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Rad-View: Generic Contrast Agents 

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 CT modality focus page provides information, videos, podcasts, and the latest news about industry product developments, trial results, screening guidelines, and protocol guidance that touch on the use of CT across the healthcare continuum, from various cancer screenings, such as lung and colon, to cardiothoracic imaging, to appendicitis, and more.

When it comes to brain imaging, functional MRI – commonly called fMRI – is considered the gold standard. However, it can be costly, time consuming, and come with several restrictions that can prohibit use with certain patients. 

In recent years, investigators have been searching for a different brain imaging method that can side-step these problems and potentially provide better quality scans at the same time. Researchers from the University of Southern California Keck School of Medicine and California Institute of Technology recently succeeded. They’ve developed functional photoacoustic computed tomography (fPACT) – a technique that works by emitting a laser beam of light into the area being imaged. 

Drs. Charles Liu and Jonathan Russin join me to discuss the differences and benefits with fPACT.

Drs. Charles Liu and Jonathan Russin discuss the benefits and potential of fPACT, the alternative to functional MRI.

The Reading Room: Potential fMRI Alternative -- fPACT

COVID-19 halted all cancer screening services at the beginning of the pandemic, and slowly those scans have become more and more available -- but, not necessarily for everyone.

In many instances, racial and minority patients continue to face the same healthcare disparities that made it difficult for them to access the services at the outset. Now, the fear and trepidation associated with the pandemic are layered on top. 

Despite these difficulties, there are things healthcare institutions and providers can do to help. In this episode of 

 spoke with Shalmon Kalnicki, M.D., chair of radiation and oncology at Montefiore and Albert Einstein College of Medicine about the challenges these patients continue to face with cancer screenings. Not only did he share with us how COVID-19 has impacted this existing problem, but he also outlined the steps institutions can take to improve this situation.


In this podcast episode, Dr. Shalom Kalnicki, from Montefiore and Albert Einstein College of Medicine, discusses the disparities minority patients face with cancer screenings and what can be done to increase access during the pandemic.

The Reading Room: Racial and Ethnic Minorities, Cancer Screenings, and COVID-19

Current lung cancer screening guidelines could be overlooking African American smokers who are at risk for developing lung cancer.

According to a study published in the Sept. 15 

Journal of the American College of Radiology

 the current guideline based on the 30-pack-year threshold sets the bar too high, as most African American smokers self-report a less than 30 pack-year history. This determination sounds an alarm bell because African Americans have a high incidence of and worse outcomes from lung cancer.

“There is growing concern that there are healthcare disparities in lung cancer screening guidelines and programs,” said lead study author Anupam Basu, M.D., a diagnostic radiologist in Cook County Health. “Evidence suggests that the National Lung Screening Trial (NLST) and Preventive Services Take Force inclusion threshold of a 30-pack-year smoking history excludes a portion of African American patients at risk for lung cancer.”

Even though African Americans are more significantly impacted by lung cancer, the team said, they still only account for 4 percent of the NLST. Based on existing evidence this group does have a smoking duration history similar to their white counterparts – but, they actually smoke fewer packs a day. Consequently, they have a shorter pack history – the benchmark providers use to determine who should undergo lung cancer screening.

The team, therefore, suggested lung cancer screenings would be much more accurate and impactful if they adopted a 20-pack-year threshold.

To subscribe to The Reading Room podcast, click 

To identify a threshold that could better identify more African American smokers who could benefit from lung cancer screening, the team retrospectively reviewed low-dose CT scans from patients in their public hospital between September 2017 to December 2019. 

All total, they reviewed data from 784 patients, 57.5 percent of whom were men with an average age of 62. The majority were African American (66.2 percent), followed by white (20.4 percent), Hispanic (8.3 percent), Asian (4.8 percent), and Native American (0.3 percent).

Of the group, three-quarters – 75.5 percent – were active smokers, and just more than half – 51.5 percent revealed a pack history of fewer than 30 years. Total years smoked did not vary much by race, the team said. But, the African American experience was somewhat different, and it painted a grim picture.

“African Americans smoked fewer packs per day and had fewer pack-years compared with other races,” the team said. “African Americans were more likely to be active smokers but also more likely to report [less than] 30 pack-years compared with other races.”

Low-dose CT findings determined that lung cancer incidence did not vary by race, but African American had an incidence of 2.5 percent while whites experience 1.9 percent. Fortunately, the majority of cancers identified (75 percent) were Stage 1, and all patients had the cancerous tissues successfully removed with surgery.

Looking at lung cancer diagnosis specifically in the context of smoking brought more bad news. African Americans were the only race diagnosed with lung cancer when their self-reported pack-year history was less than 30. For smokers in this group with more than 30-pack-year histories, the incidence rate was 2.2 percent. For those with less than 30 years, it was 2.7 percent.

“We are concerned that the 30-pack-year threshold in the African American population may exclude a portion of patients who are still at risk for lung cancer,” the team said. “We propose prospective study of African Americans with [less than] 30-pack-year histories to determine the potential benefits and harms of [lung cancer screening] in this unique underserved population.”

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

In this podcast, Dr. Anupam Basu from Cook County Health in Chicago discusses the 30-pack-year threshold for lung cancer screening that overlooks at-risk African American smokers.

The Reading Room: Lung Cancer Screening Misses At-Risk African American Smokers

Lung injuries caused by vaping leave signature marks on CT scans, a follow-up study has revealed, arming radiologists with the details needed to potentially make more accurate diagnoses and help patients avoid unnecessary biopsies.

 a team led by Michael Gotway, M.D., a radiologist at the Mayo Clinic in Arizona, laid out their findings that show these lung injuries – called EVALI (electronic cigarette or vaping product use-associated lung injury) – produce patterns on chest CT scans that correlate with previously observed pathological findings.

The first reports of EVALI surfaced last year from the Centers for Disease Control & Prevention. Within the first six months after this report, almost 3,000 EVALI-related hospitalization were recorded, as well as 68 confirmed deaths. Almost all patients present with complaints of shortness-of-breath, chest pain, and constitutional symptoms that can resemble viral illness. The non-specific nature of these symptoms can make an accurate diagnosis difficult.

 Chest Imaging Reveals Traits of Vaping-Related Lung Injuries in Teens

Based on their findings, he said, 96 percent of patients exhibited multi-focal or diffuse ground-glass opacities and consolidation that involves most or all lobes bilaterally and could involve mild interlobular septal thickening and subpleural sparing. As the illness evolves, imaging findings can suggest mild architectural distortion, intralobular lines, lobular distortion, and traction bronchiectasis.

These findings can be particularly helpful, he said, when providers are imaging younger patients with chest pain and shortness-of-breath. In those cases, a diagnosis of EVALI should be strongly considered.

Even though patients may be reticent to admit they are vaping, he said, if a radiologist recognizes one of these patterns on CT, he or she can advise the clinician, potentially leading to a nicotine metabolite test and further questions about exposure. Employing that approach could help patients avoid the invasiveness, time, expense, and risk associated with unnecessary biopsies.

“These radiological findings will be especially beneficial to physicians to help them determine potentially less invasive treatment options,” Gotway said. “We could potentially make that diagnosis non-invasively through cooperation with our clinical colleagues. By alerting them to a scan pattern that is suggestive of the possibility of EVALI, we may actually save patients from having to meet a surgeon.”

Michael Gotway, M.D., cardiopulmonary radiologist with the Mayo Clinic, discusses the signature signs of EVALI on CT scans in this podcast.

The Reading Room: Signature Signs of EVALI on CT

[[{"type":"media","view_mode":"media_crop","fid":"8165","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_9348676445430","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"213","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: left;","title":" ","typeof":"foaf:Image"}}]] Bridging the two complementary modalities of PET and MR has advantages over PET/CT, as a lower dose and more differentiating modality. That's according to Osman Ratib, MD, PhD, FAHA, professor and chief of nuclear medicine in the Department of Radiology and chairman of the Department of Imaging and Medical Informatics at the University Hospital of Geneva. His orgnanization was an early adopter of PET/MR with Philips’ Ingenuity TF, which received FDA clearance in November 2011.

The system includes two devices separated by about 10 feet with a rotating table so the patient can be scanned in the same position in each machine. Data are merged via software. In this podcast, Ratib discusses the advantages of this hybrid modality, what the transition was like for hospital staff, and the future of PET/MR.

Osman Ratib, MD, PhD, FAHA, professor and chief of nuclear medicine in the Department of Radiology  at the University Hospital of Geneva, discusses the advantages and future of the hybrid PET/MR modality.

Podcast: Advantages of Hybrid PET/MR

spoke with Dr. Johnsey Leef III, a radiologist with Charleston Area Medical Center in Charleston, WV, about how the industry is responding to the call for lower dose imaging and what his department is doing to address the issue.

Diagnostic Imaging spoke with Dr. Johnsey Leef III, a radiologist with Charleston Area Medical Center in Charleston, WV, about how the industry is responding to the call for lower dose imaging and what his department is doing to address the issue.

Podcast: A Conversation about Lowering Radiation Dose

The Pulmonary Embolism (PE) Triage and Notification (PETN) module with RapidAI’s RapidPE platform reportedly demonstrated over 90 percent sensitivity and specificity rates for detection of central PE on computed tomography (CT), according to multicenter study findings presented at the 9th Annual Pulmonary Embolism Symposium.

New Multicenter Study Shows Viability of AI Tool for Detecting Central PE on CT

The use of automated detection of large vessel occlusion on computed tomography (CT) through artificial intelligence (AI) software reportedly led to an 11.2-minute reduction in triage time from the completion of imaging to initiation of endovascular therapy, according to newly published research.

AI Software for CT Detection of Large Vessel Occlusion Facilitates Reduction of Triage Time for Acute Stroke

Over 80 percent of head and neck computed tomography angiography (CTA) exams performed in the emergency department had no actionable findings for patients with non-focal neurologic complaints, and 67 percent of the exams were ordered by non-physician practitioners (NPPs), according to a newly published study.

Study Shows Significant Overutilization of Head and Neck CT Angiography in the ER

Indicated for the triage and notification of obstructive hydrocephalus on non-contrast brain computed tomography (CT), the artificial intelligence (AI)-enabled software is reportedly the first radiology triage modality to obtain the Food and Drug Administration’s (FDA) Breakthrough Device Designation.

FDA Clears AI Software for CT Detection and Triage of Obstructive Hydrocephalus

Abnormal findings on coronary computed tomography angiography-derived fractional flow reserve (CCTA-FFR) are associated with 3.2-fold higher risks of all-cause death or spontaneous myocardial infarction (MI) in patients with new-onset stable angina pectoris and coronary stenosis, according to newly published research.

Study: CCTA-Derived Fractional Flow Reserve Can Predict MI and Mortality Risks in Patients with Stable Angina

The recent Radiology Partners (RP) publication 

Neuroradiology and Stroke Clinical Pathway 

offers a practical best practice guidance for radiologists and technologists on the use and reporting of neuroimaging, including head and neck computed tomography angiography (CTA), cerebral perfusion CT and brain magnetic resonance imaging (MRI), for stroke patients.

In a recent interview, Vivek Bansal, M.D., makes it clear that the publication is geared toward achieving a consistent baseline standard for providing a high level of stroke imaging and care regardless of the size or resources of the given facility.

“We’re not rewriting the guidelines but (trying to) take some of these other hospitals or smaller practices, (facilities) with limited resources, or maybe don’t have neuroradiology specialty coverage, and bring everybody up to some baseline level to where we can say we’re giving optimal stroke care no matter where you go at any RP facility,” noted Dr. Bansal, a Houston-based neuroradiologist who serves as the national subspeciality lead for neuroradiology for Radiology Partners.

Emphasizing the constantly evolving nature and urgency of stroke care, Dr. Bansal said radiologists need to be active members of the stroke care team.

“In particular with stroke, we can’t be radiologists locked in our little reading rooms separate from everybody else and just putting out reports,” maintained Dr. Bansal. “We have to be part of the team … We have pushed to get really granular data and really help find the trouble points and fix them. That’s the key. When you do that, you get a lot of trust from your hospital system, and you can actually make processes better, and do better for the patients.”

(Editor’s note: To download the Neuroradiology and Stroke Clinical Pathway guidance, 

For more insights from Dr. Bansal, watch the video below.

In a recent video interview, Vivek Bansal, M.D., discussed a recent Radiology Partners publication that offers practical tips and best practice guidance on CT and MRI neuroimaging for stroke patients.

Practical Insights on CT and MRI Neuroimaging and Reporting for Stroke Patients

 Continuing with this discussion on generics and additional resiliency, do you see any opportunities that remain in the field or unmet needs where there are additional opportunities for generics to enter the industry? 

 Contrast media is so critical for various imaging modalities now, although CT [computed tomography] and MRI [magnetic resonance imaging] are the high-volume users. But even in nuclear medicine, we use tracers, which is the contrast media, ultrasound, [and] we have contrast media available. A lot of image-guided therapies are being performed using contrast media. I feel that the success we will see from the use of generics on the CT and MRI side will translate into more opportunities in other areas on ultrasound, as well as in nuclear medicine for molecular imaging, [positron emission tomography] CTs, and so on. This will improve access to high-quality imaging globally. It will really improve the diagnostic standards globally. It will [also] benefit patients and referring private providers. Any ambiguity that exists because of lack of clarity on images can be overcome by use of contrast media. I think it’s a matter of time. We are at the inflection point with the 2 agents that are available. We will see a lot of activity over time; people will gain confidence, and there will be greater adoption of these agents. It might start at different parts of the world, and eventually it will lead to a moment of more generic agents that are available for other modalities beyond CT and MRI. It’s an exciting time. And as I said at the start, having more choices empowers individuals to make those decisions. Some of those motivations could be financial, other motivations could be just having access to safer and cheaper agents to improve care delivery.

 I don’t think I can say much better. It is an exciting time. And any means we have to improve the access and equity of imaging it’s both diagnostic and therapeutic benefits to not [only] the United States but [also] the entire world at large. I’m all for anything that can achieve those goals.

 I think branded agents, which have been there for several decades now, can continue to innovate in the premium segment. They can invest in areas of unmet need [with] more cellularly targeted or molecularly targeted agents. I think there will be a huge demand for those agents as we move in the era of precision medicine. Having those diagnostic capabilities, along with [information technology] informatics and [artificial intelligence] tools to integrate information with diagnostic imaging data, will be foundational to fundamentally transform care delivery from how it is practiced to more precision medicine. That is the future we all have envisioned. This way will motivate the companies with branded agents to invest in and innovate new contrast agents. To give you an example: On CT the side, we have seen so much progress on the image acquisition and recon with spectral, and now photon counting CT, but the real value of these techniques is with new contrast agents. The contrast is different than iodine, both oral [and] intravenous contrast media. We want different type of agents, different molecules [that] can be discriminated with using advanced CT techniques. Then we can envision the full potential of these advanced techniques. Currently, just the conventional contrast media remains a barrier for advanced applications of these techniques. There is a huge market there as well, so I don’t think anyone should feel insecure with the availability of generic market. If you look at pharmacology, if you look at media as drugs, there are generics available that people continue to use. The branded has their market continues to grow because they can invest a lot of those resources on research and development. I [don’t] think there will be winners and losers; there will be more winners. It’s all about how [well] you play this.

 That’s a great way to look at it. Dr Sahani, thank you so much for sharing your expertise with me and the audience today. We’ve all learned a lot from you, and I look forward to seeing the different pathways that our field and contrast agents in particular take in the future.

 Thank you, Dr Cavallo, for this time and for the opportunity to discuss this very important topic. It’s an exciting time, and I think we will continue to make major progress and all these options that are available just opens up new opportunities.

Transcript is AI-generated and edited for clarity and readability.

Joseph Cavallo, MD, MBA, and Dushyant Sahani, MD, discuss unmet needs in imaging modality technology and the contrasting agents used.

Unmet Needs in Imaging Modalities

 I’m going to start by throwing out some of the major points of emphasis from the ACR when they put out recommendations for the usage of contrast media during that supply shortage. Two of the major points were utilizing alternative agents, which includes generics, if available. The second one was identifying multiple vendors for supply. Then later in their document, they wanted to prioritize agents where high-volume vials were available because a lot of the lower-volume vials contributed to excessive waste or inefficient usage of a limited supply. I’d just like to hear a little about your experience with the contrast shortage and how you think the additional supply chain resiliency may be affected by these generic agents.

 That is such a great question and a nice segue into how contrast media are important but also are in a finite amount. If you rely on only 1 supplier, there can be challenges. The lessons I learned when there was a contract crisis is we are so dependent on our suppliers [being] well staffed, well resourced, and diversified in terms of their ability to provide or meet our needs. Second, I learned how important imaging techniques [are] and [the] value of contrast media. There was such an emphasis at the highest level in the health system to this crisis because our referring provider knows radiology is a gateway for facilitating care across the health system…whether it’s inpatient care, acute care, or outpatient elective care. 

One thing we had to do [was], first of all, create a partnership with our stakeholders and with our vendors or contrast supplier. That partnership is extremely valuable. We can have expectations in terms of what supplies [we will get, as well as] the timeline for that. I think that was essential. We also prioritized contracts you used based on patient’s risk, so we created a tiered system, [determining] who could get contrast media and where we can differ the use of contrast media to clinical judgment. We moved to using more of a noncontrast exam or MRI [magnetic resonance imaging] when it was appropriate.

Then it comes down to how we effectively use contrast media that was made available. One [way was by making] sure each site had enough volume of contrast media to meet the projections of CT [computed tomography] exam volume, prioritizing acute care first. Oncology was the other one, and inpatient care—these are areas we want to make sure are well resourced with contrast media. We created a framework of a team structure with good communication and sharing. [We] created a color-coded dashboard [that showed] where we [were regarding] our contrast media supplies. If we had 7 days [or more], or less than 3 days of contrast media, we gave a color of green, yellow, or red, depending on that. Then we acted on those urgencies based on the status of contrast media volumes at different sites. The third thing we did is made sure to optimize our protocols by exploiting some of the offerings of new technology [such as] multi-energy CT or a spectral CT, where you can substantially reduce contrast by amplifying the iodine signal through some image recounts. That allowed us to drop either dose per patient by 30 to 50 ml. Higher drops were seen in those with indication for city and geographies. Finally, we used an imaging bulk pack for contrast media. We had power injectors in our system that enabled us to use the imaging bulk pack, [so] we could reduce waste and have a higher throughput in those patients. It was a very complex challenge, but we learned a lot of things. The lessons I learned are: You need to be proactive in terms of checking your supplies, you need to be diversified where your supplies are coming from, and you need to have a great relationship with your vendors. Those relationships really are on display when you need their assistance…. [I also learned to give] autonomy to your team to make those decisions, [and have] great communication. Those were some of the lessons.

Now, what does it mean? The lessons we learned from that is you cannot take things for granted. You need to be prepared, and that’s where generic contrast media can fill that unmet need if you have those challenges. We are talking about challenges in the United States, where some of the supply is still prioritized. But if you look at disparities that exist in rest of the world, those challenges are much more severe than they were. I agree with what ACR has proposed. It was also common sense to ensure that we have various options available so we don’t compromise our care delivery.

 Those are great points. [Because] we were a victim of our own success, we needed to lean operations. And, just in time, inventory management is really good at cutting costs and avoiding unnecessary expenditures in times of normal operation. As we found out, they do not have a lot of flexibility in a time of disturbance, like we saw with the acute iodinated contrast shortage. Very good points, and a lot of stuff that people learned as an industry and as individual institutions.

Experts discuss discuss the American College of Radiology recommendations regarding the use of contrast media and their guidance related to the use of generics during supply shortages.

Contrast Media: American College of Radiology Recommendations

 I want to turn our discussion to the 2 generic agents that are now available in the US for imaging. One of those is an iodinated contrast iodixanol injection, and the other is an iodine-based MRI [magnetic resonance imaging] contrast, gadoterate meglumine injection. Have you had any experience with either of these 2 agents?

 I have experience with the branded agents. I have used both of them extensively, and I even did research on the iodixanol, but I don’t have experience with the generic agents. My overall thought process is that these agents have been in use for several decades now. I don’t anticipate any different outcomes when it comes to safety or the effectiveness, but I don’t have experience in using the generic agents myself. 

 I don’t either, yet. For those not aware, iodixanol generic was approved about a year ago, last July, and the gadoterate generic was approved less than a year ago, this past October. As you know, many hospital systems have vendor or supplier contracts that can be many months or even greater than a year. I imagine there will be a transition period as people would try to potentially move over and get first-hand experience with these.

 I completely agree with you. I think this space will evolve [and] people will gain trust. They will revisit their own contracts when it comes to contrast media. There might be changes in the pricing. More competitive pricing will be offered to the customer…. Some of these changes might start at other countries. And with more research, publication, and data on the cost effectiveness of some of the changes with or our use of generic agent, [that] will influence the future practices. I think it’s a matter of time. We are at the inflection point of those changes. If you look at what COVID[-19] has done to health care or practices, there is a bigger emphasis on operation, which is not only efficiency but also cost. All these factors will play a bigger role in decision-making in terms of the choice of contrast media and the contracts and how each practice would like to bring on those generic agents or not.

 We talked about the similarity of these generics with their branded counterparts. To your knowledge, would there be anything from a prescribing or administration point of view that technologists, diagnostic, or therapeutic radiologists themselves would have to know for effective utilization of these agents?

 When it comes to generic agents, as I mentioned, there is some tremendous similarity, meaning it’s the same molecule. The safety profile has been established for this these agents over decades, and there are millions of patients who have been scanned. Those elements are foundational to the use of contrast media. How you use it depends on individual preference and practices [and whether you have a] relationship with the vendors. ACR has a very clear position on this. ACR is important for the field of radiology because it sets up standards we need to adhere to, [to] ensure we practice high-quality diagnostic imaging and therapies to ensure we optimize care delivery. In that case, ACR has given some recommendations when it comes to the use of generic agencies. You want to make sure any generic agent meets a few expectations. One is the bioequivalence in terms of the pharmacokinetics—the contrast distribution, excretion—all those things are matches to the branded [agent]. Second is [whether] it [has a] similar safety profile. The third is effectiveness of the contrast media. Generally, most generics will meet those because they have been in use. They’re a similar type of molecule. It comes down to individual trust and confidence of practices or providers if you have the right motivation and needs to use the generic agents. I think some of the research that will come out with the use of generic might bridge some of the lack in confidence, if anyone has to decide [whether] generic agents are right for them, but it will come down to individual practices. 

When it comes to protocols, I would say the protocols might be similar if you’re using a similar dose. I don’t anticipate [many] changes there. If the concentration or volume is similar, then the protocols might be similar. One point I want to emphasize is [that] if you want to make any changes to your practice, those changes, after one has piloted, [must] be system wide. Otherwise, this creates tremendous confusion. A well thought-out approach, where the stakeholders are aligned. That means not only the administrators and physicians but [also] the technologists who are in the trenches. You don’t want to create any confusion. How patients are scheduled on Epic or in your reporting templates, sometimes the older contrast agent to details are listed by default in those templates. A lot of changes have to be made to ensure there is a smooth transition from a branded agent to a generic agent.

Joseph Cavallo, MD, MBA, and Dushyant Sahani, MD, discuss generic agents iodixanol injection and gadoterate meglumine injection for the use in imaging modalities.

Generic Contrast Agents

Let’s transfer our discussion over to the topic of generics. In general, the introduction of generics within the health care field serves to lower cost to the end user, and eventually it lowers prices for that drug class overall. An additional benefit of generics that we’ve seen throughout the health care field is an increasing number of manufacturers for specific compounds, which can add resiliency to the market supply. With that overview of generics for medicine in general, what do you have to add regarding this topic as it relates to the imaging field?

 The contrast media is important. We made a case of why it is important. Having a safe and effective contrast media is essential for strong diagnostic imaging exams. Having more choices with contrast media is equally important. If you look at the major health care imperatives nationally—even if you look at internationally—there are 3 big priorities. One is access to care, and you want to provide that at population level. Secondly, we need to provide consistency in care. The quality of care is provided at the population level. Third, we want to reduce the cost.

Having said that, we need to look at all options. How we can do that not only with appropriate use of imaging test and making sure one imaging, when ordered, is the most effective and we don’t have to order additional tests to provide answers to our referring physician. We also want to make sure the imaging test is targeted with the right protocols to answer patients’ or referring providers’ questions. We also want to make sure access is optimized, and that comes through availability of imaging techniques and contrast media, which is safe and available for use. Finally, if you have many options available, that leads to competition, [which] impacts cost…. Those things are important, and the best thing we do is if you have an agent, which is a copy of the original branded agent with a similar pharmacokinetic profile, and it has been tested extensively for its safety as well as effectiveness, then a lot of those barriers can be eliminated. Then you provide choices to health care providers in terms of what contrast media you want to choose, if cost is a bigger imperative. That is one way of using generic agents if it meets your own practice needs. Secondly, you are less constrained with supply chain issues or shortages with contrast media as the source has been diversified. I think there is clearly some wisdom, and we need to have those choices available. We sometimes focus only on our own health care here in the United States, but globally, cost is a bigger constraint and access to both imaging techniques and contrast media can be challenging. Generics can fill that unmet need.

 I agree with you. You mentioned cost and access, but I would add that anytime you’re talking to those 2 properties, it’s also an equity issue, whether that be within the United States or, as you mentioned, globally.

Experts discuss the concept of generics and how they have traditionally been utilized in the healthcare space.

Role of Generics in Imaging

 You mentioned some organ-specific imaging that is very reliant on contrast in the emergency department [ED]. Specifically, there are multiple exams that would not be possible without contrast. Namely, evaluation for pulmonary embolism and a lot of our stroke-centered, arterial cerebral imaging, just to name 2 quick examples. Going further into the contrast agents, have you noticed variations between the different agents, whether it’s different formulations of iodine-containing computed tomography [CT] contrast or gadolinium-containing MRI [magnetic resonance imaging] contrast?

That’s a great question. I would say there are differences in the formulation of contrast media and those differences come down to the pharmacokinetic, the distribution of the contrast media, their excretion pattern, and their intended target organs and safety profile. In general, I think there are differences even in CT contrast media where iodine is the main molecule, and it has been the main molecule for CT contrast media. We have seen different formulations and I feel, overall, when it comes to diagnostic performance—when you compare apples to apples in terms of the concentration of the contrast media, the iodine dose, and how you deliver the contrast media in terms of the protocol—they are pretty comparable. There might be differences in the safety profile of those contrast media, but in general, if you take all FDA-approved contrast media, they have a pretty robust safety profile. There might be differences between the different formulations of contrast media, and [the safety profile] might be exacerbated a little in patients who have inherent risk or fragile organs, [such as] liver injury, kidney disease, or [any] additional risk factors. They might have more differences [in] safety events in those patients. In summary, I would say there are a lot of similarities in terms of performance and safety profile, but there are also differences.

 In my experience, it’s not so much the agent that I’ve seen produce variation between imaging but more the physiology of the patient, or the specific delivery protocol, as you were talking about. Patients with heart failure or pregnant patients, for example, will often have some altered hemodynamics that can change the quality of the contrast enhancement. Those are usually more patient-inherent factors than something to do with the specific contrast formulation, as you mentioned.

 That’s a really accurate statement, If you look at outpatient imaging where the differences are not as much between patient types, the risk profile or the safety profile of contrast media is overall pretty comparable. Fortunately, [it is] rare to encounter any major serious adverse events with contrast media. I think we need to compliment the scientists who have discovered these agents and worked a lot to ensure they test the safety profile of the contrast media and the companies who have done a lot of trials to ensure [that] by the time the contrast agent is available and approved, it has met those safety and regulatory standards.

I think we are beneficiary of those benefits of the safe and effective contrast media, and I think we [can] extend all those benefits to our providers and patients and feel gratified that we are making a difference to care delivery. Radiologists all over the world are quite busy these days with the volumes, and it speaks a lot about the trust our referring physicians have in our imaging techniques, that…they have tremendous reliance on these imaging techniques for them to make those important decisions. It’s a mixed blessing at times when we are so busy, but we also see that volumes continue to rise. This is the trust of our referring physicians and safety profile of the contrast media. Because if you look at CT and MRI, I would say majority—when I say majority of exams for cardiovascular imaging, ED oncology imaging are done with using contrast media and [positron emission tomography] CT. Of course, it makes total sense. If the tracer is applied without that, you cannot do it. I would say 70% to 80% of exam would be not as effective if we did not use these good contrast media that we have available in the arsenal.

 Some of that safety comes from continued drug development and better formulations that have been introduced over the years. For example, with iodinated contrast, the early agents were very high in osmolality, and now we’re predominantly using low-osmolality agents that are only 2 to 3 times the osmolality of blood. We even have isotonic agents at this point.

Joseph Cavallo, MD, MBA, and Dushyant Sahani, MD, provide an overview of the different imaging technique protocols needed for contrast agents.

Contrast Agent Protocol

 Let’s move on to some information about contrast agents. In your experience, how big of an impact has the use of contrast agents had in your daily practice?

 Contrast agents have played such a big role, but somehow it is underappreciated and under-recognized, and I will elaborate that further. Since the time computed tomography [CT] scans and magnetic resonance imaging [MRI] [were introduced]—2 major modalities that have a big impact on health care—initially, just the fact that we [could] create these images and see inside the body was so fascinating. Very soon we realized we had limitations. What we could do with just the imaging technique and to amplify the image quality or provide that clarity to the anatomic details and tissues, contrast agents became extremely valuable. Some of the success we have seen in imaging modalities is heavily influenced by safe and effective contrast media both on CT and MRI. I think it has engendered with patients, and referring providers have allowed them to order these types of exams in the outpatient setting where you have less oversight compared [with] when it’s done in the [emergency department] or inpatient setting.

Contrast media made a big impact on the impact [that] these imaging techniques have on health care. Sometimes we don’t appreciate the nuance of the contribution contrast media had. If you look at liver imaging as [an] example, both CT and MRI have a big impact, but the protocols are influenced by what type of contrast media we deliver and how we acquire images. The timing becomes so important, and that influences a lot…imaging in the abdomen is through contrast media protocols. Not only that, as we saw these contrast media make a difference to our diagnostic capabilities, clinical colleagues’ expectations [also] evolved. They wanted more tissue diagnosis. They wanted to have higher reliance on imaging techniques so they [could] minimize interventions [such as] having a tissue diagnosis. Then we had molecularly targeted or cellularly targeted agents that came up, and we found value for all those contrast agents in really advancing care delivery. Contrast media [is] extremely important.

If you look at positron emission tomography CTs without having a safe and effective tracer like FDG, we can’t do anything. It’s a CT scan. Without that, you have no hybrid, physiologic, [or] functional imaging capability available. Contrast media is so integral to the value [that] imaging technique adds. And despite many advances we have seen on MRI, including diffusion techniques, contrast media continues to play a very important role. One point we sometimes forget is [that] we need to be cognizant of the workforce. Globally, the workforce in radiology is much younger, and you need to provide images that are so clear that you can have a level playing field when it comes to providing the diagnosis and support to the referring providers and having all those benefits for patients. Contrast media lends that clarity on those images. If you take contrast media out of a lot of these techniques, [you] will see tremendous variability in how care is delivered [and] challenges with diagnosis and misdiagnosis. [You will also see that] the reliance on imaging techniques will drop substantially.

Radiology experts discuss the role of contrast agents in imaging and the impact these agents have on image quality. 

Role of Contrast Agents in Imaging

Hello, everyone. Thank you for joining us today. This is 

TM program, titled “Radiologist’s View Into the Role of Generic Contrast Agents in Imaging Modalities.” My name is Dr Joseph Cavallo, and I’m an assistant professor of radiology and biomedical imaging at the Yale School of Medicine. Joining me today is Dr Dushyant Sahani, a professor and chair of radiology at the University of Washington. Thank you for joining me, Dr Sahani. Let’s get started.

 Great to have you. Just so we have a good baseline for anybody joining the discussion here, [let’s] start with some of the basics. You can introduce some of the various imaging modalities we’re going to be talking about today, [as well as] their importance as it relates to prompt diagnosis and treatment.

 That’s a foundational question, when we look at imaging modalities in the field of radiology. Today…health care has been fundamentally transformed due to advances in imaging techniques. These are not [only] relevant to giving an accurate and reliable diagnosis, but imaging is also being applied for treatment selection, decision-making, monitoring effectiveness of therapies, and prognosticating patients. A lot of research and education is also being influenced by all the advances we have made in imaging technologies, and the field looks so promising as we add computation and some of the new molecularly targeted therapies. The impact of imaging and its value continues to go up.

 Yeah, I agree. It’s a really exciting time to be in the field of radiology, and it’s one of the reasons I went into this field to begin with. Getting a little more specific, could you give some brief comments on specific types of imaging modalities, specifically computed tomography [CT] scans and magnetic resonance imagings [MRIs], [as well as] some of the specific importance of each of those modalities?

 That’s a really great question. If we look at health care today, and you look at many important specialties, you realize that imaging is a gateway to care delivery. There are no major decisions being made without availability of imaging. CT has made a big impact to the progress of health care…. Certain medical specialties’ progress wouldn’t have been possible without availability of accurate, safe, and reliable imaging techniques readily available at the site of care delivery. Take acute care, for example. The whole patient triage and interventions is heavily based on imaging. I would say close to 70% of patients who come through the [emergency department] get some form of imaging. That shows you how much our referring physicians trust these imaging modalities to make the critical decision-making that has to be timely [and] more actionable for the specific task at hand. If you look at other specialties [such as] cardiovascular imaging, the whole field hinges around progress we have made on diagnostic imaging that has influenced therapies. A lot of oncologic innovations have happened because we have very high-quality imaging—whether it’s MRI, CT scan, some molecular imaging techniques [such as] positron emission tomography CTs—and the same trend continues now on the therapeutic side. Image-guided therapies rely heavily on the diagnostic imaging techniques that are available to help tailor treatment [and] precisely deliver those therapies, causing minimal impact to adjust a normal tissue and having more effective outcomes in these patients. In summary, imaging techniques like CT and MRI, but also other advanced imaging, has made a big impact to care delivery, research, innovation, and discoveries. They are also so fundamental to how modern medicine is practiced today.

 As an emergency radiologist myself, I can vouch for your statement regarding the ubiquity of specifically CT imaging on the patient care experience in the emergency department. Seems like just about everybody is needing some advanced imaging at this point, and it really helps us get the correct diagnosis from the start.

 Not only that, [but] if you look at how we are training the next generation of physicians and specialists, their training is heavily influenced by familiarity to not only what exams they order but [also] the value of these imaging techniques. Take…for example, neurology. The whole field—whether it’s stroke, tumor, or cognitive impairment—involves advanced imaging techniques. And imaging is not solely responsible for those decisions, but [it] is a major component where you integrate other information [such as] lab clinical imaging, then come up with more comprehensive or more holistic type of treatment delivery for these patients. It’s fascinating time…the progress in imaging and how it’s translating into success stories for patients on a daily basis. I feel so privileged to be part of that journey.

Joseph Cavallo, MD, MBA, and Dushyant Sahani, MD, provide a brief overview of imaging modalities and their importance in medical diagnosis and treatment.

Imaging Modalities in Medical Diagnosis and Treatment

For incidental pulmonary emboli (PE) findings on outpatient computed tomography (CT) scans, timely follow-up remains challenging due to daunting radiology worklists and potential health equity considerations, such as transportation access and language barriers, in high-risk populations.

However, in emerging pilot study research presented at the Society for Imaging Informatics in Medicine (SIIM) conference, Ali Tejani, M.D. discussed the implementation of an artificial intelligence (AI)-guided triage software for managing incidental PE findings on computed tomography (CT) scans.

Dr. Tejani and colleagues had impressive results with an approximately one-hour improvement in the median time to emergency department presentation and over a 13-hour difference in the median time to anticoagulant prescription retrieval.

(Editor’s note: For related content, see “

Emerging AI Tool Improves Worklist Triage and CT Detection of Incidental Pulmonary Embolism

Can AI Improve Triage of CT Pulmonary Angiography Exams for Acute PE?

However, Dr. Tejani emphasized that these results wouldn’t have been possible without multidisciplinary collaboration in addressing previously existing challenges in the radiology workflow, including health equity considerations, that affect the quality of care. In collaboration with CT technologists, Dr. Tejani said they established a workflow requirement that patients with outpatient chest CT studies remain at the facility during AI assessment of the imaging. 

The combination of workflow changes with AI-enabled worklist reprioritization for radiologists led to more timely follow-up care for patients with incidental PE findings on CT scans, according to Dr. Tejani, a third-year radiology resident at the University of Texas Southwestern Medical Center.

“By instituting a clinical operations initiative that helps you leverage an AI result, (it) can actually translate to this clinically meaningful change,” noted Dr. Tejani.

For more insights from Dr. Tejani, watch the video below.

In a recent video interview from the Society for Imaging Informatics in Medicine (SIIM) conference, Ali Tejani, M.D., discussed pertinent insights on leveraging the value of adjunctive artificial intelligence (AI)-enabled triage software for computed tomography (CT) scans with radiology workflow improvements to achieve “clinically meaningful change” for patients with incidental pulmonary emboli findings.

Expediting the Management of Incidental Pulmonary Emboli on CT

One of the ongoing trends with the development of artificial intelligence (AI) modalities in radiology is an increasing emphasis on improving efficiencies with non-interpretative tasks.

In a recent interview, Sonia Gupta, MD said the combination of AI and natural language processing can help retrieve and analyze key historical points from a patient’s electronic medical record (EMR). Dr. Gupta emphasized that this technology could help streamline patient triage, radiology reporting and the management of incidental finding follow-up.

“(With) incidental finding follow-up, AI reads the report and detects the findings that need follow-up … and can also insert the follow-up recommendations for you into the report. Again, this is all non-interpretative and natural language processing-based type of AI. I think that is a really great opportunity we can all utilize,” maintained Dr. Gupta, an abdominal radiologist, a board member of the American Board of Artificial Intelligence in Medicine, and the chief medical officer of Change Healthcare.

Emerging Insights on Improving Radiology Workflows

In a recent video interview, Sonia Gupta, MD discussed a number of ongoing developments with artificial intelligence (AI) in radiology, ranging from market consolidation of AI vendors to maximizing automation and efficiency with patient triage, reporting and follow-up of incidental findings.

CT

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