even if the SARS-CoV-2 virus never infiltrates the brain tissue. Using MRI scanners that were 4-to-10 times more sensitive than the traditional ones used, the team examined brain tissue from 19 patients between the ages of 5 and 73 who died within hours to two months of being diagnosed. They concentrated on tissue from the olfactory bulb and brain stems because those are two areas believed to be susceptible to the virus, but they found no evidence of SARS-CoV-2 in the tissue. They did see hyperintensities and hypointensities that revealed bleeding that could trigger an immune response, however. The team said they hope their results help other researchers in their investigative efforts.

Patients who have bullet fragments embedded in their bodies – either from new or old injuries – are often denied MRI studies due to ferromagnetic fears. However, new research published in the 

 from investigators at Emory University shows that X-ray and CT can be used to identify which fragments are safe for MRI. According to the team, non-ferromagnetic bullets have certain characteristics that show up on imaging that can allay radiologists’ worries. Specifically, bullets that leave a debris trail or appeared deformed on X-ray or CT are non-ferromagnetic. Typically, they are made of copper, copper alloy, a lead composition with a partial jacketed composition, or shotgun shot. They also did not produce heat or any detectable force or torque when tested in an MRI scanner in ballistic gel that mimicked human tissue. As a result of their work, the team created an algorithm providers can follow to help them ensure safe imaging.

So much happened in 2020, but it was difficult to focus on much other than COVID-19. Still, radiology has a bright new year ahead of it. This week, we spoke with Dr. Mina Makary, an interventional radiologist with The Ohio State University Wexner Medical Center about what he sees as trends to watch throughout the next 12 months. Yes, he acknowledged that the pandemic is still the specialty’s top priority, but he also pointed to artificial intelligence, reimbursement cuts, 3D printing, interventional radiology, and policy and culture as areas to watch, as well. You can see all the 

And, finally, this week, we are sharing our full interview with David Larson, M.D., professor of radiology at Stanford. Larson is nationally recognized as an expert in radiology ethics, and in our discussion he outlines the main points radiologists must consider and remember in order to use artificial intelligence ethically in medical imaging, as well as the challenges that exist to doing so. 

Videos

COVID-19 Damage, but No Virus in the Brain; Non-Ferromagnetic Bullets and the MRI; Six Trends to Watch in 2021; and AI and Ethics

Diagnostic Imaging Weekly Scan: Jan. 8, 2021

New evidence shows that multi-parametric MRI (mpMRI) routinely provides radiologic tumor size (RTS) measurements smaller than the actual pathologic tumor size (PTS), contradicting previous findings that it offers over-estimations.

investigators from the University of California Los Angeles David Geffen School of Medicine shared their data, showing that RTS measurements of prostate cancer tumors captured with mpMRI fall below PTS in 98 percent of cases where lesions are less than 1 cm.

MRI is the typical method for diagnosing and managing prostate cancer, but, by failing to accurately measure lesion size, said the team led by Aydin Pooli, M.D., clinical instructor of urology, using mpMRI in these situations could lead to potentially lead to under-treatment.

“Multi-parametric magnetic resonance imaging frequently underestimates pathological tumor size and the degree of underestimation increases with smaller radiologic tumor size and lower PI-RADSv2,” the team said. “Therefore, a larger ablation margin may be required for smaller tumors and lesions with lower PI-RADSv2 scores.”

Their study, they said, incorporated a larger study population than previous studies that have examined the accuracy of mpMRI.

Despite being the scan of choice with prostate cancer tumors, questions have lingered about its accuracy in depicting tumors size. To put these uncertainties to rest, Pooli’s team analyzed 461 lesions in 441 men (average age of nearly 62 years) scanned with a 3T mpMRI between June 2010 to February 2018. Their median PSA and PSA density were 6.3 ng/ml and 0.174, respectively.

Based on their analysis, the team found the mean maximum RTS and PTS were 1.6 cm and 2.4 cm, respectively, revealing that RTS, on average, underestimated PTS by 0.8 cm. In particular, they said, the discrepancies in the measurements increased as the lesions got smaller. For lesions smaller than 1 cm, the difference on mpMRI was 1.25 cm; it was 0.86 cm for lesions between 1 cm and 2 cm; and it was 0.3 cm for lesions greater than 2 cm.

These differences, they said, show that 98 percent of PTS measurements were larger than RTS for lesions less than 1 cm. These percentages were lower for lesions between 1 cm and 2 cm (88 percent) and those larger than 2 cm (63 percent), meaning that the majority of men received incorrect assessments as part of their prostate cancer management.

In addition, they said, the correlations between RTS and PTS based on biopsy Gleason Grade Group (GG) and radiologic covariates were generally low with correlation coefficients ranging between 0.1 and 0.65.

“Although the correlations were statistically significant, the degrees of correlation were generally low, which questioned the clinical usefulness of biopsy GG, PI-RADSv2 core, radiologic zone, and level in predicting PTS,” they said.

These results, they said, indicate that providers must consider additional management options for prostate cancer, and they must proceed with more caution when dealing with smaller tumors on mpMRI or with men who have lower PI-RADSv2 scores.

“Our study suggests that by relying on RTS alone we can only be sure of complete ablation of the mpMRI detected lesion if a large margin is used in the largest diameter, especially for tumors less than 2 cm,” they explained. “Smaller margins, although acceptable, will have a lower degree of certainty for complete ablation of the prostate lesion.”

They suggested incorporating tracked biopsy around the mpMRI detected prostate lesion could help overcome the tumor characterization limitations. But, there is still more research to be done, they said.

“Further work in this area should seek to develop algorithms that accurately combine RTS and patient specific factors to correctly predict patient specific factors to correctly predict PTS,” they said. “Until these algorithms exist, care must be taken when both interpreting and using mpMRI for treatment selection and planning.”

Pathological tumor size is frequently under-estimates the size of prostate tumors, particularly smaller tumors.

Multi-Parametric MRI Underestimates Prostate Tumor Size

COVID-19 has created uncertainty for medical professionals on the frontline of the pandemic. Disruptions to clinical care abound, from over-filled ICUs to over-stretched healthcare workers, creating an environment ripe for missteps and misdiagnoses.

Yet, despite the chaos and constantly changing variables, the quality of patient care is the one thing that should never suffer. Maintaining high standards through certification of healthcare professionals is the best way to ensure that patients achieve the best outcomes. Fully trained, certified healthcare professionals should be expected for every patient interaction.

Unfortunately, that’s not always the case when it comes to medical imaging. This global health crisis has shown that imaging modalities, such as ultrasound, are particularly effective in the diagnosis of COVID-19. While many hospitals and medical practices require certification, only a handful of U.S. states require medical sonographers to possess specific certifications as a job requirement. Professional training and certification reduce risk, giving healthcare providers the strongest foundation for performing accurate and timely ultrasound examinations.

Maintaining consistency-of-care is critical in normal times and, especially, during a pandemic. Certified healthcare professionals provide greater assurance that medical imaging procedures will be performed to the highest standard of care regardless of the circumstances, location, or patient’s financial situation. The technical and scientific skillsets required to achieve the certification process encourages repeatable, consistent proficiency that non-certified ultrasound users may lack.

Certification also conveys a higher level of competency to the healthcare organization. Independently validated sonography certification serves as a proxy for licensure, as licensure requirements do not exist in most states in the U.S. In states that do require licensure, the universally accepted credentials from the American Registry for Diagnostic Medical Sonography (ARDMS) are accepted as proof of proficiency.

Ultrasound examinations by certified ultrasound professionals can be invaluable in triage management as well, particularly in the identification of patients with SARS-CoV-2 pneumonia needing immediate treatment. In the high-pressure environment of acute medical settings, certified professionals are trained to manage these critically important decisions.

Finally, certified professionals elicit a sense of trust. A certified sonographer has demonstrated the theoretical knowledge and practical application skills required to perform the examination effectively and accurately. This certification provides a heightened level trust from patients, employers, and other healthcare professionals.



As health care providers become even more overloaded during a pandemic, they are asked to tend to many needs of the patient that may have been previously addressed by another specialized professional. This is where certification is important. Diagnostic accuracy is expected with highly skilled sonographers. In the absence of certified professionals using these essential diagnostic tools, there is a greater margin of error and potential for misdiagnosis. Inexperience can lead to inadequate or incorrect treatment, increased morbidity, and potential death.

 has realized misdiagnoses have been a primary contributor to patient harm. As much of our understanding of this novel virus is still unknown or unfolding, the complexity of COVID-19 and sheer number of patients being treated during the outbreak are likely to cause an increase in diagnostic errors.

Lung ultrasound is receiving increased attention with the COVID-19 pandemic, and it is important that the exam is performed by trained and certified sonographers. Certified sonographers have the knowledge of proper patient position, transducer selection, and scanning techniques. Sonographers use artifacts produced at the pleural surface to assist in determining lung pathology. Sonographic signs, such as A-lines, B-lines, lung sliding, comet tail artifacts, lung point sign, spine sign, and shred sign, are used by trained sonographers, but are difficult to distinguish to the untrained eye.A substandard ultrasound examination could cause the need for additional diagnostic methods, potentially exposing the patient to unnecessary radiation.

Speed and responsiveness of emergency care are at stake, as well. With many hospital intensive care units under siege during this pandemic, rapid, accurate diagnoses using ultrasound will be critical for managing the large volumes of critically ill COVID-19 patients.

Ultrasound imaging gives practitioners a potentially faster way to triage a patient’s condition than waiting for nasal swab results. Access to certified sonographers enables healthcare providers to put more critical expertise and knowledge on the front lines of care, improving response time and accuracy.

Other ways independently validated certification makes a difference

Certification can be a huge asset for health care practitioners who, due to the pandemic, are seeking to boost their skills and expand their careers into new professional areas. Certification assessment demonstrates that their skills and knowledge have been validated through the certification process, giving them a competitive advantage in their job seeking and advancement.

Beyond the responsiveness to healthcare crises like COVID-19, sonography certification offers significant reputational benefits to healthcare organizations. If the healthcare industry made sonography certification a greater priority, it could help establish a consistent standard of care across the United States and beyond. Standardizing care, in turn, improves patient trust.

Certification serves as proof of knowledge and carries with it a high degree of recognition for the sonographer. This recognition will instill a higher level of confidence for the healthcare provider, assuring they are hiring a highly proficient employee.

In these uncertain times, the world needs the skills that certified sonographers provide more than ever. For practitioners seeking these skills, the ARDMS administers examinations and awards certificates in all areas of diagnostic ultrasound. ARDMS certifications have been awarded to more than 100,000 medical professionals worldwide and are recognized as the global standard in sonography credentialing.

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1. Singh H, Graber ML. Improving diagnosis in health care—the next imperative for patient safety. N Engl J Med. 2015;373(26):2493-2495. 

Credentialing leads to higher-quality, more consistent care while improving patient trust.

Diagnostic Uncertainty During COVID-19 Heightens Need for Certified Sonographers Treating Patients 

Hyperfine Research, Inc., secure 510(k) clearance from the U.S. Food & Drug Administration for its Advanced AI image assessment software that can automatically measure and return annotated and segmented brain images.

This software works with Hyperfine’s Swoop™ Portable MR Imaging System, the first MRI system develop to capture brain MRI images at the patient’s bedside. In particular, this tool offers ventricular volume, image extraction, alignment, and midline shift. This data gives providers of all expertise levels the quantitate markers that are necessary for decision support, as well as the immediate feedback that can be critical for diagnostic feedback.

“With this powerful tool now built into the Swoop™ system, we are making MR imaging not only accessible at the bedside, but making it easier for providers to move quickly from scan to a recommended course of treatment,” said Khan Siddiqui, M.D., Hyperfine’s chief medical officer. “The data provided by Hyperfine’s deep learning software will liberate users of our MR technology by providing simple, accessible information in just minutes.”

Software provides annotated and segmented brain images captured by Hyperfine’s portable MRI system.

Hyperfine’s Image Assessment Software Captures FDA Clearance

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

Before we get to our featured interview this week with Dr. Donald Frush, instructor of radiology in the Duke University School of Medicine and Health System, about the announced recommendation against across-the-board gonad shielding with X-ray imaging from the National Council on Radiation Protection and Measurements (NCRP), here are the top stories of the week.

In contrast to what you might have anticipated, the severity of a patient’s case of COVID-19 is not necessarily linked to how well his or her lungs will recover from the virus. Fortunately, post-recovery imaging at least shows that most people’s lungs will not experience any long-term scarring. In a study from Trinity College in Dublin, published in the 

, investigators followed 153 patients for an average of 75 days in an outpatient clinic, evaluating their condition with chest X-rays and CT, as well as a six-minute walk test. They also examined blood samples for disease indicators, such as C-reactive protein. The results surprised them. Only 4 percent of patients who had previous abnormal X-rays had any evidence of lung scarring on chest CT, and shorter six-minute walk test distances were associated with frailty and longer hospitalizations – not disease severity. These outcomes point to a need for greater cardiovascular and fitness assessment, as well as rehabilitation for patients who have fatigue and breathlessness after COVID-19 recovery.

Looking to reduce your emergency department medical imaging recall rates? It might be as easy as adding an attending radiologist to the overnight hours, according to University of Toronto researchers. This group of investigators tested an intervention at Sunnybrook Health Sciences Center from 2016 to 2018, and they found having an attending radiologist in-house after-hours sliced imaging exam recalls by approximately 90 percent. In fact, they said in their article in 

, the average number of recalls plummeted from 61 annually to 7. This drop was impressive they said since the number of images ordered in the emergency department actually rose annually during this time, climbing from 13,883 in 2016 to 15,112 in 2018. While radiology residents still provided preliminary reports and remained the main points-of-contact for referring physicians, the attending radiologists were responsible for final reports for both emergency department patients and inpatients. Not only did their intervention improve work flow, but it also improved patient comfort and safety because patient were not called back for a re-scan. In addition, emergency physicians also reported a higher level of satisfaction.

New findings this week from Vanderbilt University contradicted some alarming results published in the fall about the effects of COVID-19 on the cardiovascular health of athletes. Initially, it was reported that approximately 15 percent of athletes suffered from myocarditis, captured on cardiac MRI, after recovering from the virus. Vanderbilt’s investigators determined the real amount is 3 percent, and their findings were published by the American Heart Association in 

Vanderbilt researchers compared COVID-19-positive athletes to 60 healthy controls to make this determination. Unfortunately, they realized, no screening tests that they evaluated were effective in pinpointing which athletes had myocarditis – this was a let-down because the team had hoped those screenings would have been definitive, limiting the need for cardiac MRI to the most necessary instances. Still, in one beneficial result, they found both COVID-19-positive and health athletes experience similar levels of benign scarring in healthy heart muscle in the same location, indicating it is not a consequence of the virus and should not restrict an athlete from competition.

And, finally this week, Diagnostic Imaging spoke with Dr. Donald Frush, an instructor of radiology at Duke University School of Medicine and Duke University Health System about the recommendations against the universal use of gonad shielding during X-ray imaging that were released this week. Frush, who served as the chair of the NCRP subcommittee on gonadal shielding discussed the reasoning behind the recommendation, the challenges that exist to implementing the protocol change, what facilities can do to successfully shift their shielding practice, and the drawbacks that exist to still using shielding routinely.

COVID-19 and Long-Term Lung Effects; Reduce Emergency Department Imaging Recalls; COVID-19, Myocarditis, and Athletes; Plus, New Recommendation for X-ray Gonad Shielding

Diagnostic Imaging's Weekly Scan: Jan. 11 to Jan. 15, 2021

New lesions picked up by breast MRI scans conducted to assess neoadjuvant treatment for breast cancer are uncommon, and according to new research, they are not likely to be malignant.

Breast MRI is routinely used to evaluate a patient’s response to neoadjuvant therapy, but there is little-to-no guidance available on how to manage the new suspicious lesions that rarely occur. In a Jan. 14 article published in the 

investigators from the University of California at San Francisco (UCSF) show that new findings appear in only 5.5 percent of cases and none were malignant, potentially reducing the number of biopsies ordered.

“Our findings suggest that new lesions that arise in the setting of neoadjuvant therapy are highly unlikely to represent a new site of malignancy, particularly if the index malignancy shows treatment response,” wrote a team led by Donna A. Eckstein, M.D., from the radiology and biomedical imaging department at UCSF.

This is the first study, they said, to look at and evaluate the malignancy potential for lesions that appear on MRI during breast cancer treatment.

By examining results from 419 breast MRI scans conducted on 297 women from Jan. 1, 2010, to June 30, 2018, Eckstein’s team set out to determine the frequency and outcomes from these new suspicious lesions. Based on the exams conducted on 1.5T and 3T scanners, a group of 13 fellowship-trained breast radiologists identified 23 MRI exams – 5.5 percent – that included new suspicious findings that were distinct from those initially identified prior to neoadjuvant treatment.

These patients were treated with a variety of therapeutic combinations, including chemotherapy, anti-HER2 therapy, immunotherapy, hormonal therapy, and cyclin-dependent kinase inhibitors. And, on average, the time between baseline pretreatment breast MRI and follow-up MRI was 2.9 months.

According to the team’s analysis, all new suspicious MRI findings were assessed to be BI-RADS 4. Thirteen of the 23 lesions (56.5 percent) were contralateral to the known malignancy, nine (39.1 percent) were ipsilateral, and one (4.3 percent) involved the bilateral breasts. The lesions types included masses (69.6 percent), non-mass enhancements (21.7 percent), and focus (8.7 percent).

Overall, the team determined, these new lesions should not immediately raise a red flag if they appear on breast MRI during neoadjuvant therapy as the likelihood of malignancy is small. Still, as these results raise the possibility of averting biopsy, additional investigations are necessary. To validate that conclusion, larger studies in a variety of institutions should be conducted.

Suspicious lesions that develop during neoadjuvant therapy are uncommon, and they are highly unlikely to be malignant. 

Breast MRI-Identified Lesions During Neoadjuvant Therapy Are Largely Benign

Offering mammograms to inpatients could be a good way to screen women who might otherwise face challenges in getting imaged.

For many women, mammograms fall by the wayside either because they do not have transportation to the clinic or they cannot get time off work. To address this problem, investigators from Massachusetts General Hospital (MGH) tested an inpatient-mammogram intervention to see if it could be an easier way to tackle preventive care needs.

“We designed the study to reach the patients who face significant barriers to completing their mammograms in the outpatient setting,” said first author Andrew S. Hwang, M.D., MPH, and MGH internist.

Hwang’s team published their results in the January issue of 

Breast cancer screening rates are particularly low among Medicaid and dual-eligible patients, according to existing national and local data. If this intervention is successful, he said, it could help reduce disparities by simultaneously addressing patients’ acute and preventive care needs.

To test their intervention, Hwang’s team pinpointed women who were Medicaid and dual-eligible, had been admitted to MGH’s general medicine service between March 2019 and March 2020, and who were overdue for a mammogram. These inpatients also had a primary care provider associated with MGH with whom they could follow up for any abnormal results.

Overall, the team identified 21 women who met these criteria, and 17 went through with the inpatient mammogram – four were discharged before the screenings could be scheduled. For 35 percent of the screened group, this was their first mammogram – the remaining patients were overdue for a scan by an average of four years. All but one mammogram was negative, and providers recommended that patient pursue additional imaging to rule out cancer.

It is important to note, Hwang said, that scheduling a mammogram during the inpatient stay did not extend the patient’s hospitalization. Consequently, he and his team would like to extend the intervention to patients who are admitted into other areas of the hospital, as well as expand it to include other preventive services for low-income men and women, such as fecal immunochemical tests for colorectal cancer screening. Such innovative measures will be vital to addressing patients’ psychosocial needs and breaking down the barriers to care that many of them experience.

“[As] our healthcare system transitions from fee-for-service to value-based payment models, improving health outcomes among underserved patient populations will become increasingly important,” he said. “Completing preventive screening tests, such as mammograms, during hospitalizations can be one way to help patients who might otherwise miss preventive care.”

A pilot study intervention successfully provides mammograms for patients who face screening challenges. 

Innovative Inpatient Mammograms Can Diminish Breast Cancer Screening Disparities

This patient presented after having swallowed numerous nails, as can be seen on this abdominal KUB radiograph. The image reveals multiple foreign bodies projected over the expected location of the stomach, duodenum, and distal small bowel loops.

Key Take-aways: When faced with a similar image, look for free air that would indicate the presence of any foreign body that could have resulted in perforation. However, to exclude perforation, free air, or abscess – if signs of infection are present – as well as other complications, additional CT imaging may be necessary. In addition, conduct serial imaging to monitor the patient and to ensure the foreign bodies move through the GI tract.

Case submitted by M.T., Niknejad, M.D., to the radRounds Radiology Network

Patient swallows multiple foreign bodies.