As an experienced journalist but a neophyte to radiology, I went to Chicago with a healthy mixture of curiosity and trepidation. I had prepared for the RSNA sessions I was assigned to cover but wondered if the megatechnical presentations would be over my head.

While many of the sessions proved daunting, and the material was dense and sometimes nearly impenetrable, I was somehow able to discern enough to write multiple daily reports that were at least accurate, if not full of deep insights. But I found it amazingly stimulating and, of course, incredibly informative, to hear such accomplished scientists discuss projects into which they had obviously invested much time, energy, and zeal.

I had covered scientific presentations before and interviewed experts from many fields, but the sheer number of international experts, the cutting-edge technology, and the breadth of the scientific material were truly impressive.

Besides letting me speak with esteemed radiologists of every stripe, the conference allowed me to finally meet my far-flung colleagues from the U.K., Washington, DC, and Wisconsin, who were all gracious and helpful in sharing their expertise about all things radiological.

The Windy City was frigid but very cosmopolitan, and Chicago was still on an "Obama high." Evening receptions, such as the one held at the Art Institute of Chicago, were fun and lavish: They featured fine food and libations, live music, a distinguished, well-dressed crowd, all set in gorgeous venues festooned for the holidays.

I returned to San Francisco tired but filled with newfound excitement and enthusiasm to write about radiology's dynamic role in healthcare.

Articles

International experts, cutting-edgetechnology impress RSNA newbie

Two years ago, my 70-yearold father-in-law decided his 3500-square-foot house was too big and his household needed to downsize. They bought a lot on the edge of our farm and built their new house of 5700 square feet.

I resist correcting him on the meaning of “downsize” for several reasons. First, it is very convenient when your eight- and 10-year-old sons can drive themselves to the baby-sitter in a go-cart. Second, their six-car garage includes a complete shop with a 10-ton auto lift. Finally, there is the 11th commandment, “Thou shalt not criticize thine in-laws if thou wantest anything from thy spouse.”

The house has a kitchen fit for Martha Stewart and a shower the size of her jail cell. My boys love it. It has handheld sprayers and nozzles on the walls and ceiling. While I like a shower big enough for two, room for eight does not really appeal to me. Still, if it makes the boys want to spend Friday night at grandpa's, I love it.

Recently, our hospital hired a new CEO. She has brought fresh approaches, new ideas, and new challenges for our hospital and my department. This is a good thing. It would be a great thing if I weren't facing so many different challenges and changes already. It seems everywhere I turn there are forces aimed at my practice, like those nozzles in the showersaurus.

The past few years have seen an onslaught of articles and editorials from radiology pundits on the impending demise of the general radiologist. Most are published by the radiology alphabet groups (the ACR, ARRS, RSNA), which seem to be dominated by subspecialists.

That doesn't mean they are wrong, they just need to be taken with a grain of salt.

Teleradiology has made access to subspecialists easier but not mandatory. I believe I add a lot to the overall care in my hospital by my presence. I answer questions about “the best test” for a clinical problem, and I give patients a professional to deal with when they have questions.

But it doesn't take much imagination to picture my eight-person group replaced by three onsite generalists and a network of subspecialists. The snag may be that this network wants to be paid.

This detail is another nozzle aimed at my back. In our hospital, the computer codes patients by insurance category. The fastest growing group is “sp” for self-pay, which, translated into English, means nonpay. How many teleradiology networks accept nonpay? Do the network neuroradiologists really want to read the 2 a.m. C-spine series on the migrant farmworker for free? As the economy worsens and the uninsured population rises, we'll see if the publicly traded nighthawk companies and specialist networks volunteer their services.

Fortunately, we have a new president. The poor guy is walking into a storm of guano, and he is expected to fix it all. How will President Obama handle healthcare? He is a lawyer. His closest friends are lawyers. We know upfront which issue in healthcare will not be fixed.

What about the rest? I like the idea of universal health insurance, and I hope he can make it happen. But I wonder if this will help my income or hasten the demise of general radiology. Finally, there are those guns aimed at us by other specialties who want to do their own imaging.

This is the most fixable cause of rising healthcare costs in the U.S. Just stop self-referrals and watch imaging volumes stabilize. And it wouldn't hurt general radiology.

The future of radiology, especially general radiology, is getting harder to predict, but given all the forces in play, I suspect we may get hosed.

Two years ago, my 70-yearoldfather-in-law decided his3500-square-foot house wastoo big and his household neededto downsize.

Radiology gets sent off to the washhouse

Studies examining the clinical histories of patients who developed nephrogenic systemic fibrosis after treatment at distinguished teaching hospitals in New York City and Vienna suggest that gadoliniumbased contrast dose and post-MRI hemodialysis are keys to controlling the rare but deadly skin disorder.

NSF is possibly associated with gadolinium-based MRI agents administered to kidney disease patients.

The first case was documented in early 1997. The International Center for Nephrogenic Fibrosing Dermopathy Research at Yale University had identified more than 300 confirmed cases as of January 2009.

It is not clear if any new cases were reported last year, according to Dr. Emanuel Kanal, a professor of radiology at the University of Pittsburgh.

Some medical device and pharmaceutical companies report that no new cases arose, he said in an interview, but NSF patients have said during online discussions that they are aware of new cases.

Studies presented at the 2008 RSNA meeting shed light on how to avoid NSF, according to Dr. Martin Prince, a professor of radiology at Weill Medical College of Cornell University.

“Though we don't fully understand NSF, we have learned enough to virtually eliminate it as a concern,” he said in an interview.

Prince presented results at RSNA 2008 from case reviews involving 83,121 patients at Columbia Presbyterian Medical Center and Cornell New York Hospital from January 1997 to July 2007.

Of 31 biopsy-confirmed NSF cases at the two hospitals, Prince identified 15 in which the patient received gadolinium contrast at one of the two facilities.

On the basis of that evaluation, Prince found that a single dose of gadolinium-based contrast media is safe. No NSF cases were associated with 74,124 patients who received a single dose.

For dialysis patients who have estimated glomerular filtration rates (eGFR) of less than 15 mL/min, no new cases appeared after the hospitals began administering 0.1 mmol/kg doses of gadolinium-based contrast when a contrast agent was recommended for MRI and same-day dialysis was performed on these patients.

The study found that the NSF incidence rate dropped from 8.8% to 0.4% for patients with an eGFR of less than 15 mL/min when dialysis was performed within two days of contrast administration.

High contrast dose was also a major contributor. Ten cases were associated with the administration of a single dose of at least 32 mmol/kg to 5119 patients at the two hospitals. Their incidence rate was 0.2%. No cases were reported for the 5725 patients who received a standard dose.

In a separate study, researchers at the Medical University of Vienna Medical Center established a positive association between cumulative dose of gadolinium-based MR contrast media and NSF from a 10-year review of records for 552 patients with endstage renal disease.

Dr. Gertraud Heinz-Peer and colleagues examined the prevalence of NSF among 195 dialysis patients exposed to gadolinium-based contrast in 325 MR procedures.

Five cases followed gadoliniumenhanced MR. They developed symptoms an average of 5.4 months after their last gadolinium infusion. Diagnosis was confirmed with a deep skin biopsy or medical or histopathological records. Four of six patients were on hemodialysis. One patient showed NSF symptoms 18 months before CE-MRI. One patient died.

The researchers established no correlation between NSF onset and patient age or gender; underlying kidney disease; type of therapy; serum phosphate, calcium, or iron concentrations; number of gadolinium contrast administrations; and mean residual renal clearance.

Patients who developed NSF were administered an average 63 mL of contrast compared with 30 mL for patients who did not develop the disease.

Other significant cofactors were a history of thrombosis, recent surgery, and a combination of hemodialysis and peritoneal dialysis, Heinz- Peer said.

Even with additional experience with NSF, Kanal argues that more information about the disease is needed before physicians can count on preventive strategies to eradicate it.

In contrast to Prince's position, Kanal disputed that single dosing and hemodialysis guarantee patient protection.

Numerous exceptions appear in the peer-reviewed literature showing that NSF can arise after a single dose or among patients who underwent dialysis within 24 hours of contrast administration, Kanal said.

International consensus emphasizes avoiding the use of gadoliniumbased agents for kidney disease patients if contrast is not necessary and minimizing its use when it is required, Kanal said. In addition to partial dosing, dialysis patients should be dialyzed immediately following MRI.

It is also commonly thought that patients with reduced kidney function who are administered macrocylic agents, such as ProHance, are less likely to develop NSF than patients who received linear gadolinium-based compounds, such as Omniscan or Magnevist, the two agents associated with most of the NSF cases.

Overall, physician vigilance has proven to be the most powerful medicine preventing NSF, Kanal said.

Though acute renal failure can still escape detection, radiologists are generally more aware about the presence of renal disease and more willing to either reduce dosages or perform noncontrast MRI for such patients, or to switch to an agent that appears to be less closely associated with NSF development.

“I think that these factors have played crucial roles in the marked decrease in the incidence of this disease that we have seen to date,” he said.

Studies examining the clinical historiesof patients who developednephrogenic systemic fibrosis aftertreatment at distinguished teachinghospitals in New York City andVienna suggest that gadoliniumbasedcontrast dose and post-MRIhemodialysis are keys to controllingthe rare but deadly skin disorder

Clinicians identify tacticsthat minimize risk of NSF

I read with interest your article on nephrogenic systemic fibrosis and the “heavy collateral damage” that radiologists face due to the off-label uses of gadolinium agents and subsequent development of NSF in some patients (“

Radiologists meet with heavy collateral damage

,” December, page 23). While the points are largely difficult to dispute, I just want to note that there is a lot that we do in interventional radiology that is off-label, such as the way that stents are utilized (FDA concerns noted).

The rhetoric in the article is a bit inflammatory, suggesting that radiologists are to be shamed for ignorance or worse, when most are likely to be well educated and following standards of care that are taught by leaders and mentors in our fields. A similar type of discussion has been going on now for some time now regarding the uses of ionizing radiation in CT scans, with polarizing viewpoints that at times seem more like pointing fingers than actually facilitating constructive dialogue. A toning down of the accusatorial commentary may be appreciated by some of your readers.

Jason Smith, M.D., Assistant Professor, Department of Radiology
 Loma Linda University, Loma Linda, CA

I read with interest your article on nephrogenic systemic fibrosis and the “heavy collateraldamage” that radiologists face due to the off-label uses of gadoliniumagents and subsequent development of NSF in somepatients

Edgy NSF article may have gone too far

X-ray, the past and current workhorse in radiology, still garners the majority of all imaging studies. But when it comes to new advances, the modality tends not to generate the excitement associated with the higher tech alternatives of CT, MR, and PET.

That may have changed a bit with the 2008 RSNA meeting. A new generation of portable digital radiography detectors shouldered its way onto the stage and drew a lot of attention on the exhibit floor. These detectors, which can operate independently both in and outside of the radiography suite, promise new economies for those who have embraced DR and those yet to do so.

They also offer big improvements in workflow and, in many settings, a big improvement in the safety of operations.

To date, most DR systems have been confined to specific locations and setups, usually a wall- or table-mounted bucky that captures data and sends them to a PACS. Computed radiography provided the flexibility and portability of film while allowing a transition to digital. But unless you had a CR reader where the scan was captured, the techs most often wound up running it back to a place where it could be viewed and then transmitted to the PACS for reading. Without immediate feedback, problems can occur:

• Quality assurance. What if the scan was over- or underexposed, or missed the region of interest? The tech then faced the difficult question of whether to go back and repeat it on a crowded schedule or go ahead and send it through, hoping the radiologist wouldn't complain. If the scan was taken in the intensive care unit, the tech may have forgotten to move aside the ECG leads, thus rendering the image unreadable. Even if CR plates can be read near where they were taken, reading those plates takes time that adds up.

• Patient identification. A variety of systems, usually paper-based and sometimes including yellow sticky notes, were designed to associate the cassette with the patient, but they were not failure proof. Sticky notes or other papers got mixed up as batches of cassettes were processed.

Only recently have DR plates been rugged or light enough to move around. Now they are, and by matching CR's portability, they may offer a good option for many facilities. They can more easily be placed under a bedridden patient's back or held in place to image the head or limb.

Particularly attractive is the notion that they can now go where they are needed, capture images that can be checked for quality in a matter of seconds, and then be transmitted into a PACS.

This digital convenience should also make it possible to more effectively capture patient demographic data and associate it with the image in the PACS. Dr. David Hirschorn, director of informatics at Staten Island University and an editorial advisor for Diagnostic Imaging, said he can envision a scenario where the portable DR system is actually connected to the patient's wrist tag and narrows down the DICOM modality work list to only exams ordered for that patient, preventing the exam from being mislabeled.

This process is not without some challenges. There will be networking issues involved in transmitting data-intensive x-ray images over wireless-or even wired-networks in hospitals. Many hospitals have invested in CR and have thoroughly mastered all the quality and workflow issues involved, so a new investment may not make sense for them. Further, much of what I've described above could be accomplished with portable x-ray machines that have portable wireless CR readers.

Still, it seems fairly clear that the idea of portable and wireless DR detectors marks a significant potential gain and some new thinking about how to manage x-ray imaging in a busy hospital environment. That's an important advance at a time when efficiency and a reduction in medical errors are being demanded.

X-ray, the past and current workhorse in radiology,still garners the majority of all imagingstudies.

Game changes with new portable and wireless digital radiography

Researchers at the University of Texas M.D. Anderson Cancer Center in Houston have confirmed what mammographers have long suspected: Digital screening mammograms may take twice as long to read as film.

Dr. Tamara Miner Haygood and colleagues clocked four radiologists as they interpreted 268 digital and 189 screen-film mammograms. They compared interpretation times for such variables as BI-RADS classification or availability of older soft- or hard-display comparative studies. Researchers also noted individual radiologists’ modus operandi. They found that it took all readers an average of four minutes to interpret digital screening mammograms but only slightly more than two minutes to read film studies. They published their findings in the January issue of the American Journal of Roentgenology.

Study confirms: Digitalmammo lengthens read time

Researchers were stunned when preliminary results of an ongoing study showed that patients who undergo vertebroplasty may die sooner than patients with vertebral fractures who do not undergo the procedure.

“It doesn’t make any sense to us,” said coauthor Dr. Robert J. McDonald from Mayo Clinic’s Medical Scientist Training Program.

McDonald and colleagues in Rochester, MN, compared survival rates of patients treated with vertebroplasty for vertebral fractures with those treated conservatively. A preliminary data analysis suggested the former had a significantly reduced life expectancy when compared with the latter.

The study remains a work-in-progress, however, and McDonald advised against jumping to conclusions before final results are in. He released the preliminary findings at the 2008 RSNA meeting.

Vertebroplasty data hint atnegative effect on survival

Despite encouraging earlier results, the much-awaited follow-up phase III DIAS-2 trial on ischemic stroke patients treated with desmoteplase after the onset of symptoms did not show any improvement in clinical response at 90 days.

In previous investigational trials, the new drug, which is derived from vampire bat saliva, was shown to have a highly specific action and to be safe and effective over a longer treatment window than tissue plasminogen activator (tPA). Dr. Werner Hacke and colleagues at the University of Heidelberg in Germany assessed patients with acute stroke who were randomized within three hours of symptom onset to receive desmoteplase or placebo. There were no statistically significant differences in response rates between low/high dose of desmoteplase or placebo (47%/36% versus 46%).

Findings appeared in the February issue of The Lancet Neurology.

Despite encouraging earlier results, themuch-awaited follow-up phase III DIAS-2trial on ischemic stroke patients treated withdesmoteplase afterthe onset of symptomsdid not showany improvement inclinical response at90 days.

Vampire bat thrombolytic study findings disappoint

An incidental finding of multiple sclerosistype lesions during brain MRI is no fluke. A new study has found that some patients develop the physical symptoms of the disease within five years of the abnormalities' discovery on MRI.

The study involved 44 subjects with different indications for brain MR who showed abnormalities similar to those that occur in MS. The researchers monitored the participants to determine whether they developed the disease. About a third of participants developed MS symptoms within approximately five years. Investigators noted, however, that more research is needed to fully understand the correlation between these abnormalities and MS.They published results in the Dec. 10 online issue of Neurology.

An incidental finding of multiple sclerosistypelesions during brain MRI is no fluke. Anew study has found that some patientsdevelop the physical symptoms of the diseasewithin five years of the abnormalities'discovery on MRI.

Incidental finding on MRIpoints to multiple sclerosis

University of California, San Diego scientists are developing a new imaging modality that will study the body/brain dynamics of humans engaged in normal activity.

The Swartz Center for Computational Neuroscience at UCSD is creating the concurrent brain and body imaging modality MoBI (Mobile Brain/Body Imaging) under a four-year $3.4 million research grant from the U.S. Navy Office of Naval Research. According to principal investigator Scott Makeig, Ph.D., the insight provided by fMRI could be used by MoBI to “read” motivations behind actions by performing cognitive monitoring. If successful, the technique will allow functional studies outside the confined laboratory setting, such as screening the brain activity of workers in stressful situations.

3D neuro imaging techniquerealizes Orwellian vision

Diagnostic imaging utilization rates don’t just swing wildly across the 10 Medicare regions. According to Thomas Jefferson University researchers, the areas with the highest utilization rates also have the lowest percentage of radiologists.

TJU radiology chair Dr. Vijay Rao and colleagues looked at trends in noninvasive imaging services over a five-year period ending in 2006 using the Medicare Part B feefor- service database. In 2006, utilization rates per 1000 beneficiaries ranged from a high of 4532 in the Atlanta region to a low of 2901 in the Seattle region. Radiologists’ share of the imaging services provided ranged from 69% in the Boston region to a low of 58% in the Atlanta region. Plotting radiologist share against the overall utilization rates showed that the higher the utilization rate, the lower the percentage of radiologists providing the services. Rao released findings at the 2008 RSNA meeting.

Diagnostic imaging utilization rates don’t just swing wildly across the 10 Medicare regions.

Imaging utilization increaseswhere radiologists wane

Conventional radiography/fluoroscopy has always been cumbersome.

The equipment is big and bulky, and the examination is time-consuming, as technologists wrestle with cassettes between exposures and wait for film to develop.

The introduction of digital flatpanel detectors is not only streamlining the configuration of R/F rooms and simplifying throughput. It is also improving the detection of pathology, reducing radiation dose, and increasing patient comfort. It is assessing motion in real-time as well, so radiotherapy can be delivered in the highest tolerable dose to the most precisely defined tumor target.

Flat-panel detectors from major suppliers such as Varian and Trixell can be found in R/F systems by GE, Hitachi, Philips, Shimadzu, Siemens, and Toshiba.

One advantage of the digital flat panel is its large area. In contrast to image intensifiers, which have a maximum size of 16 inches, general-purpose flat-panel detectors are 14 x 17 or 17 x 17 inches. The larger coverage means fewer exposures and faster exam time.

“Doctors can catch live motion video, take exposures here and there, and do all of the spot filming they want on one exposure. Generally in the past, techs would have to step in and do a series of five or six exposures.

Imaging has gotten much faster because there is no cassette handling. Now the radiologist pushes a button, the exposure is made, and a few seconds later, the radiologist gets the image and can go on to the next. He or she doesn't have to switch between the radiography and fluoroscopy world,” said Tom Truesdell, manager of radiography/fluoroscopy for Siemens Medical Solutions. Speed means not only better throughput; it also improves lesion detection.

“The response time of a digital flatpanel R/F system is very fast. You are on rapid fire taking images. So you are more likely to capture the pathology you are seeking. You also know right away whether you have the image you want,” said Dr. Edward Lubat, managing partner of Radiology Associates of Ridgewood in Waldwick, NJ.

Unlike image intensifiers, which are not geometrically accurate and produce pincushion distortion at the edges, flat panels have uniform image quality from edge to edge. Flat-panel technology also has higher detective quantum efficiency (DQE) than image intensifier charge-coupled device camera systems, which translates into superior small area contrast resolution and improved visibility of small vessels and catheters, according to Dr. Rick Colbeth, vice president of flatpanel technology for Varian.

Flat-panel technology has greatly improved image quality on the fluoroscopy side. As a result, radiologists in Europe are finding that they can use lower-dose fluoroscopy and still capture diagnostic events without needing to switch to high-dose, highresolution radiography. Prof. Yvan Palmers, director of imaging services for Ziekenhuis Oost-Limburg in Ghent, Belgium, has acquired a diagnostic- quality image in the fluoroscopy mode that used 30% of the radiation dose required by the traditional radiography mode.

Flat panels are smaller and lighter than image intensifier CCD camera systems, so digital R/F systems tend to be more maneuverable. Added space beneath the system allows the table to be lowered to a 19-inch height for easy and more comfortable patient transfers. Reduced ancillary equipment and increased distance between the table and the imaging tower facilitate patient positioning. If it weren't for flat-panel technology, real-time gating during imageguided radiation therapy would be impossible, said Dr. Todd Scarbrough, medical director of Melbourne Internal Medical Associates Cancer Center in Melbourne, FL.

Now that a flat-panel device has been attached to a linear accelerator, Scarbrough can track the movement of a fiducial metallic marker on the surface of a tumor as it moves with the respiratory cycle in order to synchronize the release of a beam of radiation.

“We can't move the radiation beam around, but we can find out where the tumor is and turn the beam on or off depending on the respiratory cycle. It's important for us to be exceedingly accurate with how we delivery radiotherapy, and flat-panel imaging lets us do that. It allows us to decrease side effects and go to a higher dose because we are confident about where the radiation is going,” Scarbrough said.

Conventional radiography/fluoroscopyhas always been cumbersome.

Diagnostic Imaging Vol 31 No 2