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.

Whitney J. Palmer

The performance of a new artificial intelligence (AI) algorithm used to assess chest X-rays for the presence of tuberculosis was virtually equivalent to that of radiologists.

, a team of investigators from South Korea shared the results of how well their algorithm evaluated these scans. Chest X-ray is the go-to scan for detecting and assessing tuberculosis.

Finding an effective and efficient way to analyze these scans quickly is critical, they said. The countries most affected by the disease are also ones that are least likely to have enough providers who are skilled in detection.

To meet this need, the team, led by Seowoo Lee from the Seoul National University Hospital’s radiology department, created an algorithm that could identify active pulmonary tuberculosis on chest X-rays. They used 6,654 scans from patients with active disease and those who had recovered to train their tool. Specifically, 3,327 X-rays came from patients with pulmonary tuberculosis, and 3,182 were from patients with normal chest X-rays.

The algorithm performed well. Not only was it capable of pinpointing the presence of tuberculosis, but it outperformed pulmonologists. Its abilities were also comparable to radiologists, the team said, and it could help with categorizing patients in low-resource areas.

“The network may help radiologically triage patients with active tuberculosis by excluding healed tuberculosis in high-burden countries and may assist in monitoring the activity of mycobacterial diseases that require long-term treatment,” they said.

To reach these results, the team assessed their model’s performance with two datasets. Set 1 included 89 patients and 148 X-rays, and Set 2 was comprised on controlled data from 366 patients and more than 3,700 images.

According to the analysis from two pulmonologists and two thoracic radiologists, the algorithm produced a slightly higher area under the curve for Set 1 than one pulmonologist – 0.83 compared with 0.69, respectively. Performance was similar to that from the radiologists – 0.79 to 0.80. With Set 2, the model’s area under the curve (0.84) was, once again, higher than the pulmonologists (0.71) and comparable to the radiologist (0.79 and 0.80).

Based on these outcomes, the team said, the algorithm has the potential to catch more cases of tuberculosis, bringing a higher level of patient care to infected individuals.

“If a deep learning network can accurately differentiate active tuberculosis from healed tuberculosis on radiographs, then this will provide more efficient triage for testing in limited-resource settings by decreasing unnecessary testing individuals less likely to have active tuberculosis,” they said.

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Tool outperformed pulmonologists for detection of the infection.

Chest X-Ray Algorithm on Par with Radiologists for Tuberculosis Detection

Pairing PET/MRI imaging with radiopharmaceuticals can offer double benefits to patients. Not only can it accurately pinpoint malignant brain tumors, but it can help individuals side-step invasive procedures.

Although this combination, including radiopharmaceuticals, such as 

F-FET), is already known to improve diagnostic performance, less is known about the role it plays in clinical decision-making.

a team of investigators from Germany examined how the combination worked with patients who have brain tumors.

For their study, the team led by Cornelia Brendle from the University Hospital Tuebingen radiology department, evaluated how well 

F-FET PET/MR performed in detecting malignant brain tumors. Not only did the combination pinpoint these tumors with 85-percent accuracy, it also changed patient management decisions in 33 percent of cases. Additionally, the findings from the combination helped 20 percent of patients avert unnecessary follow-up procedures.

Based on these outcomes, the team said, it is possible that the combination could help patients who have non-malignant brain tumors who could likely fare better with a watchful waiting approach.

To reach their results, the team conducted a retrospective investigation with 189 patients who had brain tumors and who underwent multi-parametric 

F-FET PET/MR imaging between 2017 and 2018. Patients were considered to have a new diagnosis if the scan detected any untreated, suspicious lesions.

According to their analysis, in 93 percent of cases, this combination approach was able to successfully detect both actively growing malignant tumors or those that were being successfully treated. Consequently, this type of imaging option could help inform clinical decisions that could bring the most appropriate treatment options to patients in the most timely way.

Although further research is needed, the team said, the combination approach can offer benefits to patients.

F-FET PET to MRI…in a hybrid scanner has been reported to be reasonable in terms of cost-effectiveness in selected patients,” they said.

Combination can also help patients avoid unnecessary invasive procedures.

PET/MRI + Radiopharmaceuticals Can Identify Malignant Brain Tumors

If you use ultrasound gel regularly, you’ll want to pay attention to a recent recall from the U.S. Food & Drug Administration (FDA).

In an Aug. 4 announcement, the FDA recalled eight lots of Eco-Med Pharmaceuticals ultrasound gel, citing contamination.

As of publication time 15 patients have contracted confirmed bacterial infections from the Eco-Gel 200 ultrasound gel. Additional cases are suspected but have not been confirmed.

Eco-Gel advised its customers to immediately discontinue use of the product and return it, if possible.

“Eco-Med has initiated this recall and quarantine due to bacterial contamination in the affected lots of ultrasound gel with 

complex (Bcc),” officials said in the FDA notification. “The source(s) of the bacterial contamination is currently unknown. Eco-Med is conducting a comprehensive investigation to determine the root cause of this contamination and take all necessary corrective action.”

Affected patients can be asymptomatic, or they could develop a serious infection, such as bloodstream infections that can cause sepsis or death.

Lot number B029, distributed March 26, 2021

Lot number B030, distributed March 30, 2021

Lot number B031, distributed April 5, 2021

Lot number B032, distributed April 7, 2021

Lot number B040, distributed April 26, 2021

Lot number B041, distributed April 26, 2021

Lot number B055, distributed May 26, 2021

The lots were sold under these brand names in the United States:

MediChoice Ultrasound Gel, by Owens & Minor

MediChoice Ultrasound Gel, by Mac Medical Supply Co.

Gel was sold under eight different brand names.

FDA Recalls 8 Lots of Ultrasound Gel for Contamination

Utilization of head and neck CT angiography (CTA) in the emergency department ballooned, outpacing all other neurological exams.

a team of investigators from the Georgia Institute of Technology (Georgia Tech) determined that the compound annual growth rate for these scans was 25 percent to 27 percent from 2007 to 2017. Unenhanced head CT was the most common neuroimaging exam in the emergency department, they said.

“The rapid growth of head and neck CTA observed in the fee-for-service Medicare population is also observed in the commercially insured and Medicare Advantage populations,” said Selin Merdan, Ph.D., associate director of the Value Analytics Lab in Georgia Tech’s department of industrial and systems engineering.

For their study, Merdan’s team evaluated the annual emergency department utilization of head CT, head MR, head CTA, neck CTA, head MR angiography (MRA), neck MRA, and carotid duplex ultrasound. They based their assessment on patient-level claims from Optum’s De-identified Clinformatics Data Mart database – a database that includes between 12 million and 14 million commercial and Medicare Advantage health plan enrollees.

They adjusted utilization rates using annual relative proportions of age groups and stratified by patient demographics, payer type, and provider state to account for an older sample population.

Based on their analysis, they determined emergency department neuroimaging use spiked 72 percent overall during the study period. Specifically, they found these increases: 69 percent for head CT, 67 percent for MRI, 1,100 percent for head CTA, 1,300 percent for neck CTA, 36 percent for head MRA, 52 percent for neck MRA. They also identified a slight drop of 8 percent for carotid duplex ultrasound.

Credit: American Journal of Roentgenology

In addition, among patients 65 and older, head CT and CTA of the head and neck experienced a continuous increase of 48 percent and 1,011 percent, respectively, for every 1,000 emergency department visits.

These findings, the team said, warrant paying closer attention to neuroimaging use in the emergency department.

“The appropriateness of this growth should be monitored as the indications for CTA expand and more incidental findings are uncovered,” the team said.

Use of head and neck CTA has increased significantly among commercially insured and Medicare Advantage patients. 

ED Neuroimaging Spikes over Decade

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CT use is on the rise with patients who have minor injuries. As a result, emergency departments are seeing more and more cervical spine imaging.

Journal of the American College of Radiology

a team of investigators from Emory University and Massachusetts General Hospital revealed that the number of spine scans have tripled among some groups. In fact, across the country, spine injuries account for more than 800,000 of the 40 million scans captured every year in emergency departments.

Minor trauma accounts for most of these images, they said.

“Although [injury severity score] is typically used as a tool for research and quality improvement and is not available in real time, we believe our observations could nonetheless inform ongoing efforts (e.g. Choosing Wisely initiatives, decision support tools, pre-authorization processes, and consensus statement for optimizing [emergency department] imaging) to ensure the most appropriate use of cervical spine imaging in the acute setting,” the team said.

Theirs is the first study to analyze imaging utilization with claim-based injury severity scores.

For their study, the team evaluated the records for 11,346,684 trauma encounters in the emergency department that occurred between 2009 and 2018. Using an injury severity score algorithm with diagnosis codes, they categorized injuries as minor, intermediate, and major. Overall, the team determined that minor injuries were part of 68 percent of emergency department visits while intermediate and major injuries accounted for 31 percent and 0.6 percent, respectively.

According to their analysis, not only did cervical spine imaging spiked by 5.7 percent each year, but CT scans also ballooned by 10.5 percent annually. In contrast, radiography fell by 2.7 percent each year. The biggest CT utilization increases occurred with minor injuries, but radiography use was consistent. However, for intermediate and major visits, radiography was less common.

Based on these results, more work is needed to curtail CT utilization, they concluded. Focusing on clinical decision support tools could be an effective way to control imaging use with these minor injuries.

“Our work suggests that an increase focus on CT imaging may be warranted in similar future initiatives,” they said. “Further study is necessary to assess appropriateness, implications on costs and population radiation dose, and factors influencing ordering decision making.”

Imaging use has spiked annually for nine years.

Emergency CT Use for Minor Spine Injuries Is On the Rise

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. 



New Guidance for Percutaneous Lung Ablation

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.





