Published on the Jan. 18, 2013, DiagnosticImaging.com website
By Whitney L.J. Howell
Since last fall, radiology practices and departments nationwide have grappled with a continued shortage of barium agents used in multiple imaging studies. Recent reports indicate the shortage shows no sign of slowing, and several providers say they’ve had to alter their approach to patient care.
According to Bracco Diagnostics Inc., a leading, worldwide barium supplier, barium is in low availability globally. A September 2012 letter to customers from the company announced a significant number of barium requests are on backorder.
“With the continued efforts of our barium suppliers, we are attempting to make all of the key backordered products available as soon as possible,” Tom Ortiz, Bracco director of North America CT business and worldwide product director of oral imaging, said in the letter. “However, at this time, there are procedures for which we are unable to provide products.”
For example, Bracco has not fulfilled orders for small bowel, esophageal, and other CT studies.
Scripps Health in California is among those facilities struggling to meet patient needs with a limited barium supply, said Jeremy Enfinger, lead radiologic technologist at the Scripps Mercy Chula Vista Hospital.
“We got to the point where we had scheduled patients but not enough barium to complete the studies for the day,” he said. “There were several times that we used a courier to deliver supplies from one of our other hospitals within the organization. But, eventually, they stopped allowing us to do that because they had also run out.”
With the future barium supply level still in question, Enfinger postulated the industry might be pushed into using more water-soluble contrast agents to fulfill patient needs.
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/contrast-agents/content/article/113619/2123820
Published on the Jan. 24, 2013 DiagnosticImaging.com website
By Whitney L.J. Howell
Once available only to radiologists who purchased new MRI equipment, MR elastography technology is becoming widely available as an upgrade feature to older machines. This expansion not only greatly improves patient care, industry experts said, but it also impacts costs and efficiency.
MR Elastography (MRE) — now available at 100 locations on five continents — is the industry-preferred method for assessing liver stiffness or elasticity. This condition characterizes liver disease and is most often diagnosed through palpation. However, there is a limit to how much tissue providers can feel. While conventional MRI is a powerful tool, liver disease, such as fibrosis or cirrhosis, creates no anatomical changes to the organ, making identification difficult and often requiring a needle biopsy.
“MR elastography provides a safer, more comfortable, non-invasive alternative to
liver biopsy for assessing liver disease,” said Richard Ehman, MD, professor and chair of radiology at the Mayo Clinic in Minnesota, noting that needle biopsies are often painful.
Being able to analyze liver health in a faster, more reliable way is particularly important now, he said, as the level of obesity and the associated fatty liver disease is rising in the United States. Currently 1 in 3 Americans lives with fatty liver disease, and within 10 years, he said, this condition will be the leading cause for liver transplant. MRE is also beneficial in diagnosing and treating the 25 percent of Hepatitis C patients who develop liver fibrosis, the large build-up of proteins in the liver that eventually leads to cirrhosis.
What Is MRE and How Does It Work?
Approved by the FDA in 2009, MRE is a non-invasive, highly-sensitive method for determining the level of liver disease through the use of low-frequency mechanical waves. It is designed to facilitate faster diagnosis and avoid potentially dangerous — and often inaccurate — liver biopsies, said Ehman, who pioneered the MRE technology and worked with GE Healthcare to bring it to market.
Once installed, this tool pumps 60 Hz waves through a plastic tube to a small, non-metallic drum placed over the abdomen. Slower wave movement correlates to higher stiffness. Standard MRI imaging captures the miniscule movements of the tissue, and, using a special algorithm, converts the data into a color-scale picture that corresponds to the level of liver stiffness.
MRE differs from ultrasound elastography. With the ultrasound method, a probe is pushed across tissue, and a scanner records how the tissue deforms. However, Ehman said, this doesn’t provide a quantitative measure of the tissue’s actual stiffness.
According to Ehman, an MRE scan can be completed with four breath holds — approximately a minute — and is often conducted and billed as part of other abdominal MRI protocols. Based on the color-scale picture, radiologists can instantaneously know whether the patient has a healthy or diseased liver. Liver tissue stiffness is measured in kiloPascals (kPa), with a normal liver having a stiffness of roughly 2 kPa, the same consistency of fat inside the body. Diseased livers range from 3 kPa to more than 10 kPa.
Since MRE’s FDA approval, GE Healthcare has been the main vendor for the tool with its MR Touch product. Siemens has also worked with the Mayo Clinic to provide MRE on its existing MAGNETOM Aera and Skyra MR machines.
Overall, said Richard Hausmann, GE’s president and CEO officer of global MR business, MRE greatly enhances what MRI studies provide.
“MRE offers an accurate assessment of stiffness in the liver, even for deeper tissues not reached by palpation,” he said. “It’s helped increase confidence in diagnoses in this area, and it’s one piece in an attempt to make overall diagnosis less invasive.”
To read the remainder of the story at its original location: http://www.diagnosticimaging.com/mri/content/article/113619/2124974
Published on the Jan. 29, 2013, DiagnosticImaging.com website
By Whitney L.J. Howell
One of the most commonly used imaging tools in a radiologist’s arsenal is the contrast agent. It enhances the appearance of structures and fluids, but it isn’t without risks and challenges. And, it’s up to radiologists, industry experts say, to make sure your patients and staff understand how to use it and why.
While less than 1 percent of patients experience a negative response to a contrast agent, according to a Mayo Clinic study, everyone involved with a scan using contrast should be aware of all possible outcomes and know how to handle them. The American College of Radiology offers guidance in how to best administer these agents, but creating the optimal experience for the patient involves more than selecting the right agent and using the correct measurement.
“You’re giving someone a drug, and there’s a risk to that. Patients have to understand that risk,” said Lawrence Marks, MD, chair of radiation oncology at the University of North Carolina at Chapel Hill School of Medicine. “They have to understand the value of the test, but like everything else in medicine, your actions should be based on a discussion with the patient before you do it.”
Educating the Patient
Although the risks can be minor, you should always consider if using contrast is even necessary, said Jeffrey Kanne, MD, associate professor of thoracic imaging and quality and safety vice chair at the University of Wisconsin School of Medicine and Public Health. If you can obtain the same information with the same level of specificity without using an agent, then do so, he said. That is always the safest option.
However, if contrast media is necessary, make it as easy to understand as possible. Like many procedures in radiology, the use of contrast media includes complex terminology that is potentially unfamiliar to patients. Always explain what the contrast media is and what it does in basic terminology — then, employ the teach-back method.
“Make sure you have patients explain back to you what you said. It’s a very valid way of ensuring patients truly understand,” Kanne said. “If they can recount back, you know they understand. If not, it’s clear you haven’t communicated effectively, and you need to try a different approach.”
One such strategy is a patient education website that addresses the risks associated with contrast media and tells patients what information you will need to ensure not only their safety, but also the best imaging results. For example, the University of Washington Medical Center maintains a patient education page that answers questions about need and risk in easy-to-understand language.
In addition, be willing to sit with patients and give them the opportunity to voice their questions and concerns. The most common worry patients have, Kanne said, is the misconception that contrast agents are radioactive. Others — many of whom experienced previous-generation contrast agents — fear the procedure will be painful and cause a burning sensation.
To read the remainder of the story at its original location: http://www.diagnosticimaging.com/contrast-agents/content/article/113619/2125650
Published on the Jan. 10, 2013, DiagnosticImaging.com website
By Whitney L.J. Howell
On January 1, the long-debated and much-opposed medical device tax went into effect. To date, medical device manufacturers have clearly stated their opposition, but industry leaders portend practicing radiologists also have reason to be concerned.
Barely a week old, this measure levies a 2.3 percent tax on all medical devices. The law calls for manufacturers to pay for the tax added to the sale price of the device, but many worry the cost will not only trickle down to providers, but will also, ultimately, stymy the progression of patient care by hindering research and development efforts.
“As radiologists, most of us chose the specialty because it’s a field that incentivizes technological innovation that can make enormous differences in patient care,” said Geraldine McGinty, MD, chair of the American College of Radiology (ACR) Economics Commission. “Payment or health care policies that would, in any way, negatively impact innovation are things that make us feel uncomfortable.”
The device tax will inevitably impact practitioners’ bottom lines, she said. The actual dollar amount is yet unknown, but manufacturers will be forced to pass some of the tax increase on to their customers. The price hike will likely be an unwelcome addition to existing imaging reimbursement cuts and the difficulties radiologists already face with collecting payments from patients. Equipment purchasing decisions could become more complicated or could be postponed, she said.
In addition to individual monetary concerns, radiologists should also worry about what the medical device tax could mean for their ability to provide the most up-to-date patient care. According to the Medical Imaging and Technological Alliance (MITA), this initiative is a job-killer because it makes outsourcing jobs overseas more attractive. But research and development efforts will also be a casualty, said MITA Executive Director Gail Rodriguez.
According to a recent MITA survey, 29 percent of manufacturers anticipate slicing into their research and development budgets as a way to cover the anticipated $287 million associated with the device tax. This change could leave providers without new technological innovations for treating patients, MITA said.
To read the remainder of the story at its original location: http://www.diagnosticimaging.com/practice-management/content/article/113619/2122393
Published on the Dec. 24, 2012, Diagnostic Imaging website
By Whitney L.J. Howell
Are medical imaging tests as dangerous — or perhaps more so — than the disease they’re used to detect? It’s a question often asked by patients, referring physicians, and the news media. As radiologists have acknowledged the risk associated with CT scans, the industry has taken steps to keep doses as low as possible without compromising the quality of the study.
However, when making decisions about the use of certain imaging, the timing of radiation-induced cancer risks is also important to consider, according to Harvard assistant professor of radiology Pari Pandharipande, MD, MPH. In the January 2013 issue of Radiology, Pandharipande, also an abdominal radiologist at Massachusetts
General Hospital, and her colleagues explored the importance of considering the relative timing of when a patient experiences a disease and when they incur radiation-induced cancer risks from an imaging study.
Diagnostic Imaging spoke with Pandharipande about this research.
Why did you decide to look at the risk associated with disease versus the risk of radiation-induced cancer from CT?
I’m a genitourinary and gastrointestinal radiologist by training, and I read a lot of scans for patients who are being followed with CT after treatment for testicular cancer. As part of my clinical practice, I know they receive a lot of scans at a young age. In collaboration with one of the oncologists here at Massachusetts General Hospital, I became interested in looking at what the radiation-induced cancer risks of those scans were over a lifetime relative to the risks of the disease itself.
When we conducted this analysis, we found that while the lifetime mortality risks from surveillance CT scans are slightly less than from testicular cancer, the loss of life expectancy attributable to the CT scans is much less. This is because of the delayed timing of deaths from radiation-induced cancers relative to deaths from testicular cancer itself.
That’s how this project came about: We want to do the best by these patients, and in that process, we have to try and understand how the risks from CT might affect them. Our goal is to reduce CT-related cancer risks for this patient group, but as a first step, we need to understand how these risks manifest over the lives of these patients.
Why is it important that people are aware of the timing of cancer risks from CT?
The concepts that we present regarding the importance of the timing of radiation-induced cancer risks can be applied to any disease process in which there’s an immediate risk that a physician is trying to avoid through imaging — one that would occur sooner in life than the risk of radiation-induced cancer from imaging. The difference in timing must be considered when you make an imaging decision because timing changes the relevance.
Risks incurred later in life are not the same as those faced in the present. That is the take-home message.
When you boil down this comparison, what is it that policymakers and referring physicians need to realize?
An important element to recognize is that while the metric of “life expectancy loss” does capture the timing of different risks over a population’s lifetime, reported life expectancy loss, in modeling studies, is averaged over a population and isn’t experienced by an individual patient. Most people understand risk as a certain chance of experiencing a particular event in their lives. It’s a challenge to figure out how to explain the importance of timing to a person — to explain what it means and deconstruct it in a way that’s understandable.
I hope this paper highlights that risks from radiation-induced cancers are conceptually difficult and that more research and effort should be placed on risk communication and physician and patient decision-making. Simply pointing out a risk to someone, be it a physician or a patient, is not enough guidance. We have to include the idea of timing, as well.
To read the remainder of the Q&A at its original location: http://www.diagnosticimaging.com/low-dose/content/article/113619/2121105?pageNumber=1
Published in the Dec. 24, 2012, Raleigh News & Observer and Charlotte Observer
By Whitney L.J. Howell
It’s a pretty common scene in a bar or club on any given Friday or Saturday night. One, maybe two, guys are eagerly chatting-up the hot girl with the cocktail in her hand. They’re trying their best to be witty, to be charming, to do anything to potentially win her affections – even using each other’s best lines.
Until now, however, no one considered that mice might be doing the same thing. But they could be. In fact, they’re probably more aggressive about it. Male mice don’t stop at pleasant conversation. They’ll chase a female while singing to her and trying to smell her.
Strange as it all may sound – and it does defy conventionally held beliefs about the ability of mice to “talk” – Erich Jarvis, Ph.D., neurobiology associate professor at Duke University, and his team
have discovered that mice may have some of the same brain features that humans and songbirds use for vocalizations and pitch changes.
“It’s accepted dogma that humans and songbirds are the only beings that have the four brain areas needed to produce vocalizations,” said Jarvis, who is also a Howard Hughes Medical Institute investigator. “Based on our research, we believe mice have more limited versions of these behavior and brain traits.”
The HHMI, National Science Foundation, and the National Institutes of Health funded Jarvis’ research.
The findings indicate that male mice may be able to learn how to change their vocalizations to match another male mouse. If correct, scientists may be forced to reconsider a belief they’ve held for 60 years – that vocal learning is unique to humans and a small cadre of songbirds.
With his former grad student Gustavo Arriaga, Jarvis used gene expression markers, which lit up neurons in the motor cortex – the part of the brain involved in planning, control and voluntary movement – of each mouse’s brain while they sang. When these song-specific neurons were damaged, the mice couldn’t keep their songs on-pitch or consistently repeat them, verifying their connection to vocalization.
In addition to the markers, the team injected a tracer to map the signals that controlled the songs as they migrated from neurons in the motor cortex to the brainstem and on to the larynx muscles. According to Jarvis, this direct channeling from motor cortex to larynx was the biggest surprise and puts into question whether these projections in mice work the same way as in humans and birds: Can mice learn vocalizations?
To make this determination, the team first had to record the sounds
mice make. They placed a pair of male mice in a cage with a single female to prompt communication and used a 4-inch high-sensitivity microphone to capture the sounds. The powerful microphone was necessary because mice “speak” at a frequency between 30 and 40 KHz – too high-pitched for humans to detect. Humans hear sounds between 14 and 15 KHz.
Jarvis’s team monitored 12 pairs of male mice over an 8-week period to see whether they began to imitate each other or the pitch of their songs converged. They conducted the experiment twice, and by the eighth week, he said, the less-dominant mouse had modified its song to emulate the dominant male.
By digitally modulating the recordings to a frequency audible to humans, the investigators demonstrated that, by the end of the experiment, the male mice had virtually identical songs.
“The mice were changing their pitch so the smaller animal matched the song of the larger male,” Jarvis said. “This is a simple form of imitation – it’s pitch. Until now, it was thought that they didn’t have this ability for vocal learning.”
Not everyone agrees with these findings, however. Kurt Hammerschmidt, a vocalization expert at the German Primate Center, is reticent to fully accept that mice can be true vocal learners. The problem, he said, is that Jarvis’ team simply didn’t analyze a large enough number of mice.
“Fewer animals is OK in neurobiological studies because we know anatomical structures found in one animal are also present in other animals,” Hammerschmidt said. “But with behavioral studies, we need more animals to look at motivation, arousal and experience.”
Hammerschmidt and other scientists worldwide have conducted experiments similar to Jarvis’s and have not replicated his findings. Hammerschmidt also disagrees that pitch convergence alone indicates that mice are vocal learners.
“All other studies focused on male courtship songs failed to find any evidence that learning is involved in the development of these vocalizations,” he wrote. “None of all other terrestrial mammals, except humans, are able to produce new sounds.”
Additional research is needed, Hammerschmidt said, to verify whether Jarvis’s findings are correct.
If Jarvis and his team are correct, though, these findings could impact both science and health care.
Although mice don’t have the same speaking ability as humans have, understanding their potential capacity for vocal learning could shed light on how speech works in people, as well. It could open the door for further research into the brain’s circuitry and the basic principles of speech, Jarvis said.
The greatest impact of this research, however, could be its effect on neurological disease, he said. In particular, autism is the brain disorder that has the biggest impact on speech, and the NIH and Congress have invested millions to study the causes and biological makeup of this condition. In these studies, investigators have been able to take the gene variant from a child with autism and put it into the mouse genome, but they’ve been unable to pinpoint which area of the brain is affected. This research eliminates that limitation.
“Now, we have the brain pathway for them to look and play around with,” Jarvis said. “It could open the door for some gene drug therapy on this part of the brain or help determine how we can affect the whole system.”
Published on the Dec. 6, 2012, DiagnosticImaging.com website
By Whitney L.J. Howell
Decades ago, radiology and radiation oncology decided to separate, giving rise to two distinct specialties. But times and technologies have changed, and it is, perhaps, time for two branches of radiology to consider a close relationship, said one industry expert.
During this year’s RSNA annual meeting last month in Chicago, William Shipley, MD, a radiation oncology professor at Harvard Medical School and chair of the Massachusetts General Hospital Genitourinary Oncology unit, proposed a partnership between radiation oncology (RO) and interventional radiology (IR).
“With all our new training and new societies, perhaps we’ve gone too far away from each other,” he said. “To survive as a specialty, we must adapt and look at which areas could marry.”
But is such a pairing necessary? According to Shipley, yes. Both RO and IR are facing challenges that they could better weather together. A paradox exists in RO, he said. As the specialty has become for technologically advanced, it has ceded many of its duties to other types of providers. For example, medical oncologists and surgeons frequently conduct patient evaluations, ablation, and brachytherapy procedures. IR faces a similar concern — unless these providers assume clinical responsibility for patients, they will lose ground to physicians who can acquire and learn to use the same imaging equipment.
“There are remarkable parallels between interventional radiology and radiation oncology,” he said. “I believe they’re running on the same track and at the same gauge. It’s time for their train tracks to merge.”
RO and IR would still continue as separate specialties. The goal, he said, would be to create a new certification — image-targeted oncology — for those residents interested in mastering skills in both areas. There’s already a great deal of overlap. RO has already become more imaging based, mirroring IR with its use of 3D, 4D, and stereotactic imaging. In addition, both types of providers use the same technologies, such as needles and ultrasound equipment. And, both still hold to continuing the oral exam.
In order for this merger to work, RO and IR must both bring attributes to the table. According to Shipley, RO would bring model of training that includes cancer biology, staging, chemotherapy strategy, and a process of care that incorporates medical and surgical oncology. Conversely, IR would offer a broad portfolio of therapies, including an ablative therapy that is complementary to radiation therapy.
“Radiation oncology is very good at irradiating the microbes of small-volume disease. And, most ablative technologies handle larger tumors, but they don’t address microscopic disease,” Shipley said. “Imagine how powerful it could be if we put them together.”
The advantages of combining these two branches of radiology would extend beyond offering a new training track to medical students and residents, he said. Patients who need these services would also benefit.
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/conference-reports/rsna2012/content/article/113619/2118473
Published on the Nov. 26, 2012, DiagnosticImaging.com website
By Whitney L.J. Howell
CHICAGO — With challenges looming on nearly every front, radiology needs a new group of strong leaders to navigate the trials and strengthen the profession, industry experts said at this year’s RSNA annual meeting.
Given proper leadership training, current radiology residents are positioned to be the profession’s next generation of leaders. But their training — if not already underway — must begin now if they’re going to fill the current void in the industry, said Richard Gunderman, MD, professor and vice chair of radiology at the University of Indiana.
“There are lots of radiology departments in the United States that lack leadership. Many have titular leaders, but in fact, they’re not being led or they’re being led poorly,” he said. “A lot of capability of the faculty and resident is lying dormant, and people are becoming more disengaged and discouraged than invigorated and encouraged.”
He recommended that faculty engrain in their residents the importance of team work — group accomplishment over individual successes — and embrace a leadership model that encourages others to work to their potential and contribute to either their practice or department.
It’s also paramount, he said, to encourage residents to think creatively so they will be best prepared to tackle future roadblocks.
“The single most important aspect of our residents isn’t their technical skills or their cognitive knowledge base. It’s their imagination,” Gunderman said. “What are we doing to foster the development of imagination in this next generation of radiologists?”
And, that creativity and outside-the-box thinking will be vital to addressing the difficulties the industry already knows are coming. Declining reimbursement, a new payment model, decreasing case volume, and encroaching teleradiology companies are just a few of the changes that threaten to erode the influence radiology departments and practices currently enjoy, said Vijay Rao, MD, chair of radiology at Jefferson Medical College at Thomas Jefferson University.
Surviving these trials requires a cultural shift in priorities that must start with residents, she said. Rather than perpetuate the culture of entitlement that is pervasive in many corners of radiology, faculty and private practitioners should teach residents to focus on quality and putting the patient first.
“We need to cultivate professionalism and eradicate apathy in the profession,” she said. “We must focus on reducing or eliminating inappropriate studies and doing the right thing by the patient.”
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/conference-reports/rsna2012/content/article/113619/2116427