Everything you need to know about Computed Tomography (CT)

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March 2017 Imaging Pearls - Learning Modules | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ March 2017
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    • ”RadiologyInfo.org is a public information portal designed to support patient care and broaden public awareness of the essential role radiology plays in overall patient health care. Over the past 14 years, RadiologyInfo.org has evolved considerably to provide access to more than 220 mixed-media descriptions of tests, treatments, and diseases through a spectrum of mobile and desktop platforms, social media, and downloadable documents in both English and Spanish. In 2014, the RSNA-ACR Public Information Website Committee, which stewards RadiologyInfo.org, developed 3- to 5-year strategic and implementation plans for the website. The process was informed by RadiologyInfo.org user surveys, formal stakeholder interviews, focus groups, and usability testing.”

      
Enhancing Public Access to Relevant and Valued Medical Information: Fresh 
Directions for RadiologyInfo.org 
Geoffrey D. Rubin, Arun Krishnaraj, Mahadevappa Mahesh, Ramji R. Rajendran, Elliot K. Fishman
J Am Coll Radiol 2017 (in press) 

    • 
“Over the past year, visits to RadiologyInfo.org have increased by 60.27% to 1,424,523 in August 2016 from 235 countries and territories. Twenty-two organizations have affiliated with RadiologyInfo.org with new organizations being added on a monthly basis. RadiologyInfo provides a tangible demonstration of how radiologists can engage directly with the global public to educate them on the value of radiology in their health care and to allay concerns and dispel misconceptions. Regular self-assessment and responsive planning will ensure its continued growth and relevance.”


      Enhancing Public Access to Relevant and Valued Medical Information: Fresh 
Directions for RadiologyInfo.org 
Geoffrey D. Rubin, Arun Krishnaraj, Mahadevappa Mahesh, Ramji R. Rajendran, Elliot K. Fishman
J Am Coll Radiol 2017 (in press) 

    • 
“However, participants expressed concerns that the language and images were too “doctor-centric” and expected a more “patient-centric” focus and reassuring tone. They expressed concerns about navigating and remaining oriented within the site and had difficulty interpreting some of the information categories. Participants requested 
that the site have a warmer look and feel, prioritization of topics of greatest interest to patients, more efficient access to content relevant to their queries, and integration of patient-friendly images and videos. Finally, they noted that RadiologyInfo.org did not always appear at the top of search results when participants generated their own search terms.”

      
Enhancing Public Access to Relevant and Valued Medical Information: Fresh 
Directions for RadiologyInfo.org 
Geoffrey D. Rubin, Arun Krishnaraj, Mahadevappa Mahesh, Ramji R. Rajendran, Elliot K. Fishman
J Am Coll Radiol 2017 (in press) 

    • “To evolve the site further and improve its outreach, the committee has pursued an active social media campaign. Our efforts on social media are primarily through the two leading platforms, Facebook and Twitter. To date the site has garnered more than 240,000 likes on its Facebook page and more than 3,000 followers on Twitter. Social media platforms allow direct and real-time connections with patients, something a website cannot accomplish. As this aspect of RadiologyInfo evolves, care must be taken to ensure that responses are quick and vetted for appropriateness.”
Enhancing Public Access to Relevant and Valued Medical Information: Fresh Directions for RadiologyInfo.org 
Geoffrey D. Rubin, Arun Krishnaraj, Mahadevappa Mahesh, Ramji R. Rajendran, Elliot K. Fishman
J Am Coll Radiol 2017 (in press) 

    • “TAKE-HOME POINTS
      RadiologyInfo.org is an authoritative and trusted portal designed to support public care and public awareness of the essential role radiology in health care. 
-  Recent enhancements to the site have aimed to improve its usefulness for patients and their families. 
-  With more than 1.4 million visitors in August 2016 from 235 countries and territories worldwide, monthly engagement has grown by more than 60% from the prior year. 
-  Diversification of access through social media channels as well as mobile platforms has expanded the reach of RadiologyInfo.org.”
Enhancing Public Access to Relevant and Valued Medical Information: Fresh Directions for RadiologyInfo.org 
Geoffrey D. Rubin, Arun Krishnaraj, Mahadevappa Mahesh, Ramji R. Rajendran, Elliot K. Fishman
J Am Coll Radiol 2017 (in press)
    • PURPOSE: To show the benefit of three-dimensional (3D) reconstructions of preoperative imaging for surgical performance.

      CONCLUSIONS: 3D reconstructions of preoperative imaging lead to better surgical performance in a difficult laparoscopic training environment. Surgeons gain a 3D impression of patients' individual anatomy easier, faster, and more reliable. Providing 3D reconstructions previous to surgery should be routinely implemented for patients with complex anatomical situations.


      Three-Dimensional Reconstruction of Preoperative Imaging Improves Surgical Success in Laparoscopy.
Simpfendorfer T et al.
 J Laparoendosc Adv Surg Tech A 2016 Dec 2. [Epub ahead of print]

    • “ By virtue of its information technology-oriented infrastructure, the specialty of radiology is uniquely positioned to be at the forefront of efforts to promote data sharing across the healthcare enterprise, including particularly image sharing. The potential benefits of image sharing for clinical, research, and educational applications in radiology are immense. In this work, our group—the Association of University Radiologists (AUR) Radiology Research Alliance Task Force on Image Sharing—reviews the benefits of implementing image sharing capability, introduces current image sharing platforms and details their unique requirements, and presents emerging platforms that may see greater adoption in the future. By understanding this complex ecosystem of image sharing solutions, radiologists can become im- portant advocates for the successful implementation of these powerful image sharing resources.”


      Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Cloud-based image sharing platforms based on interoperability standards such as the IHE-XDS-I profile are currently the most widely used method for sharing of clinical radiological images and will likely continue to grow in the coming years. Conversely, no single image sharing platform has emerged as a clear leader for research and educational applications. Radiologists, clinicians, investigators, technologists, educators, administrators, and patients all stand to benefit from medical image sharing. With their continued support, more wide- spread adoption of image sharing infrastructure will assuredly improve the standard of clinical care, research, and education in modern radiology.”

      
Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Sharing of primary imaging data also makes further research more efficient and can substantially reduce the cost of subsequent studies. In research efforts utilizing extremely large data sets, such as those found in radiogenomics and radiomics research, sharing and exchange of images facilitates linking radiological data with large biological and genetic data sets, thereby enabling the use of big data analysis methods to uncover correlations between imaging phenotypes and underlying genetic and functional molecular expression profiles.”

      
Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Practical considerations must also factor into the design of implemented workflow. For example, transfer of DICOM imaging studies through portable media such as compact discs has been demonstrated as untenable and unsustainable between institutions as image sharing gains traction. Instead, decentralized upload of DICOM data into a PACS system from 
remote terminals helps distribute the workload between mul- tiple departments, reduces the time required by a central physical processing center, saves the time required for physical transportation of the media, and retains the physical media at the point of care.”

      
Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Commercial PACS and standalone image sharing plat- form also have not been evaluated in the scientific literature, but market analysis is being conducted through surveys by research companies such as peer60. In peer60’s report, vendors with the largest reported market share among large healthcare institutions include McKesson’s Conserus Image Repository, IBM’s Merge, Nuance PowerShare Network, GE Centricity with OneMedNet BEAM, LifeIMAGE, Philips IntelliSpace Portal, ABI Health Sectra, and Agfa Healthcare Enterprise Imaging.”


      Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Modern educational practices in radiology require facilitated learning using computer-based modules and active simulation as part of the learning experience. As part of this trend, there has been tremendous growth in the number of online, case-based learning tools. In their purest form, these tools can take the form of PACS-like, web- based teaching files, which offer almost unlimited scalability for case acquisition and distribution, and may also include the ability to pose questions to radiology trainees, track responses, and categorize cases, ideally with seamless integration with a clinical PACS system.”


      Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Cloud-based image sharing platforms based on interoperability standards such as the IHE-XDS-I profile are currently the most widely used method for sharing of clinical radiological images and will likely continue to grow in the coming years. Conversely, no single image sharing platform has emerged as a clear leader for research and educational applications. Radiologists, clinicians, investigators, technologists, educators, administrators, and patients all stand to benefit from medical image sharing. With their continued support, more wide- spread adoption of image sharing infrastructure will assuredly improve the standard of clinical care, research, and education in modern radiology.”


      Image Sharing in Radiology— A Primer 
Chatterjee AR et al.
Acad Radiol 2017; 24:286–294
    • “Even more exciting is the finding that in some cases, computers seem to be able to “see” patterns that are beyond human perception.This discovery has led to substantial and increased interest in the field of machine learning— specifically, how it might be applied to medical images.”


      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)

    • “These algorithms have been used for several challenging tasks, such as pulmonary embolism segmentation with computed tomographic (CT) angiography (3,4), polyp detection with virtual colonoscopy or CT in the setting of colon cancer (5,6), breast cancer detection and diagnosis with mammography (7), brain tumor segmentation with magnetic resonance (MR) imaging (8), and detection of the cognitive state of the brain with functional MR imaging to diagnose neurologic disease (eg, Alzheimer disease).”


      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)
    • “If the algorithm system optimizes its parameters such that its performance improves—that is, more test cases are diagnosed correctly—then it is considered to be learning that task.”



      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)
    • “Training: The phase during which the ma- chine learning algorithm system is given labeled example data with the answers (ie, labels)—for example, the tumor type or correct boundary of a lesion.The set of weights or decision points for the model is updated until no substantial improvement in performance is achieved.”


      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)
    • “Deep learning, also known as deep neural network learning, is a new and popular area of research that is yielding impressive results and growing fast. Early neural networks were typi- cally only a few (<5) layers deep, largely because the computing power was not sufficient for more layers and owing to challenges in updating the weights properly. Deep learning refers to the use of neural networks with many layers—typically more than 20.”


      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)
    • “CNNs are similar to regular neural networks. The difference is that CNNs assume that the inputs have a geometric relationship—like the rows and columns of images. The input layer of a CNN has neurons arranged to produce a convolution of a small image (ie, kernel) withthe image.This kernel is then moved across the image, and its output at each location as it moves across the input image creates an output value. Although CNNs are so named because of the convolution kernels, there are other important layer types that they share with other deep neural networks. Kernels that detect important features (eg, edges and arcs) will have large outputs that contribute to the final object to be detected.”


      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)
    • “Machine learning is already being applied in the practice of radiology, and these applications will probably grow at a rapid pace in the near future.The use of machine learning in radiology has important implications for the practice of medicine, and it is important that we engage this area of research to ensure that the best care is afforded to patients. Understanding the properties of machine learning tools is critical to ensuring that they are applied in the safest and most effective manner.”


      Machine Learning for Medical Imaging 
 Bradley J. Erickson et al.
 RadioGraphics 2017 (in press)
    • BACKGROUND CONTEXT: In today’s health-care climate, magnetic resonance imaging (MRI) is often perceived as a commodity—a service where there are no meaningful differences in quality and thus an area in which patients can be advised to select a provider based on price and convenience alone. If this prevailing view is correct, then a patient should expect to receive the same radiological diagnosis regardless of which imaging center he or she visits, or which radiologist reviews the examination. Based on their extensive clinical experience, the authors believe that this assumption is not correct and that it can negatively impact patient care, outcomes, and costs.”


      Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period
Herzog R et al.
The Spine Journal (in press)
    • “Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations. Of the interpretive findings, 32.7% appeared only once across all 10 of the study examinations' reports. A global Fleiss kappa statistic, computed across all reported findings, was 0.20±0.06, indicating poor overall agreement on interpretive findings. The average interpretive error count in the study examinations was 12.5±3.2 (both false-positives and false-negatives). The average false-negative count per examination was 10.9±2.9 out of 25 and the average false-positive count was 1.6±0.9, which correspond to an average true-positive rate (sensitivity) of 56.4%±11.7 and miss rate of 43.6%±11.7.”

      
Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period
Herzog R et al.
The Spine Journal (in press)
    • “Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations. Of the interpretive findings, 32.7% appeared only once across all 10 of the study examinations' reports. A global Fleiss kappa statistic, computed across all reported findings, was 0.20±0.06, indicating poor overall agreement on interpretive findings.”

      
Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period
Herzog R et al.
The Spine Journal (in press)
    • “Ultimately, it is the authors' opinions that accurate and complete diagnostic information at the onset of an injury or illness is critical to improve the chances for a patient's full recovery. However, reducing diagnostic errors and variability in reported findings will require the development and adoption of systematic mechanisms for measuring diagnostic MRI quality, including error rates. The authors acknowledge that accurately measuring interpretive errors at scale is a significant challenge and that some health-care providers may be reluctant to adopt such a system due to concerns around exposure of their errors, negative impact on reimbursement, and potential liability.”


      Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period
Herzog R et al.
The Spine Journal (in press)
    • “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors, increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”

      
Interpretive Error in Radiology.
Waite S et al.
  AJR Am J Roentgenol 2016 Dec 27:1-11
    • “In 1949, Garland [8] found a 33.3% error rate in the interpretation of positive lms based on group consensus opinion and an 8% intrareader variation (when a reader disagrees with him or herself when rereading a study). This rate of error has remained virtually unchanged. In a mix of abnormal and normal studies representative of a typical clinical practice, the error rate is approximately 4%.”


      Interpretive Error in Radiology.
Waite S et al.
  AJR Am J Roentgenol 2016 Dec 27:1-11
    • “A recognition error is a failure of the ba- sic mechanism of object recognition; the radiologist fixates on the target for a duration shorter than the threshold dwell time considered sufficient to recognize lesion features . The threshold for lesion detection depends on the imaging modality and ranges from 500 to 1000 ms . Both search and recognition errors are considered perceptual errors.”

      
Interpretive Error in Radiology.
Waite S et al.
  AJR Am J Roentgenol 2016 Dec 27:1-11
    • “Sokolovskaya et al. reported that when radiologists were asked to interpret studies at twice their baseline speed, the number of major misses increased from 10% to 26.6%. Because re- imbursement in many practices is based on productivity, there is a strong financial incentive to read as many studies—without breaks—as possible. A sustained artificially high interpretative rate can result in additional interpretive errors from both general and oculomotor fatigue.”


      Interpretive Error in Radiology.
Waite S et al.
  AJR Am J Roentgenol 2016 Dec 27:1-11
    • “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”

      
Interpretive Error in Radiology.
Waite S et al.
  AJR Am J Roentgenol 2016 Dec 27:1-11
Adrenal

    • “Imaging characteristics of adrenal tumors on CT scan predict benign pathology 100% of the time. Regardless of size, when interpreted as benign on CT scan, laparoscopic adrenalectomy, if technically feasible, should be the technique used when surgery is offered, or close surveillance may be a safe alternative.”


      Computed Tomography in the Management of Adrenal Tumors: Does Size Still Matter?
Azoury SC, Nagarajan N, Young A, Mathur A, Prescott JD, Fishman EK, Zeiger MA.
J Comput Assist Tomogr. 2017 Jan 20. (in press)
    • ”Pathology was benign in 88.4%, indeterminate in 2.3%, and malignant in 9.3%, with a median tumor diameter of 2.7 cm (interquartile range, 1.7-4.1 cm) and 9.5 cm (interquartile range, 7.1-12 cm) in the benign and malignant groups, respectively (P < 0.001). Of the tumors with benign features on CT, 100% (143/143) had benign final pathology.


      Computed Tomography in the Management of Adrenal Tumors: Does Size Still Matter?
Azoury SC, Nagarajan N, Young A, Mathur A, Prescott JD, Fishman EK, Zeiger MA.
J Comput Assist Tomogr. 2017 Jan 20. (in press)
    • “In resected adrenal tumors, the presence of nonbenign ImF is more sensitive for malignancy than mass size (100 vs. 55 %) with equivalent specificity. Regardless of mass size, adrenalectomy should be strongly considered when non-benign ImF are present.”


      Adrenal Imaging Features Predict Malignancy Better than Tumor Size.
Yoo JY et al.
Ann Surg Oncology 2015 Dec;22 Suppl 3:S721-7. 

    • “If size ≥4 cm had been used as the sole criterion for surgery, 45 % of malignancies (9/20) would have been missed including 8 metastases and an ACC.”


      Adrenal Imaging Features Predict Malignancy Better than Tumor Size.
Yoo JY et al.
Ann Surg Oncology 2015 Dec;22 Suppl 3:S721-7. 

Chest

    • “The largest meta-analysis to date exam- ined over 10,000 patients up to the year 2009 and reported incidental PE had a prevalence of 2.6% (95% CI, 1.9–3.4%), with a higher prevalence in patients with VTE risk factors such as malignancy (3.1%) and inpatient status (4.0%).”

      
Management of the Incidental Pulmonary Embolism 
Victor Chiu, Casey O’Connell 
AJR 2017; 208:485–488 

    • “Although treatment of symptomatic PE with anticoagulation results in a clear reduction in mortality, the bene ts of treating incidental PE have not yet been evaluated in a large prospective study. The risk of major bleeding while on anticoagulation for any VTE is 7.2 per 100 patient-years, making the decision to treat one of great consequence, particularly in higher risk patients such as those in the ICU and those with cancer.”


      Management of the Incidental Pulmonary Embolism 
Victor Chiu, Casey O’Connell 
AJR 2017; 208:485–488 

    • “The National Comprehensive Cancer Network also recommends treatment of incidental PE similar to that for symptomatic PE in patients with cancer and recommends against routinely obtaining repeat imaging.”

      
Management of the Incidental Pulmonary Embolism 
Victor Chiu, Casey O’Connell 
AJR 2017; 208:485–488 

    • “Pulmonary CTA is well established as a fast and reliable means of excluding or diagnosing PE. Continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality. Advances in risk strati cation and prognostication from pulmonary CTA examinations should further re ne its clinical value while minimizing the potential harm from overutilization and overdiagnosis."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “This technique is effective despite the variable embrace by clinicians of the d-dimer test, a test that suffers from low specificity. However, the advantage of this laboratory marker lies in its high negative predictive value, so that acute PE can be safely excluded by a negative d-dimer result. In case of elevated d-dimer values, pulmonary CTA should be performed."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “For example, pulmonary CTA has emerged as a formidable prognostic marker to gauge the 
severity of hemodynamic compromise from acute PE and identify patients at heightened risk for fatal or nonfatal adverse events, thus guiding clinical management toward more aggressive therapy. The main methods that have been described to categorize the hemodynamic relevance and severity of PE are imaging markers of right heart strain, methods for clot burden quantification, and lung perfusion measurements."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “For clinical purposes, across all endpoints, the right ventricle (RV) diameter–left ventricle (LV) diameter ratio on pulmonary CTA has the strongest predictive value and most robust evidence base for adverse clin- ical outcomes in patients with acute PE. A ratio of more than 1 on traverse images and of more than 0.9 using true four-chamber view reconstructions is considered indicative of right heart strain and has been shown to predict adverse outcomes and early death."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “One study investigating spectral optimization in monochromatic dual-energy pulmonary CTA with reduced iodine load suggested that 60 keV may be the optimal energy level to analyze the thoracic circulation . Other investigators have also concluded that iodine load can be reduced when virtual monoenergetic images extrapolated to photon energies of 50 or 70 keV are used ."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “Pulmonary CTA is well established as a fast and reliable means of excluding or diagnosing PE. Continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality. Advances in risk stratification and prognostication from pulmonary CTA examinations should further refine its clinical value while minimizing the potential harm from overutilization and overdiagnosis."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
Contrast

    • STUDY OBJECTIVE: The study objective was to determine whether intravenous contrast administration for computed tomography (CT) is independently associated with increased risk for acute kidney injury and adverse clinical outcomes.

      CONCLUSION: In the largest well-controlled study of acute kidney injury following contrast administration in the ED to date, intravenous contrast was not associated with an increased frequency of acute kidney injury.
Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.


      Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE,  Klein EY 
Ann Emerg Med 2017 Jan 19. pii: S0196-0644(16)31388-9 

    • “Rates of acute kidney injury were similar among all groups. Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to 1.16). This was true in all subgroup analyses regardless of baseline renal function and whether comparisons were made directly or after propensity matching. Contrast administration was not associated with increased incidence of chronic kidney disease, dialysis, or renal transplant at 6 months.”
Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.


      Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE,  Klein EY 
Ann Emerg Med 2017 Jan 19. pii: S0196-0644(16)31388-9 

Kidney

    • “Computed tomography (CT) urography is the best noninvasive method of evaluating the upper urinary tract for urothelial malignancies. However, the utility of CT urography is heavily contingent on the use of proper image acquisition protocols. This article focuses on the appropriate protocols for optimizing CT urography acquisitions, including contrast administration and the timing of imaging acquisitions, as well as the use of ancillary techniques to increase collecting system distention. In addition, imaging findings are discussed that should raise concern for urothelial carcinoma at each of the 3 segments of the urinary tract: the intrarenal collecting systems, ureters, and bladder.”

      
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “One of the unique features of transitional cell carcinoma, regardless of whether it arises in the upper or lower urinary tract, is its strong tendency for both recurrence and multifocality, with almost 4% of patients with bladder cancer going on to develop a transitional cell carcinoma in the upper urinary tract.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “A study by Dillman and colleagues found inferior urinary tract distension with the split-bolus technique. In our own experience, this protocol is particularly problematic when evaluating the ureters, with poor distention of the distal ureters. Another potential disadvantage of this protocol is decreased sensitivity for small or subtle renal cell carcinomas, because only 2 postcontrast phases are available for eval- uation of the renal parenchyma, as opposed to 3 phases in the single-bolus technique.”

      
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “In patients less than 35 years old, ostensibly at much lesser risk of developing renal malignancies, we acquire only noncontrast, arterial, and delayed phase images, because the odds of the patient having either a renal parenchymal lesion or a significant abnormality in the other parenchymal organs of the upper abdomen are much less, making venous phase acquisitions of less value.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “In particular, MIP images allow the entirety of the collecting systems and ureters to be viewed at a single glance (providing a global overview of the collecting systems), which is a great advantage compared with standard axial image review, in which the intrarenal collecting systems and ureters are constantly moving in and out of plane, making careful evaluation difficult.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “Diffuse bladder wall thickening is very unlikely to represent malignancy, and most often represents infectious cystitis or an artificially thickened bladder wall caused by bladder decompression. However, the presence of focal or asymmetric bladder wall thickening should always raise concern for malignancy, and should prompt further evaluation with cystoscopy.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “Accordingly, some sites of subtle urothelial thickening may be more apparent on the arte- rial phase images as a result of associated hypervascularity and enhancement. In general, any type of urothelial thickening, when focal, should raise concern for malignancy, with many ureteral tumors showing irregular, nodular soft tissue thickening, rather than circumferential or smooth wall thickening.”


      Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
    • “The presence of focal wall thickening or a discrete nodule/mass should raise concern for the presence of malignancy anywhere in the upper or lower urinary tract and should prompt further evaluation with direct visualization. Nevertheless, there are multiple benign entities that could potentially mimic findings of malignancy. In particular, urothelial thickening is a common finding, and, when bilateral and diffuse throughout the collecting systems, is much more likely to be the sequela of infection, rather than tumor, particularly when the wall thickening is smooth and regular.”

      
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EK
Radiol Clin North Am 2017 Mar;55(2):225-241.
Quotes

    • “A radiology practice’s success hinges on attracting the best staff and providers. Recruitment campaigns should create marketing materials that incorporate images and video to best convey the character and the mission of the organization. People want to be part of organizations that have an important mission.”


      The Power of Stories in Brands, Business, and Life.
Anna Griffin, Madison B. Johnson, Elliot K. Fishman,  Karen M. Horton, Pamela T. Johnson 
J Am Coll Radiol 2017 Feb 20 S1540-1440

    • “Similarly, residency and fellowship training programs can engage medical student applicants with online video clips designed to illustrate the resident culture. One of the most common metrics that students describe in their decision- making process is “whether I feel like it’s a good fit.” Web-based resources that tell the story of life within a department can be very effective in the competitive recruitment arena.”


      The Power of Stories in Brands, Business, and Life.
Anna Griffin, Madison B. Johnson, Elliot K. Fishman,  Karen M. Horton, Pamela T. Johnson 
J Am Coll Radiol 2017 Feb 20 S1540-1440
    • “Although patient selection of a radiology department is often limited by their provider’s referral patterns and insurance requirements, departments can offer potential patients unique insight into the people that provide the imaging services through storytelling video clips. Radiology is often perceived as an impersonal specialty because we have not traditionally provided direct patient care. Practices that can demonstrate the character of their faculty and staff will provide potential and existing patients with the reassurance of a positive patient experience.”


      The Power of Stories in Brands, Business, and Life.
Anna Griffin, Madison B. Johnson, Elliot K. Fishman,  Karen M. Horton, Pamela T. Johnson 
J Am Coll Radiol 2017 Feb 20 S1540-1440
Stomach

Vascular

    • “The largest meta-analysis to date exam- ined over 10,000 patients up to the year 2009 and reported incidental PE had a prevalence of 2.6% (95% CI, 1.9–3.4%), with a higher prevalence in patients with VTE risk factors such as malignancy (3.1%) and inpatient status (4.0%).”

      
Management of the Incidental Pulmonary Embolism 
Victor Chiu, Casey O’Connell 
AJR 2017; 208:485–488 

    • “Although treatment of symptomatic PE with anticoagulation results in a clear reduction in mortality, the bene ts of treating incidental PE have not yet been evaluated in a large prospective study. The risk of major bleeding while on anticoagulation for any VTE is 7.2 per 100 patient-years, making the decision to treat one of great consequence, particularly in higher risk patients such as those in the ICU and those with cancer.”

      
Management of the Incidental Pulmonary Embolism 
Victor Chiu, Casey O’Connell 
AJR 2017; 208:485–488 

    • “The National Comprehensive Cancer Network also recommends treatment of incidental PE similar to that for symptomatic PE in patients with cancer and recommends against routinely obtaining repeat imaging.”


      Management of the Incidental Pulmonary Embolism 
Victor Chiu, Casey O’Connell 
AJR 2017; 208:485–488 

    • “Pulmonary CTA is well established as a fast and reliable means of excluding or diagnosing PE. Continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality. Advances in risk strati cation and prognostication from pulmonary CTA examinations should further re ne its clinical value while minimizing the potential harm from overutilization and overdiagnosis."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “This technique is effective despite the variable embrace by clinicians of the d-dimer test, a test that suffers from low specificity. However, the advantage of this laboratory marker lies in its high negative predictive value, so that acute PE can be safely excluded by a negative d-dimer result. In case of elevated d-dimer values, pulmonary CTA should be performed."

      
State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “For example, pulmonary CTA has emerged as a formidable prognostic marker to gauge the 
severity of hemodynamic compromise from acute PE and identify patients at heightened risk for fatal or nonfatal adverse events, thus guiding clinical management toward more aggressive therapy. The main methods that have been described to categorize the hemodynamic relevance and severity of PE are imaging markers of right heart strain, methods for clot burden quantification, and lung perfusion measurements."

      
State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “For clinical purposes, across all endpoints, the right ventricle (RV) diameter–left ventricle (LV) diameter ratio on pulmonary CTA has the strongest predictive value and most robust evidence base for adverse clin- ical outcomes in patients with acute PE. A ratio of more than 1 on traverse images and of more than 0.9 using true four-chamber view reconstructions is considered indicative of right heart strain and has been shown to predict adverse outcomes and early death."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “One study investigating spectral optimization in monochromatic dual-energy pulmonary CTA with reduced iodine load suggested that 60 keV may be the optimal energy level to analyze the thoracic circulation . Other investigators have also concluded that iodine load can be reduced when virtual monoenergetic images extrapolated to photon energies of 50 or 70 keV are used ."


      State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • “Pulmonary CTA is well established as a fast and reliable means of excluding or diagnosing PE. Continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality. Advances in risk stratification and prognostication from pulmonary CTA examinations should further refine its clinical value while minimizing the potential harm from overutilization and overdiagnosis."

      
State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism 
Moritz H. Albrecht et al.
 AJR 2017; 208:495–504
    • Bicuspid Aortic Valve: Associated Conditions
      - Coarctation of the aorta
      - Hypoplastic left heart syndrome
      - Williams syndrome
      - Turner syndrome
      - Marfan’s syndrome
All images on this site are © 2017 Elliot K. Fishman, MD.