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Everything you need to know about Computed Tomography (CT) & CT Scanning

April 2020 Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ April 2020

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Adrenal

  • “ACC is a rare, highly malignant tumor with a reported annual incidence of 1 cases per million in the united states according to the Surveillance, Epidemiology, and End Results- registry (SEER) database for ACC cases identified from 1974 to 2014. The previous reported annual incidence was 0.5–2 cases per million. Females are affected more commonly than males. The reported female-to-male ratio is 1.34:1, and most cases are unilateral. A bimodal age distribution has been described for ACC with one peak occurring in the first decade and a second peak later in the fifth decade of life. However, this bimodal presentation has been questioned with a recent study suggesting a predominantly unimodal distribution with a median age of diagnosis of 55 years.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • Primary Adrenal Carcinoma: Presentation
    - Hormonal abnormality (i.e. Cushings)(40-60%)
    - Flank or back pain (30%)
    - Incidental finding on CT (10-15%)
  • “The most common clinical presentation for functioning ACC is Cushing’s syndrome, characterized by symptoms related to excess corticosteroid synthesis including truncal obesity, diabetes, hypertension, easy bruising, and menstrual cycle irregularities. In females, virilization resulting from excess androgens may accompany signs of excess cortisol. A small percentage of male patients, present with signs of estrogen excess, such as gynecomastia, breast tenderness, decreased libido, and testicular atrophy.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “Although the majority of ACCs develop sporadically, many cases arise in association with various familial cancer syndromes including Li–Fraumeni, Beckwith–Wiedemann, and Lynch syndromes. Several genetic alterations have been noted to play an important role in the pathogenesis of ACC. Most of the drivers for the pathogenesis of ACC are related to mutations or downregu- lation of tumor suppressor genes, overexpression of certain growth factors, chromosomal aberrations, and dysregulation of certain important signaling pathways.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “Ki67 is among the most important markers in differentiating benign from malignant adrenal lesions. Lesions with Ki67 index greater than 5% are likely to be malignant. Moreover, Ki67 positivity is considered the single most important predictor for local recurrence after complete R0 surgical resection of ACC. Tumors with less than 10% Ki67 have significantly better clinical outcomes than those with greater than 10% Ki67.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “ACCs are typically large, with roughly 70% of tumors larger than 6 cm at the time of diagnosis. Size of the adrenal tumor, pattern of contrast enhancement, and degree of heter- ogeneity by CT are all important predictors of the malignant potential of the adrenal lesion. ACC is typically heterogeneous by CT and displays mixed intratumoral attenuation. An attenuation value of more than 10 HU on non-contrast CT has high sensitivity for detecting malignancy (93%), but a specificity of only 71–73%. Contrast enhancement is heterogeneous and may be increased peripherally due to central necrosis. ACC characteristically displays less washout of contrast than benign adrenal adenomas (absolute washout < 60% and relative washout < 40%). However, the use of adrenal washout charac- teristics should be reserved for homogenous well-defined masses.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “ACCs are typically large, with roughly 70% of tumors larger than 6 cm at the time of diagnosis. Size of the adrenal tumor, pattern of contrast enhancement, and degree of heterogeneity by CT are all important predictors of the malignant potential of the adrenal lesion. ACC is typically heterogeneous by CT and displays mixed intratumoral attenuation. An attenuation value of more than 10 HU on non-contrast CT has high sensitivity for detecting malignancy (93%), but a specificity of only 71–73%. Contrast enhancement is heterogeneous and may be increased peripherally due to central necrosis.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “An irregular tumor margin is a sign of aggressiveness; however, its absence is not a reliable sign of benignity. A thin rim of well-defined enhancement commonly detected around ACC likely represents the tumor capsule. Invasion of periadrenal fat and the surrounding organs or vasculature are other specific features of malignancy. IVC invasion is common at the time of diagnosis, and therefore, it is recommended that CT images extend to the level of the right atrium to exclude right atrial thrombus. Metastases are also relatively common at time of presentation, and the most common sites are in the liver, lung, bone, and retroperitoneal lymph nodes.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “An irregular tumor margin is a sign of aggressiveness; however, its absence is not a reliable sign of benignity. A thin rim of well-defined enhancement commonly detected around ACC likely represents the tumor capsule. Invasion of periadrenal fat and the surrounding organs or vasculature are other specific features of malignancy. IVC invasion is common at the time of diagnosis, and therefore, it is recommended that CT images extend to the level of the right atrium to exclude right atrial thrombus.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • “Although the presence of macroscopic fat is most commonly seen in benign myelolipoma, ACC may show areas of macroscopic fat as well. Other imaging and biochemical features should be kept in consideration to differentiate this rare manifestation of ACC from myelolipoma, as previously discussed. With any adrenal lesion, the appropriate workup depends on a variety of factors. Incorporating clinical, imaging, and biochemical data allow the formulation of a proposed systematic approach.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
  • Mimics of Adrenal Carcinoma
    - Pheochromocytoma
    - Adrenal adenoma
    - Adrenal metastases
    - Adrenal lymphoma
    - Ganglioneuroma and ganglioneuroblastoma
    - Adrenal hemorrhage and pseudocyst
    - Adrenal hemangioma
  • "Due to the high recurrence rate of ACC, close follow-up is recommended even after complete resection. Follow-up with abdominal CT or MRI and CT of the chest every 3 months for the first 2 years is recommended. Additional monitoring of steroid hormones level is essential, especially in hormonally active tumors to detect early recurrence. After 2 years of follow-up, the interval may be increased to every 6 months for 5 years. Approximately 90% of cases recur during the first five years after resection, so there is no clear recommendation for patient surveillance after 5 years. Annual follow-up for another 5 years might be adapted according to the clinical situation and the judgment of the physician.”
    Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management
    Ayahallah A. Ahmed et al.
    Abdominal Radiology 2020 (in press)
Chest

  • “Screening mammography aims to identify breast cancer at earlier stages of the disease, when treatment can be more successful . Despite the existence of screening programmes worldwide, the interpretation of mammograms is affected by high rates of false positives and false negatives .Here we present an artificial intelligence(AI) system that is capable of surpassing human experts in breast cancer prediction. To assess its performance in the clinical setting, we curated a large representative dataset from the UK and a large enriched dataset from the USA. We show an absolute reduction of 5.7% and 1.2% (USA and UK) in false positives and 9.4% and 2.7% in false negatives.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • “In an independent study of six radiologists, the AI system outperformed all of the human readers: the area under the receiver operating characteristic curve (AUC-ROC) for the AI system was greater than the AUC-ROC for the average radiologist by an absolute margin of 11.5%. We ran a simulation in which the AI system participated in the double-reading process that is used in the UK, and found that the AI system maintained non-inferior performance and reduced the workload of the second reader by 88%. This robust assessment of the AI system paves the way for clinical trials to improve the accuracy and efficiency of breast cancer screening.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • "The optimal use of the AI system within clinical workflows remains to be determined. The specificity advantage exhibited by the system suggests that it could help to reduce recall rates and unnecessary biopsies. The improvement in sensitivity exhibited in the US data shows that the AI system may be capable of detecting cancers earlier than the standard of care. An analysis of the localization performance of the AI system suggests it holds early promise for flagging suspicious regions for review by experts. Notably, the additional cancers identified by the AI system tended to be invasive rather than in situ disease.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • "Beyond improving reader performance, the technology described here may have a number of other clinical applications. Through simulation, we suggest how the system could obviate the need for double reading in 88% of UK screening cases, while maintaining a similar level of accuracy to the standard protocol. We also explore how high-confidence operating points can be used to triage high-risk cases and dismiss low-risk cases. These analyses highlight the potential of this technology to deliver screening results in a sustainable manner despite workforce shortages in countries such as the UK . Prospective clinical studies will be required to understand the full extent to which this technology can benefit patient care.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • “Type A aortic dissection is a surgical emergency occurring when an intimal tear in the aorta creates a false lumen in the ascending aorta. Prompt diagnosis and surgical treatment are imperative to optimize outcomes. Surgical repair requires replacement of the ascending aorta with or without aortic root or aortic arch replacement. Surgical outcomes for this highly lethal diagnosis have improved, with contemporary survival to discharge at Centers of Excellence of 85% to 90%. Survival is related to prompt treatment, preexisting medical comorbidities, presence or absence of end organ malperfusion, extent of aortic repair required, and the development of postoperative complications.”
    Acute Type A Aortic Dissection.
    Elsayed RS1, Cohen RG1, Fleischman F1, Bowdish ME2.
    Cardiol Clin. 2017 Aug;35(3):331-345
  • “The aorta is a conduit that extends from the left ventricle that delivers pulsatile blood distally to organs and tissue beds. Acute dissection of the ascending aorta is a lethal disease that requires prompt diagnosis and surgical intervention. Once almost exclusively a postmortem diagnosis, improvements in the accuracy of diagnostic modalities, anesthetic techniques, extracorporeal perfusion, methods of end organ protection during aortic replacement, types of prosthetic grafts, surgical techniques, and critical care have markedly improved outcomes over the last 40 years.”
    Acute Type A Aortic Dissection.
    Elsayed RS1, Cohen RG1, Fleischman F1, Bowdish ME2.
    Cardiol Clin. 2017 Aug;35(3):331-345
  • “If the dissection involves the ascending aorta, it is a Stanford type A. If the ascending aorta proximal to the innominate artery is not involved in the process, the dissection is called a Stanford type B. The less commonly used DeBakey classification system was initially proposed in 1955 and then modified in 1965 and 1982 to correspond more closely with the Stanford classification system based on whether the ascending aorta was involved regardless of the site of the intimal tear or distal extent of the dissection.DeBakey type I and II dissections both involve the ascending aorta; however, a type I extends beyond the innominate artery, whereas a type II is confined to the ascending aorta. DeBakey type I and II dissections both correspond to a Stanford type A dissection. A DeBakey type III dissection corresponds to a Stanford type B dissection, where the ascending aorta proximal to the innominate artery is not involved.”
    Acute Type A Aortic Dissection.
    Elsayed RS1, Cohen RG1, Fleischman F1, Bowdish ME2.
    Cardiol Clin. 2017 Aug;35(3):331-345
  • “Aortic dissection is the most common and disastrous event to affect the aorta. It occurs nearly 3 times as frequently as rupture of abdominal aortic aneurysms in the United States.Studies of acute aortic syndromes recorded at tertiary care centers suggest that type A aortic dissection remains the most frequently transferred emergency through regional rapid transport systems.It occurs with a greater frequency than type B aortic dissections, while both types occur more frequently in men in the sixth decade of life. Women with aortic dissection are more likely to present at an older age than men and to have atypical symptoms, which often delays the diagnosis and subsequent treatment, leading to higher mortality in some studies.”
    Acute Type A Aortic Dissection.
    Elsayed RS1, Cohen RG1, Fleischman F1, Bowdish ME2.
    Cardiol Clin. 2017 Aug;35(3):331-345
  • “Aortic dissection is the most common and disastrous event to affect the aorta. It occurs nearly 3 times as frequently as rupture of abdominal aortic aneurysms in the United States.Studies of acute aortic syndromes recorded at tertiary care centers suggest that type A aortic dissection remains the most frequently transferred emergency through regional rapid transport systems.It occurs with a greater frequency than type B aortic dissections, while both types occur more frequently in men in the sixth decade of life.”
    Acute Type A Aortic Dissection.
    Elsayed RS1, Cohen RG1, Fleischman F1, Bowdish ME2.
    Cardiol Clin. 2017 Aug;35(3):331-345
  • Risk factors for aortic dissection
    Lifestyle and cardiovascular risk factors
    • Long-term hypertension
    •  Old age
    • Dyslipidemia
    • Pregnancy-induced hypervolemia
    • Weight-lifting
    • Smoking
    • Cocaine abuse
  • Risk factors for aortic dissection
    Congenital and connective tissue disorders
    • Bicuspid aortic valve
    • Marfan syndrome
    • Loeys-Dietz syndrome
    • Ehlers-Danlos syndrome
    • Turner syndrome
  • Risk factors for aortic dissection
    Trauma-Aortic transection
    • Motor vehicle deceleration injury
    • Falling from height
  • Risk factors for aortic dissection
    Iatrogenic
    • Cardiac catheterization
    • Arterial cannulation for cardiopulmonary bypass
    • Aortic cross-clamping during valvular or aortic surgery
    • Intra-aortic balloon pumps
  • Risk factors for aortic dissection
    Vascular inflammation
    Autoimmune disease
    • Giant cell arteritis
    • Takayasu arteritis
    • Bechet disease
  • Risk factors for aortic dissection
    Infectious disease
    • Syphilis
    • Tuberculosis
  • “We propose four categories for reporting CT imaging findings potentially attributable to COVID19, each with suggested standardized language (Table 1). The reporting language does not offer an exact likelihood for COVID-19 pneumonia, which depends on several factors including prevalence in a community, exposure, risk factors, and clinical presentation. Rather, the reporting language focuses on CT findings reported in the literature and the typicality of these features in COVID-19 pneumonia rather than other diseases. Included in the reporting language are unique coding identifiers in brackets that can then be used for future data mining.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “Typical features are those that are reported in the literature to be frequently and more specifically seen in COVID-19 pneumonia in the current pandemic. The principal differential diagnosis includes some viral pneumonias, especially influenza, and acute lung injury patterns, particularly organizing pneumonia, either secondary, such as from drug toxicity and connective tissue disease, or idiopathic.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “Indeterminate features are those that have been reported in COVID-19 pneumonia but are not specific enough to arrive at a relatively confident radiological diagnosis. An example would be diffuse GGO without a clear distribution. This finding is common in COVID-19 pneumonia but occurs in a wide variety of diseases such as acute hypersensitivity pneumonitis, Pneumocystis infection, and diffuse alveolar hemorrhage, which are difficult to distinguish by imaging alone. .”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “Atypical features are those that are reported to be uncommon or not occurring in COVID-19 pneumonia and are more typical of other diseases such as lobar or segmental consolidation in the setting of a bacterial pneumonia, cavitation from necrotizing pneumonia, and tree-in-bud opacities with centrilobular nodules, as can occur with a variety of community acquired infections and aspiration.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “Negative for pneumonia implies that there are no parenchymal abnormalities that could be attributable to infection. Specifically, GGO and consolidation are absent. Importantly, there may be no findings on CT early in COVID-19. Conversely, CT has been reported to be more sensitive than RT-PCR earlier in the course of the disease, although this result may change with local RT-PCR test characteristics.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “Imaging appearances in the standardized reporting language are based upon available literature at the time of writing in March 2020, noting the retrospective nature of many reports, including biases related to patient selection in cohort studies, examination timing, and other potential confounders. As radiologists’ experience with COVID-19 increases, our categorization of these findings as typical, indeterminate, or atypical may evolve.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “We propose four categories for the suggested standardized CT reporting language of COVID-19 based on current literature and expert consensus. We acknowledge that for patients with unexpected findings that could be attributed to COVID-19, the matter is complex and that “viral pneumonia” is a reasonable alternative. As always, radiologists should follow the ACR Practice Parameters for Communication of Diagnostic Imaging Findings. If COVID-19 is a potential incidental diagnosis, staff at the site performing the exam should be notified to initiate SOP for potential exposure. We also acknowledge that practice patterns vary and this document is intended to provide guidance. If a radiologist chooses to mention COVID-19 in CT reports, this is a standard framework that can be adopted. Consensus between local imaging and clinical providers is essential to establish an agreed-upon approach.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020https://doi.org/10.1148/ryct.2020200152

  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020https://doi.org/10.1148/ryct.2020200152
  • “In this retrospective case series, chest CT scans of 21 symptomatic patients from China infected with the 2019 novel coronavirus (2019-nCoV) were reviewed, with emphasis on identifying and characterizing the most common findings. Typical CT findings included bilateral pulmonary parenchymal ground-glass and consolidative pulmonary opacities, sometimes with a rounded morphology and a peripheral lung distribution. Notably, lung cavitation, discrete pulmonary nodules, pleural effusions, and lymphadenopathy were absent. Follow-up imaging in a subset of patients during the study time window often demonstrated mild or moderate progression of disease, as manifested by increasing extent and density of lung opacities.”
    CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)
  • “This newly discovered virus has been temporarily named the 2019 novel coronavirus (2019-nCoV). Coronaviruses belong to the family Coronaviridae and the order Nidovarales, a family that includes viruses that cause diseases ranging from the common cold to severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS).”
    CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)
  • Key Results
    • Of 21 patients with the 2019 novel coronavirus, 15 (71%) had involvement of more than two lobes at chest CT, 12 (57%) had ground-glass opacities, seven (33%) had opacities with a rounded morphology, seven (33%) had a peripheral distribution of disease, six (29%) had consolidation with ground-glass opacities, and four (19%) had crazy-paving pattern.
    • Lung cavitation, discrete pulmonary nodules, pleural effusions, and lymphadenopathy were absent.
    • Fourteen percent of patients (three of 21) presented with a normal CT scan.
    CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)
  • “Viruses are a common cause of respiratory infection. Imaging findings of viral pneumonias are varied, overlapping with other infectious and inflammatory lung diseases. Viruses in the same viral family share a similar pathogenesis; therefore, CT may help identify distinguishing patterns and features in immunocompetent patients. These preliminary data suggest that the CT findings for 2019-nCoV have many similar features to the other coronaviruses: SARS and MERS.”
    CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)
  • “Lung involvement with a peripheral predominance was also seen in SARS and MERS. Likewise, previous coronavirus pneumonias were also associated with a crazy-paving pattern (defined as thickened interlobular septa and intralobular lines with superimposed ground-glass opacification), which was also seen in some of our patients. The absence of pulmonary cavitation, pleural effusions, and lymphadenopathy noted in our data.”
    CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)
  • “There is value in recognizing that the CT appearance of 2019-nCoV shares some similarities with that of other diseases that cause viral pneumonia, particularly those within the same viral family (SARS and MERS). Presently, worldwide public health measures are updating and evolving on a daily basis to manage this current outbreak. As new cases are identified, other unique pulmonary CT imaging manifestations may emerge as potential points for discernment in this patient population.”
    CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)

  • CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)
    Chung M et al.
    Radiology 2020 (in press)
  • Key Points
    • High-resolution CT (HRCT) of the chest is critical for early detection, evaluation of disease severity and follow-up of patients with the novel coronavirus pneumonia.
    • The manifestations of the novel coronavirus pneumonia are diverse and change rapidly.
    • Radiologists should be aware of the various features of the disease and temporal changes.
    Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. 
    Pan, Y., Guan, H., Zhou, S. et al. Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06731-x
  • “The mean number of affected lobes was 3.3 ± 1.8. Nineteen (30.2%) patients had one affected lobe, five (7.9%) patients had two affected lobes, four (6.3%) patients had three affected lobes, seven (11.1%) patients had four affected lobes while 28 (44.4%) patients had 5 affected lobes. Fifty-four (85.7%) patients had patchy/punctate ground glass opacities, 14 (22.2%) patients had GGO, 12 (19.0%) patients had patchy consolidation, 11 (17.5%) patients had fibrous stripes and 8 (12.7%) patients had irregular solid nodules. Fifty-four (85.7%) patients progressed, including single GGO increased, enlarged and consolidated; fibrous stripe enlarged, while solid nodules increased and enlarged.”
    Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. 
    Pan, Y., Guan, H., Zhou, S. et al. Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06731-x
  • "Coronavirus is a large RNA virus family. Six subtypes have been identified in the past, including SARS and MERS. 2019-nCoV is a new subtype whose genetic structure is 82% similar to SARS-CoV [2]. The source of infection is wild animals, which may be Chinese chrysanthemum head bats or snakes. 2019-nCoV can be transmitted through droplets or contact, and may also be transmitted through the fecal-oral route, with a high incidence and rapid infection, posing a huge threat to global public health [3]. Therefore, detecting the disease accurately and quickly is of great significance. Chest HRCT is an important screening tool for 2019-nCoV due to its high sensitivity and convenience. This study collected 63 confirmed new coronavirus pneumonia patients’ chest CT to analyze their imaging manifestations.”
    Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China.
    Pan, Y., Guan, H., Zhou, S. et al. Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06731-x
  • “This study shows that the most common manifestations of new coronavirus pneumonia are patchy/punctate ground glass opacities (85.7%), patchy consolidation (19.0%), and mainly distributed in a sub-pleural area; chest CT of the patients for re-examination after 3–14 days were also observed. It was found that, as the disease progressed, the range of ground glass density patches and consolidation increased, which were mainly distributed in the middle and outer zones of the lung. When patients' condition would improve, a little fibrous stripe may appear. Conversely, when patients' condition worsened, the lungs showed diffuse lesions, and the density of both lungs increased widely, showing a "white lung" appearance, which seriously affects the patient's lung function.”
    Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. 
    Pan, Y., Guan, H., Zhou, S. et al.  Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06731-x

  • Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. 
    Pan, Y., Guan, H., Zhou, S. et al. 
    Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06731-x

  • Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. 
    Pan, Y., Guan, H., Zhou, S. et al. 
    Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06731-x
  • Purpose: We aimed to compare chest HRCT lung signs identified in scans of differently aged patients with COVID-19 infections.
    Methods: Case data of patients diagnosed with COVID-19 infection in Hangzhou City, Zhejiang Province in China were collected, and chest HRCT signs of infected patients in four age groups (<18 years, 18-44 years, 45-59 years, ≥60 years) were compared.
    Results: Small patchy, ground-glass opacity (GGO), and consolidations were the main HRCT signs in 98 patients with confirmed COVID-19 infections. Patients aged 45–59 years and aged ≥60 years had more bilateral lung, lung lobe, and lung field involvement, and greater lesion numbers than patients <18 years. GGO accompanied with the interlobular septa thickening or a crazy-paving pattern, consolidation, and air bronchogram sign were more common in patients aged 45-59 years, and ≥60 years, than in those aged <18 years, and aged 18-44 years.
    Conclusions: Chest HRCT manifestations in patients with COVID-19 are related to patient’s age, and HRCT signs may be milder in younger patients.
    High-resolution computed tomography manifestations of COVID-19 infections in patients of different ages
    Chen Z, Fan H, Cai J et al.
    European Journal of Radiology(2020) ,doi:https://doi.org/10.1016/j.ejrad.2020.108972
  • Results: Small patchy, ground-glass opacity (GGO), and consolidations were the main HRCT signs in 98 patients with confirmed COVID-19 infections. Patients aged 45–59 years and aged ≥60 years had more bilateral lung, lung lobe, and lung field involvement, and greater lesion numbers than patients <18 years. GGO accompanied with the interlobular septa thickening or a crazy-paving pattern, consolidation, and air bronchogram sign were more common in patients aged 45-59 years, and ≥60 years, than in those aged <18 years, and aged 18-44 years.
    Conclusions: Chest HRCT manifestations in patients with COVID-19 are related to patient’s age, and HRCT signs may be milder in younger patients.
    High-resolution computed tomography manifestations of COVID-19 infections in patients of different ages
    Chen Z, Fan H, Cai J et al.
    European Journal of Radiology(2020) ,doi:https://doi.org/10.1016/j.ejrad.2020.108972
  • “In this study, the lesions of patients were mainly located in the lower lobe of the right lung. This finding may be related to the thick and short physiological structure of the right lower lobe bronchus, which may have allowed the virus to enter this area more easily. In addition, whether the air bronchogram is associated with the central representation needs further study. The lesions of patients were mostly distributed in peripheral zone of the lung (80.7%), probably because the virus mainly affects the terminal bronchioles and lung parenchyma around the respiratory bronchioles in the early stage.”
    High-resolution computed tomography manifestations of COVID-19 infections in patients of different ages
    Chen Z, Fan H, Cai J et al.
    European Journal of Radiology(2020) ,doi:https://doi.org/10.1016/j.ejrad.2020.108972
  • “In patients, GGO with a crazy paving pattern or interlobular septum thickening was the most common sign (48.8%), with PGGO (33.2%) second-most common. The lesions were mostly 1–3 cm patchy or nodular opacity (49.4%), and 56.2% of the lesions were accompanied with signs of air bronchogram.”
    High-resolution computed tomography manifestations of COVID-19 infections in patients of different ages
    Chen Z, Fan H, Cai J et al.
    European Journal of Radiology(2020) ,doi:https://doi.org/10.1016/j.ejrad.2020.108972
    (GGO, ground-glass opacity; PGGO, pure ground-glass opacity)
  • “Possible reasons for these findings are as follows: 1) adolescent cases are mostly third-generation infection cases, which may involve mainly family cluster cases. Furthermore, COVID-19 has weak virulence, resulting in lighter imaging signs in these patients ; 2) minors have immature lung structure development, resulting in atypical HRCT signs, and; 3) a COVID-19 attack on the immune system is more likely to cause diffuse alveolar damage and a large number of inflammatory exudations in middle-aged and older patients with more baseline diseases.”
    High-resolution computed tomography manifestations of COVID-19 infections in patients of different ages
    Chen Z, Fan H, Cai J et al.
    European Journal of Radiology(2020) ,doi:https://doi.org/10.1016/j.ejrad.2020.108972
  • “Finally, it's worth noting that the HRCT is depicting one second within the entire development of COVID-19, therefore different patterns might be expected in patients that undergo follow up. According to previous studies, , the lesions are related to the evolution time: they mainly manifests as GGO in the early stage (0-4 days),an increased crazy-paving pattern in the progressive stage (5-8 days) , consolidation in the peak stage (9-13 days), gradient resolution of consolidation in the dissipative stage (≥14 days).”
    High-resolution computed tomography manifestations of COVID-19 infections in patients of different ages
    Chen Z, Fan H, Cai J et al.
    European Journal of Radiology(2020) ,doi:https://doi.org/10.1016/j.ejrad.2020.108972
  • “CT is a useful tool for the surveillance of pneumonic lesions and is more likely to detect early and/or mild lesions in the virus lifecycle. Therefore, CT examinations play an important role in detecting or monitoring pulmonary parenchyma in patients suspected with COVID-19 pneumonia. Secondly, not all patients with COVID-19 have abnormal CT features. The real-time reverse transcriptase-polymerase chain reaction amplification of the viral DNA is considered the “gold standard”. Therefore, a CT examination and nuclear acid test should be used together for detecting COVID-19. Thirdly, fever and cough have been the most frequent initial symptoms, and radiologists should pay attention to these chief symptoms. Lastly, the history of exposure to other patients with COVID-19 or the epidemic area is critical to know. In conclusion, radiologists should make a comprehensive analysis when diagnosing COVID-19 infection that is beyond just assessing the radiological features.”  
    Key Considerations for Radiologists When Diagnosing the Novel Coronavirus Disease (COVID-19).
    Lei P, Mao J, Huang Z, Liu G, Wang P, Song W.    
    Korean J Radiol. 2020 Jan;21:e44.   https://doi.org/10.3348/kjr.2020.0190
  • “In conclusion, the patients with COVID-19 pneumonia had a typical transition from early stage to advanced stage and advanced stage to dissipating stage. The manifestations of single or multiple ground-glass opacities were observed and distributed along the bronchovascular or subpleural in the pulmonary parenchyma in the early stage, higher density consolidations were presented in the advanced stage, and ground-glass opacities and consolidations were absorbed in dissipating stage. However, the patients with fibrosis in follow CT were older, with longer LOS, higher rate of ICU admission than that of those who without fibrosis.”
    The Progression of Computed Tomographic (CT) Images in Patients with Coronavirus Disease (COVID-19) Pneumonia
    Lei, Dr. Pinggui
    Journal of Infection 2020 (in press)

  • Artificial Intelligence and COVID-19
  • Key Results:
    • A deep learning method was able to identify COVID-19 on chest CT exams (area under the receiver operating characteristic curve, 0.96).
    • A deep learning method to identify community acquired pneumonia on chest CT exams (area under the receiver operating characteristic curve, 0.95).
    • There is overlap in the chest CT imaging findings of all viral pneumonias with other chest diseases that encourages a multidisciplinary approach to the final diagnosis used for patient treatment.
    Artificial Intelligence Distinguishes COVID-19 from Community Acquired Pneumonia on Chest CT
    Lin Li t al.
    Radiology 2020 (in press)
  • “In this study, we designed and evaluated a three-dimensional deep learning model for detecting coronavirus disease 2019 (COVID-19) from chest CT images. On an independent testing data set, we showed that this model achieved high sensitivity (90% [95% CI: 83%, 94%] and high specificity of 96% [95% CI: 93%, 98%] in detecting COVID-19. The AUC values for COVID-19 and community acquired pneumonia (CAP) were 0.96 [95% CI: 0.94, 0.99] and 0.95 [95% CI: 0.93, 0.97], respectively.”
    Artificial Intelligence Distinguishes COVID-19 from Community Acquired Pneumonia on Chest CT
    Lin Li t al.
    Radiology 2020 (in press)
  • Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson*, Fernando U. Kay*, Suhny Abbara, Sanjeev Bhalla, Jonathan H. Chung, Michael Chung, Travis S. Henry, Jeffrey P. Kanne, Seth Kligerman, Jane P. Ko, Harold Litt
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152 
  • “We aim to provide guidance to radiologists in reporting CT findings potentially attributable to COVID-19 pneumonia, including standardized language to reduce reporting variability when addressing the possibility of COVID-19. When typical or indeterminate features of COVID-19 pneumonia are present in endemic areas as an incidental finding, we recommend contacting the referring providers to discuss the likelihood of viral infection. These incidental findings do not necessarily need to be reported as COVID-19 pneumonia. In this setting, using the term “viral pneumonia” can be a reasonable and inclusive alternative. However, if one opts to use the term "COVID-19" in the incidental setting, consider the provided standardized reporting language. In addition, practice patterns may vary, and this document is meant to serve as a guide. Consultation with clinical colleagues at each institution is suggested to establish a consensus reporting approach. The goal of this expert consensus is to help radiologists recognize findings of COVID-19 pneumonia and aid their communication with other healthcare providers, assisting management of patients during this pandemic.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152 
  • “Several papers have found that COVID-19 typically presents with GGO with or without consolidation in a peripheral, posterior, and diffuse or lower lung zone distribution. GGO has also been frequently reported to have round morphology or a “crazy paving” pattern. However, a significant portion of cases have opacities without a clear or specific distribution. A predominant perihilar pattern was not reported (8). Bronchial wall thickening, mucoid impactions, and nodules (“tree-in-bud” and centrilobular) seen commonly in infections, are not typically observed. Lymphadenopathy and pleural effusion have been rarely reported.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “The frequency of imaging findings also depends on when infected patients are imaged. A slight majority of patients had a negative CT during the first two days after symptom onset with GGO usually developing between day 0 and 4 after symptom onset and peaking at 6-13 days. Therefore, a negative CT should not be used to exclude the possibility of COVID-19, particularly early in the disease. Later in the course of the disease, the frequency of consolidation increases as does the likelihood of seeing a reverse halo or atoll sign, typically absent near the time of symptom onset.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
  • “Chest CT findings can precede positivity on reverse transcriptase polymerase chain reaction testing (RT-PCR). Early reports of RT-PCR sensitivity vary considerably, ranging from 42% to 71%, and an initially negative RT-PCR may take up to 4 days to convert in a patient with COVID-19 (26). The reported sensitivities and specificities of CT for COVID-19 vary widely (60 to 98% and 25% to 53%, respectively), likely due to the retrospective nature of the currently published studies, including lack of strict diagnostic criteria for imaging and procedural differences for confirming infection. The positive and negative predictive value of chest CT for COVID-19 are estimated at 92% and 42%, respectively, in a population with high pretest probability for the disease (e.g., 85% prevalence by RT-PCR). The relatively low negative predictive value suggests that CT may not be valuable as a screening test for COVID-19 at least in earlier stages of the disease.”
    Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.
    Scott Simpson et al.
    Published Online:Mar 25 2020 https://doi.org/10.1148/ryct.2020200152
Contrast

  • OBJECTIVE: The objective of our study was to compare the quality of bowel opacification from three different positive oral contrast agents-barium sulfate, diatrizoate, and iohexol-at abdominopelvic CT.
    CONCLUSION: The frequency of inhomogeneous bowel opacification was lower for iohexol than for diatrizoate or barium sulfate. Barium showed the highest frequency of bowel lumen heterogeneity. The iodinated agents showed greater increases in mean CT attenuation from the proximal bowel segments to the distal bowel segments than barium sulfate.
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • RESULTS: Fewer artifacts were detected with iohexol (4.3%) as the oral contrast agent than with diatrizoate (13.0%) and barium sulfate (14.3%) (each, p < 0.05). Barium showed a greater frequency of bowel lumen heterogeneity (388/831 segments, 47%) than iohexol (155/679, 23%) and diatrizoate (185/763, 24% segments) (p < 0.001). Barium showed higher CT attenuation than iohexol and diatrizoate in the stomach but lower CT attenuation in the ileum (each, p < 0.05).
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “We found that the frequency of nonuni- form opacification of bowel was higher with oral diatrizoate and barium sulfate than with iohexol at CT. The CT attenuation of all three types of positive oral contrast agents is lowest in the stomach and highest in the ileum, and the increase in CT attenuation from proximal to distal bowel is greater for diatrizoate and iohexol than for barium sulfate.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “There is a surprising paucity of published data on the comparative value of positive oral contrast material versus neutral or no oral contrast material for most general indications for abdominal CT. Nevertheless, in a consensus expert statement by the American College of Radiology and Society for Pediatric Radiology, positive oral contrast material is recognized to improve the delineation of bowel disease, such as abscesses or hypovascular tumors, from nonbowel disease and is also recognized to improve the delineation of bowel leaks.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “Although multiple studies of emergency department patients with relatively small sample sizes suggest that avoidance of oral contrast material may improve cost efficiency in that niche scenario, extrapolation of these narrowly staged studies to broader patient populations is not founded on solid evidence. Larger prospective multiinstitution studies that compare the value of positive, neutral, and no oral contrast material for the speed, accuracy, and confidence in diag- nosis of critical abdominal disease diagnoses in outpatients, oncology patients, and patients undergoing postoperative evaluations and in other scenarios are clearly needed.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • "In conclusion, we found that inhomogeneous opacification of the bowel lumen was more frequently seen with oral diatrizoate or barium sulfate than with oral iohexol at CT of the abdomen and pelvis. The iodinated agents showed a greater progressive increase in CT attenuation in more distal bowel segments than the more proximal bowel segments than was seen with barium sulfate. Further study is warranted to assess for the effects of these differences in bowel opacification on disease detection.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • Objectives: To determine whether positive oral contrast agents improve accuracy of abdominopelvic CT compared with no, neutral or negative oral contrast agent.
    Key points: 
    • There is no difference in the accuracy of CT with or without oral contrast agent.
    • There is no difference in the accuracy of CT with Gastrografin or water.
    • Omission of oral contrast, utilizing neutral or negative oral contrast agent saves time, costs and decreases risk of aspiration.
    Use of Positive Oral Contrast Agents in Abdominopelvic Computed Tomography for Blunt Abdominal Injury: Meta-Analysis and Systematic Review
    Chau Hung Lee 1, Benjamin Haaland, Arul Earnest, Cher Heng Tan
    Eur Radiol, 23(9), 2513-21
  • Introduction: Positive oral contrast is no longer deemed necessary for abdominopelvic computed tomography (CT) scans. Studies have shown water to be an equally effective oral contrast agent. However, to our knowledge no study has compared effectiveness between gastrografin and water in the same patient, which will provide a more objective evaluation of the two oral contrast agents. We aim to make a head-to-head comparison of water as neutral oral contrast (OC) against gastrografin as positive OC for abdominopelvic CT scans in the same patient.
    Conclusions: Water can be used in place of gastrografin as oral contrast in abdominopelvic CT without compromising visualization of abdominopelvic organs.
    Water as Neutral Oral Contrast Agent in Abdominopelvic CT: Comparing Effectiveness With Gastrografin in the Same Patient
    C H Lee 1, H Z Gu 2, B A Vellayappan 3, C H Tan   
    J Malaysia, 71 (6), 322-327 Dec 2016
  • Methods: A retrospective review of 206 abdominopelvic CT scans of 103 patients was performed. The scans were reviewed in consensus by two blinded radiologists. The ability to visualise each abdominopelvic organ, contrast- associated artefacts and small bowel wall delineation, was qualitatively scored on a 5-point scale. Each patient had two sets of scores, one with water and another with gastrografin as OC. Paired scores from the two OCs were evaluated by Wilcoxon signed rank test to determine any significant difference in performance between the two OCs for visualisation of abdominopelvic anatomy on CT.
    Water as Neutral Oral Contrast Agent in Abdominopelvic CT: Comparing Effectiveness With Gastrografin in the Same Patient
    C H Lee 1, H Z Gu 2, B A Vellayappan 3, C H Tan   
    J Malaysia, 71 (6), 322-327 Dec 2016
  • “There are several limitations of our study. First, detection of abdominopelvic pathology was not directly assessed. However, it can be extrapolated that optimal visualization of normal anatomical structures with water as OC would generally translate into similar diagnostic confidence in detecting pathology.”
    Water as Neutral Oral Contrast Agent in Abdominopelvic CT: Comparing Effectiveness With Gastrografin in the Same Patient
    C H Lee 1, H Z Gu 2, B A Vellayappan 3, H Tan   
    J Malaysia, 71 (6), 322-327 Dec 2016
  • "Our study confirms that water as a neutral OC is comparable to gastrografin in terms of enabling visualisation of abdominopelvic organs. This is in agreement with evidence in the literature. Moreover, comparing performance of the two OC agents in the same patient in our study gives a more accurate assessment. We suggest that water can be used in place of gastrografin as oral contrast in abdominopelvic CT without compromising scan interpretation.”
    Water as Neutral Oral Contrast Agent in Abdominopelvic CT: Comparing Effectiveness With Gastrografin in the Same Patient
    C H Lee 1, H Z Gu 2, B A Vellayappan 3, C H Tan
    J Malaysia, 71 (6), 322-327 Dec 2016
  • OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy.
    CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy. , it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • “A disturbing recent trend, however, is the increasing decision to forego positive oral contrast material largely (or solely) for increased patient throughput, typically driven by nonradiologists such as emergency department (ED) physicians, surgeons, and even health system administrators. As radiologists, we need to ensure that such financially driven nonmedical justifications are in the best interest of our patients.”
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10

  • Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • Indications for Positive Oral Contrast
    - Suspected postoperative bowel leak
    - Suspected gastrointestinal fistula
    - Suspected interloop abscess or other fluid collection
    - Oncologic staging and surveillance
    - Nonspecific abdominal pain or other symptoms (subacute)
  • "I believe that there is definitely still a role for positive oral contrast material in modern state-of-the-art abdominal CT. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process.”
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • “Our Emergency physicians do not see that oral contrast administration for CT hampers operational efficiency; in fact, they have expressed gratitude to our department for care in diagnosis. They have stated that delays in patient turnaround are more frequently related to overall demand on the scanner and not to the oral contrast consumption period. They are all acutely aware of the serious consequences of missed or incorrect diagnoses (either leading to inappropriate hospital admission or discharge), and will always choose good medical care over time slashing, corner cutting methods that impress the dashboard monitors perhaps at the expense of excellence in patient care.”
    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
    Megibow A.J.
    Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
  • “In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”
    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
    Megibow A.J.
    Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
Deep Learning

  • “Morphological features reflect volume, shape, and 3D geometric properties of the segmented ROI/VOI. Examples include diameter, surface area, volume, surface‐to‐volume ratio (an indirect measurement to assess spiculations), compactness, and sphericity. It also describes certain tumor characteristics, including location, vascularization, and presence of necrosis. These features are especially useful in tumor prognostication and diagnosis, including in the differentiation of benign and malignant lesions.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • "First-order statistics features are based on the first‐order histogram that describes distribution of voxel intensities in an image. The most common first‐order features are as fol‐ lows: (a) mean/median, average intensity of the pixels in the ROI/VOI; (b) standard deviation, dispersion of the mean, higher values indicate a wide range of intensity of the pixels in the ROI/VOI; (c) skewness, asymmetry of histogram, with positive values corresponding to a longer right tail of the his‐ togram; (d) kurtosis, magnitude of the histogram, with posi‐ tive values indicating that the curve is taller than a normal distribution; and (e) entropy, irregularity or randomness of the intensities, high values demonstrate a more heterogeneous area.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • "Second-order statistics features consider the inter‐voxel relationships in an image. Using grey level dependence matrices, the second‐order statistical features can be classi‐ fied into three groups: (a) grey level co‐occurrence matrix (GLCM); (b) grey level run length matrix (GLRLM); and (c) grey level size zone matrix (GLSZM). While GLCM considers the incidence of voxels of the same grey value at a predetermined distance along a fixed direction, GLRLM considers the incidence of voxels of the more than one grey alue using a fixed direction and GLSZM uses all matrix directions in the same evaluation.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • “Superior or higher-order statistics features these features have the advantage of considering the relationship with neighboring voxels [36] and are obtained using neighbor‐ hood grayscale difference matrices [32]. In this process, higher‐order statistical methods impose filter grids on the image to extract repetitive or nonrepetitive patterns.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • “Screening mammography aims to identify breast cancer at earlier stages of the disease, when treatment can be more successful . Despite the existence of screening programmes worldwide, the interpretation of mammograms is affected by high rates of false positives and false negatives .Here we present an artificial intelligence(AI) system that is capable of surpassing human experts in breast cancer prediction. To assess its performance in the clinical setting, we curated a large representative dataset from the UK and a large enriched dataset from the USA. We show an absolute reduction of 5.7% and 1.2% (USA and UK) in false positives and 9.4% and 2.7% in false negatives.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • “In an independent study of six radiologists, the AI system outperformed all of the human readers: the area under the receiver operating characteristic curve (AUC-ROC) for the AI system was greater than the AUC-ROC for the average radiologist by an absolute margin of 11.5%. We ran a simulation in which the AI system participated in the double-reading process that is used in the UK, and found that the AI system maintained non-inferior performance and reduced the workload of the second reader by 88%. This robust assessment of the AI system paves the way for clinical trials to improve the accuracy and efficiency of breast cancer screening.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • "The optimal use of the AI system within clinical workflows remains to be determined. The specificity advantage exhibited by the system suggests that it could help to reduce recall rates and unnecessary biopsies. The improvement in sensitivity exhibited in the US data shows that the AI system may be capable of detecting cancers earlier than the standard of care. An analysis of the localization performance of the AI system suggests it holds early promise for flagging suspicious regions for review by experts. Notably, the additional cancers identified by the AI system tended to be invasive rather than in situ disease.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • "Beyond improving reader performance, the technology described here may have a number of other clinical applications. Through simulation, we suggest how the system could obviate the need for double reading in 88% of UK screening cases, while maintaining a similar level of accuracy to the standard protocol. We also explore how high-confidence operating points can be used to triage high-risk cases and dismiss low-risk cases. These analyses highlight the potential of this technology to deliver screening results in a sustainable manner despite workforce shortages in countries such as the UK . Prospective clinical studies will be required to understand the full extent to which this technology can benefit patient care.”
    International evaluation of an AI system for breast cancer screening
    Scott Mayer McKinney et al
    Nature | Vol577 | 2January2020
  • Purpose: This study sought to establish a robust and fully automated Type B aortic dissection (TBAD) segmentation method by leveraging the emerging deep learning techniques.
    Conclusion: Deep learning-based model provides a promising approach for accurate and efficient segmentation of TBAD and makes it possible for automated measurements of TBAD anatomical features.
    Fully automatic segmentation of type B aortic dissection from CTA images T enabled by deep learning
    Long Cao et al.
    European Journal of Radiology 121 (2019) 108713

  • Fully automatic segmentation of type B aortic dissection from CTA images T enabled by deep learning
    Long Cao et al.
    European Journal of Radiology 121 (2019) 108713
  • Using the proposed deep learning-based models and workflow , we successfully demonstrated the feasibility of automatic TBAD segmentation. First, based on high-quality ground truth annotated by experts, we revealed that a CNN network with a multi-task output is capable of segmenting the TBAD into the whole aorta, TL, and FL simultaneously. CNN3 achieved the best DCSs of (0.93 ± 0.01, 0.93 ± 0.01, and 0.91 ± 0.02 for the whole aorta, TL, and FL, respectively), and calculated aortic lumen volumes that closely corre- spond to those of manual segmentation with only 0.038 ± 0.006 s per slice. These results indicate a significant step forward towards the automated measurement of TBAD.
    Fully automatic segmentation of type B aortic dissection from CTA images T enabled by deep learning
    Long Cao et al.
    European Journal of Radiology 121 (2019) 108713
  • “Human image analysis is based upon pattern recognition . In medicine, radiologists use pattern recognition when making a diagnosis. It is the heart of the matter. Pattern recognition has two components: pattern learning and pattern matching. Learning is a training or educational process; radiology trainees are taught the criteria of a normal chest X-ray examination and observe hundreds of normal examinations, eventually establishing a mental pattern of “normal.” Matching involves decision-making; when an unknown chest film is presented for interpretation, the radiologist compares this unknown pattern to their “normal” pattern and makes a decision as to whether or not the case is normal, or by exclusion, abnormal.”
    Medical Image Analysis: Human and Machine
    Robert Nick Bryan et al.
    Acad Radiol 2020; 27:76–81
  • "For a computer algorithm to mimic the radiologist in daily practice, it too must incorporate thousands of widgets and vast quantities of diverse data. Such a task may not be impossible, but it does not seem eminent. Furthermore, a radiologist can, when necessary, switch from heuristics to the deliberative mode and “open” the box to explain why they made a particular diagnosis. This often involves the explication of associated KFs (mass effect) that may simultaneously be important for clinical management (decompression).”
    Medical Image Analysis: Human and Machine
    Robert Nick Bryan et al.
    Acad Radiol 2020; 27:76–81
  • “A computer using contemporary computational tools functionally resembling human behavior could, in theory, read in image data as it comes from the scanner, extract KFs, find matching diagnoses, and integrate both into a standardized radiology report. The computer could populate the report with additional quantitative data, including organ/lesion volumetrics and statistical probabilities for the differential diagnosis. We predict that within 10 years this conjecture will be reality in daily radiology practice, with the computer operating at the level of subspecialty fellows. Both will require attending oversight. A combination of slow and fast thinking is important for radiologists and computers.”
    Medical Image Analysis: Human and Machine
    Robert Nick Bryan et al.
    Acad Radiol 2020; 27:76–81
  • “A much better characterization of the foreseeable future may be that although the demand for radiology services is likely to increase, and in an environment in which health care  resources will continue to be limited, AI, properly used, could help radiologists manage an increase in the demand for radiological services more efficiently ensuring that as a specialty  we can continue to provide optimal care for our patients.”
    Integrating Artificial Intelligence into Radiologic Practice: A Look to the Future
    Bibb Allen, Keith Dreyer, Geraldine D. McGinty
    JACR 2019 (in press)
  • “Whatever happens in radiology, the process will be equally gradual, allowing radiologists to potentially transform from report generators to the central managers of our patients’ diagnostic information integrating data from a variety of sources all facilitated by AI. If we sit back and do nothing, there is a chance we could be marginalized by AI. On the other hand, if we play a leadership role in AI development, the best days for radiologists, our specialty, and our patients are yet to come. So please consider us AI optimists too—not that AI will replace radiologists, but that AI will make us better physicians.”
    Integrating Artificial Intelligence into Radiologic Practice: A Look to the Future
    Bibb Allen, Keith Dreyer, Geraldine D. McGinty
    JACR 2019 (in press)
  • “Furthermore, AI does not have to be perfect to be helpful. Not  all radiologists perform identically on every case we interpret, and for that matter neither will AI. If AI recognizes abnormalities not identified by all radiologists and at the same time all radiologists also find abnormalities not recognized by AI, then the combination of humans plus AI has great potential to improve care.”
    Integrating Artificial Intelligence into Radiologic Practice: A Look to the Future
    Bibb Allen, Keith Dreyer, Geraldine D. McGinty
    JACR 2019 (in press)
  • "Patient preference as a reason to doubt autonomous radiological care by machines is debatable, and patient preferences will likely evolve. However, we consider medical care not unlike air travel. As air travelers, we want the aircraft we are flying on to have all of the latest automated features and recognize that the planes can indeed fly themselves. However, when will the public be ready to fly on pilotless airplanes? The combination of a human pilot assisted by robust computer automation seems to be current public preference. The same could be said for automated health care.”
    Integrating Artificial Intelligence into Radiologic Practice: A Look to the Future
    Bibb Allen, Keith Dreyer, Geraldine D. McGinty
    JACR 2019 (in press)
  • "In conclusion, we agree that there is more “unfounded hype” offered by those who believe AI will autonomously perform diagnostic imaging 281 interpretations and replace other aspects of physician care. We contend AI will significantly impact the practice of radiology but not diminish the need for well-trained radiologists.”
    Integrating Artificial Intelligence into Radiologic Practice: A Look to the Future
    Bibb Allen, Keith Dreyer, Geraldine D. McGinty
    JACR 2019 (in press)
  • "Whatever happens in radiology, the process will be equally gradual, allowing radiologists to potentially transform from report generators to the central managers of our patients’ diagnostic information integrating data from a variety of sources all facilitated by AI. If we sit back and do nothing, there is a chance we could be marginalized by AI. On the other hand, if we play a leadership role in AI development, the best days for radiologists, our specialty, and our patients are yet to come."
    Integrating Artificial Intelligence into Radiologic Practice: A Look to the Future
    Bibb Allen, Keith Dreyer, Geraldine D. McGinty
    JACR 2019 (in press)
  • “All belong to the supervised learning category where a known example is paired with a known label and both are used to train, or teach, the algorithm. This algorithm can then generalize to new, never before seen data of a similar type and scope. Supervised learning requires the input of trained experts, such as radiologists, and is expensive and time-consuming. Semi-supervised learning builds on a set of supervised learning examples to automatically label new, unlabeled training data. Unsupervised learning is a set of techniques that take untrained, unlabeled data and group it; such as k-means clustering, autoencoders, and dimensionality reduction techniques such as principal component analysis.”
    Machine Learning Principles for Radiology Investigators
    Borstelmann SM
    Acad Radiol 2020; 27:13–25
  • “While DL algorithms have exceeded the capabilities of classical statistical machine learning techniques on specific imaging tasks like multiclass classification, they require a large amount of data to function, are computationally expensive, and can be relatively opaque. ML algorithms are sometimes an easier way to get to an equivalent result, and can be used in tandem with DL. An initial evaluation of a smaller preliminary dataset may not be possible with a complex DL algorithm, but the lesser data requirements of a ML algorithm may yield significant insights and guidance at an earlier stage of data aggregation and overall study design.”
    Machine Learning Principles for Radiology Investigators
    Borstelmann SM
    Acad Radiol 2020; 27:13–25
Incidentaloma

  • - 1326 consecutive patients underwent EBCT coronary artery scoring exams
    - 25 % former or current smokers
    - 2 Board -certified CT radiologists reviewed examinations on a workstation using mediastinal windows, lung windows and bone windows
    - Significant extra-cardiac abnormalities were noted
    Prevalence of Significant Noncardiac Findings on Electron-Beam Computed Tomography Coronary Artery Calcium Screening Examinations
    Horton KM, Post WS, Blumenthal RS, Fishman EK
    Circulation 2002;106:532-534
  • “In this study, 7.8% of patients undergoing screening EBCT examinations for coronary artery calcification were found to have important extracardiac pathology requiring additional work-up. Therefore, it is essential that a radiologist review the entire examination.”
    Prevalence of Significant Noncardiac Findings on Electron-Beam Computed Tomography Coronary Artery Calcium Screening Examinations
    Horton KM, Post WS, Blumenthal RS, Fishman EK
    Circulation 2002;106:532-534
  • “Extracardiac findings were detected in 41 patients (24.7%). Findings were classified as minor (19.9%) or major (4.8%). Among the major findings, which had an immediate impact on patient management and treatment, were bronchial carcinoma and pulmonary emboli.”
    Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings
    Haller S et al
    AJR 2006 July; 187(1):105-110
  • “In the present study, 56.2% of asymptomatic patients undergoing coronary MDCT angiography were found to have significant extracardiac pathology requiring additional workup. Therefore it is essential that a radiologist should review the scans for abnormalities in structures other than the coronary arteries.”
    Prevalance of Significant Noncardiac Findings on coronary Multidetector Computed Tomography Angiography in Asymptomatic Patients
    Gil BN et al.
    J Comput Assist Tomogr 2007;31:1-4
  • “Among 6920 patients, 1642 (23.7%) had one or more extracardiac findings for a total of 1,901 findings in the broad viewing scheme. Of the 6.920 patients, 16.2% had a finding necessitating therapy, workup or followup.”
    Extracardiac Findings on Coronary CT Angiograms: Limited Versus Complete Image Review
    Johnson KM et al.
    AJR 2010; 195:143-148
  • “Volume analysis revealed that 35.5% of the total chest volume was displayed on dedicated coronary artery MDCT focused on the heart, whereas 70.3% of the chest was visible when MDCT raw data were reconstructed with the maximal field of view.”
    Coronary artery imaging with contrast-enhanced MDCT: extracardiac findings
    Haller S et al
    AJR 2006 July; 187(1):105-110
  • “Viewing of cardiac CT scans obtained only at a limited field of view can result in missing more than 67% of nodules greater than 1 cm. and more than 80% of nodules smaller than 1 cm.”
    Pulmonary Nodules Detected at Cardiac CT: Comparison of Images in Limited and Full Fields of View
    Northam M et al.
    AJR 2008; 191;878-881
  • “The prevalence of lung cancer at Cardiac CT was 0.31%; and 68% of these malignancies were at a resectable stage. Use of a limited FOV at cardiac scanning led to a large majority (89% (32 of 36 cancers) of the lung cancers detected at full thoracic scanning being missed; thus, inclusion of the entire chest at cardiac CT is advisable.”
    Lung Cancer Detected at Cardiac CT: Prevalence, Clinicoradiologic Features, and Importance of Full Field of View Images
    Kim TJ et al.
    Radiology 2010; 255:369-376
  • “The prevalence of lung cancer at Cardiac CT was 0.31%; and 68% of these malignancies were at a resectable stage. Use of a limited FOV at cardiac scanning led to a large majority (89% (32 of 36 cancers) of the lung cancers detected at full thoracic scanning being missed; thus, inclusion of the entire chest at cardiac CT is advisable.”
  • “It is essential that the entire imaging data set, including full-FOV images, be evaluated at cardiac CT, because viewing in the limited FOV at cardiac scanning may result in the majority of lung cancers that could be detected on full-FOV images being missed.”
    Lung Cancer Detected at Cardiac CT: Prevalence, Clinicoradiologic Features, and Importance of Full Field of View Images
    Kim TJ et al .
    Radiology 2010; 255:369-376
  • Large field of view vs Small field of view
    - Large field of view was 35-40 cm and review was of soft tissue and lung windows
    - Small field of view was 25 cm to include the heart and was reviewed at soft tissue windows only
  • “Almost one fourth of all patients who underwent diagnostic coronary CT angiography in this study had extracardiac findings. Several serious diagnoses were missed with the limited viewing approach, but use of the broad viewing approach led to more workup and follow-up imaging.”
    Extracardiac Findings on Coronary CT Angiograms: Limited Versus Complete Image Review
    Johnson KM et al.
    AJR 2010; 195:143-148
  • “In the focused viewing scheme, 90.9% of the findings necessitating therapy, 64.1% necessitating workup, and 51.2% necessitating follow-up were missed. Use of the focused approach resulted in fewer false positive diagnosis but 5 malignant tumors of the breast, 88 lung infiltrates, 43 cases of lymphadenopathy, 2 cases of polycystic kidney, one breast abscess and one case of splenic flexure diverticulitis were missed.”
Liver

  • “Radiomics is a new field in medical imaging with the potential of changing medical practice. Radiomics is characterized by the extraction of several quantitative imaging features which are not visible to the naked eye from conventional imaging modalities, and its correlation with specific relevant clinical endpoints, such as pathology, therapeutic response, and survival. Several studies have evaluated the use of radiomics in patients with hepatocellular carcinoma (HCC) with encouraging results, particularly in the pretreatment prediction of tumor biological characteristics, risk of recurrence, and survival.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • Radiomics is an emerging field that converts medical imaging into high‐dimensional mineable features, providing a quantitative assessment of the image. These features can then be associated to clinical endpoints, such as pathology, therapeutic response, and survival. With the quantitative analysis of digital imaging, radiomics can potentially detect specific characteristics of a disease that otherwise could not be accessed visually with a potential to inform future precision medicine.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • “Radiomics is characterized by the extraction of quantitative imaging features from conventional imaging modalities using computer based algorithms and the correlation of these features with relevant clinical endpoints, such as pathology, therapeutic response, and survival. These quantitative data are called radiomics features, of which texture features are a subset.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)

  • State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • “Morphological features reflect volume, shape, and 3D geometric properties of the segmented ROI/VOI. Examples include diameter, surface area, volume, surface‐to‐volume ratio (an indirect measurement to assess spiculations), compactness, and sphericity. It also describes certain tumor characteristics, including location, vascularization, and presence of necrosis. These features are especially useful in tumor prognostication and diagnosis, including in the differentiation of benign and malignant lesions.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • "First-order statistics features are based on the first‐order histogram that describes distribution of voxel intensities in an image. The most common first‐order features are as fol‐ lows: (a) mean/median, average intensity of the pixels in the ROI/VOI; (b) standard deviation, dispersion of the mean, higher values indicate a wide range of intensity of the pixels in the ROI/VOI; (c) skewness, asymmetry of histogram, with positive values corresponding to a longer right tail of the his‐ togram; (d) kurtosis, magnitude of the histogram, with posi‐ tive values indicating that the curve is taller than a normal distribution; and (e) entropy, irregularity or randomness of the intensities, high values demonstrate a more heterogeneous area.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • "Second-order statistics features consider the inter‐voxel relationships in an image. Using grey level dependence matrices, the second‐order statistical features can be classi‐ fied into three groups: (a) grey level co‐occurrence matrix (GLCM); (b) grey level run length matrix (GLRLM); and (c) grey level size zone matrix (GLSZM). While GLCM considers the incidence of voxels of the same grey value at a predetermined distance along a fixed direction, GLRLM considers the incidence of voxels of the more than one grey alue using a fixed direction and GLSZM uses all matrix directions in the same evaluation.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
  • “Superior or higher-order statistics features these features have the advantage of considering the relationship with neighboring voxels [36] and are obtained using neighbor‐ hood grayscale difference matrices [32]. In this process, higher‐order statistical methods impose filter grids on the image to extract repetitive or nonrepetitive patterns.”
    State‐of‐the‐art in radiomics of hepatocellular carcinoma: a review of basic principles, applications, and limitations
    Santos JM et al.
    Abdominal Radiology 2019 (in press)
Pancreas

  • “In the era of personalized medicine, challenges in diagnosis and complexity of treatment strategies necessitate an MDC to achieve an accurate diagnosis and tailor patient care pathways. In addition, a large body of evidence demonstrated that poor interpersonal communication between healthcare providers accounts for ~ 80% of healthcare errors. As such, building an MDC team is strongly advocated for complex diseases which can minimize errors and result in improved patient care.”
    Value of multidisciplinary collaboration in acute and chronic pancreatitis
    Arya Haj‐Mirzaian· Bhavik N. Patel · Elliot K. Fishman · Atif Zaheer
    Abdominal Radiology 2020 https://doi.org/10.1007/s00261-019-02320-9
  • "Published literature supported the idea that MDC and MDM can improve the management of pancreatitis and pancreatic cancer. Chingkoe et al. assessed the impact of MDMs on changing management of pancreatic disorders. The total number of 252 patients, including 52 patients with acute/chronic pancreatitis, was included and abdominal CT scans and MRIs were reassessed. Authors showed that MDMs changed the imaging interpretation of 33.7% cases (moderate or significant change)—23.5% of which had acute/chronic pancreatitis. MDMs also changed the overall diagnosis of 8.7% and treatment of 17.9% cases.”
    Value of multidisciplinary collaboration in acute and chronic pancreatitis
    Arya Haj‐Mirzaian· Bhavik N. Patel · Elliot K. Fishman · Atif Zaheer
    Abdominal Radiology 2020 https://doi.org/10.1007/s00261-019-02320-9
  • "Despite promising results about the benefits of MDMs in the management of pancreatitis, the utility of MDMs is subject of debate and some limitations exist that should be addressed by future studies. First, only a few studies evaluated MDM of pancreatitis, and more structured studies focusing on pancreatitis MDMs should be performed. Second, some studies reported that MDMs have no significant impact on the clinical outcomes of patients, and the effect of MDC on overall survival is yet to be investigated. Third, a significant proportion of primary physicians do not follow MDM recommendations.”
    Value of multidisciplinary collaboration in acute and chronic pancreatitis
    Arya Haj‐Mirzaian· Bhavik N. Patel · Elliot K. Fishman · Atif Zaheer
    Abdominal Radiology 2020 https://doi.org/10.1007/s00261-019-02320-9
  • "Some tertiary medical centers utilized multidisciplinary clinics for better assessment of complex diseases. Comparing MDMs, multidisciplinary clinics have the same participants with the advantage of visiting patients, performing history and physical exams, and considering patient comorbidities and desires. In a study reviewing the medical records of 203 patients with pancreatic cancer in a multidisciplinary clinic, re-evaluation of images resulted in 18.7% change in the stage of cancer, and an overall 24% change in the management. In Van Hagen et al. study, utilizing multidisciplinary clinic resulted in a 34.5% change in the management of patients with gastrointestinal malignancies. More studies need to be performed to evaluate the beneficial impact of multidisciplinary clinics in the management of pancreatitis.”
    Value of multidisciplinary collaboration in acute and chronic pancreatitis
    Arya Haj‐Mirzaian· Bhavik N. Patel · Elliot K. Fishman · Atif Zaheer
    Abdominal Radiology 2020 https://doi.org/10.1007/s00261-019-02320-9
  • "MDC could be considered as the best practical approach for the management of patients with acute/chronic pan- creatitis, especially at tertiary care centers and developed healthcare systems. Considering the heterogeneity of pancreatitis, proper diagnosis and management require a proper interaction between radiology, pathology, gastroenterology, and surgery specialists. Critical differential diagnoses such as PDAC as well as a broad spectrum of available treatment plans necessitate the utilization of pancreatitis MDC. Further research focusing on pancreatitis MDM, teleconferences, and nationwide expert panels need to be performed. Furthermore, it is yet to be determined whether the benefits of pancreatitis MDMs outweigh the costs and disadvantages of meetings.”
    Value of multidisciplinary collaboration in acute and chronic pancreatitis
    Arya Haj‐Mirzaian· Bhavik N. Patel · Elliot K. Fishman · Atif Zaheer
    Abdominal Radiology 2020 https://doi.org/10.1007/s00261-019-02320-9 
  • “In addition to traditional methods, cinematic rendering (CR) as a novel 3D rendering technique can be used to generate photorealistic with more accurate information regarding the anatomical details. CR can assist clinicians to visualize precisely the extent of tumor vascular invasion, which might be critical for surgical planning; however, the feasibility of this method and other novel techniques in routine clinical practice is yet to be studied.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • “The survival of patients with small PDACs (particularly ≤ 20 mm), 30% at 5 years, is better than it is for patients with larger cancers. However, small tumors are the most difficult to visualize and the sensitivity of MDCT is lower for detection of small PDACs. In a retrospective study by Yoon et al. with 33 PDAC patients who underwent CT prior to the diagnosis of PDAC, the tumor could be identified in 72.7% (24/33) of cases. Of these prospectively missed cases, 87.5% (21/24) were ≤ 20 mm and 12.5% (3/24) were between 21 and 33 mm.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • “Regarding the secondary signs, the presence of common bile duct and main pancreatic ductal dilatation, pancreatic ductal caliber change and abrupt duct cut-off at the level of the tumor, abnormal pancreas contour, pancreatic atrophy, and pancreatitis are highly suspicious for small PDACs, even in the absence of a clearly defined mass. Yoon et al. showed that secondary signs could be a solution to the concerns associated with detecting small PDACs. They demonstrated that 76% of small PDAC had secondary signs—with main pancreatic duct or common bile duct dilatation (63%), abrupt pancreatic duct cut-off (63%), parenchymal atrophy (21%), and contour abnormality (14%).”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • "PDACs can sometimes be isoenhancing, and when they are, they are often misdiagnosed or unrecognized. Isoenhancing mass is defined as a lesion with an attenuation difference of < 15 HU in comparison with background parenchyma in all phases. It has been shown that 5–45% of PDACs are isoattenuating relative to the remainder pancreatic parenchyma on both late arterial and portal venous phases. Isoenhancement is more commonly seen in smaller tumors, which make the diagnosis even more challenging. It should be noted that small isoattenuating PDAC should not be regarded as early cancers, since only a small proportion of these lesions are stage T1 tumors."
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • “Among secondary imaging features of PDAC, we emphasized the importance of irregularities of the main pancreatic duct. The pancreatic duct needs to be carefully evaluated for any subtle contour irregularities, filling defects, or obstructive lesions. Several case reports have documented patients suspected to PDAC who were believed to have normal findings on previous MDCT and MRI, but subtle pancreatic duct irregularity was found in the re-assessment of prior images or endoscopic retrograde cholangiopancreatography (ERCP). From our experience, subtle pancreatic duct irregularity may be best shown on oblique coronal and sagittal MPR CT (and MR) images that optimizes visualization of the pancreatic duct.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • “In addition, elevated IgG4 levels suggest AIP, but IgG4 can be normal in some AIP patients and normal serum IgG4 does not exclude AIP. As part of both diagnosis and treatment, most AIP patients show excellent response to steroids. The imaging features of focal pancreatitis including focal AIP, acute pancreatitis, and chronic pancreatitis can mimic a focal mass, and the possible interpretation errors are discussed in the next sections.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • “Metastases to the pancreas are most commonly from cancers of the kidney, lung, breast and colorectal, and from melanoma. Overall, 15–44% of pancreatic metastases have a diffuse morphological pattern. The appearance of pancreatic metastases can be similar to primary PDAC on MDCT. Pancreatic metastases often show peripheral or homogeneous (less common) enhance- ment; while PDACs are generally hypoattenuating lesions.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • “IPMNs account for 20% of all cystic pancreatic neoplasms and are divided into main-duct, branch-duct, and mixed subtypes. Most IPMNs are incidentally detected on cross-sectional imaging performed for other clinical indications, and it has been estimated that half of the incidentally detected pancreatic cysts are IPMNs. As pre-cancerous lesions, IPMNs can progress to higher grades of dysplasia and to invasive PDAC, which results in the coexisting malignancy rate of 12–68%. In this regard, the precise diagnosis of PDAC arising from IPMN is of importance, since 10% of diagnosed PDACs are related to the underlying IPMNs.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • "MDCT is one of the most commonly used imaging modalities for the initial evaluation of suspected PDAC. Several pitfalls are associated with diagnoses of PDAC using MDCT. Optimal imaging technique is key to the detection of subtle cases, and errors in each step of image acquisition carry a potential for contributing to misdiagnosis. Accurate diagnosis requires familiarity with a variety of factors that can lead to interpretation errors. Detection of PDAC can be challenging due to intrinsic tumor features and presence of coexisting pathology that can distract the radiologist from the more subtle lesions. Normal structures and non-neoplastic diseases can also mimic the imaging appearance of PDAC. Recognition and mitigation of such technical and interpretation errors can help early PDAC diagnosis and improve patient prognosis.”
    Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors
    Arya Haj‐Mirzaian · Satomi Kawamoto · Atif Zaheer · Ralph H. Hruban · Elliot K. Fishman · Linda C. Chu
    Abdominal Radiology 2020 (in press)
  • Mimickers of PDAC: Differetial Diagnosis
    - Focal fatty infiltration
    - Intrapancreatic accessory spleen (IPAS)
    - Pancreatitis
  • "Type I AIP is associated with high serum IgG4 levels; however, high serum IgG4 levels can also be seen in 7–10% of PDAC. It was reported that an IgG4 level greater than 135 mg/dL can differentiate autoimmune pancreatitis from PDAC with 95% sensitivity and 97% specificity. On the other hand, type II AIP is often associated with normal serum IgG4 level.”
    Pancreatitis and PDAC: association and differentiation
    Sherif B. Elsherif et al.
    Abdominal Radiology 2019 (in press) https://doi.org/10.1007/s00261-019-02292-w
  • "In conclusion, differentiating pancreatic cancer from mass- forming chronic pancreatitis remains a major and primary problem in the imaging and management of pancreatic masses. There is an overlap between MFCP and PDAC on imaging for multiple modalities, but certain imaging features such as enhancement pattern/perfusion on contrast-enhanced studies, iodine content on spectral CT, main pancreatic duct findings such as the duct-penetrating sign and double-duct sign on MRCP, and ADC value on DWI may be able to suggest pancreatic cancer versus chronic pancreatitis as the likely diagnosis. Overall, biopsy is currently still necessary to establish the diagnosis. These advances in imaging nev- ertheless do show promise for developing in the future a non-invasive approach in differentiating these two entities.”
    Pancreatitis and PDAC: association and differentiation
    Sherif B. Elsherif et al.
    Abdominal Radiology 2019 (in press) https://doi.org/10.1007/s00261-019-02292-w
  • Objectives: The primary aim of this study was to determine if computed tomographic (CT) texture analysis measurements of the tumor are independently associated with progression-free survival (PFS) and overall survival (OS) in patients with unresectable pancreatic ductal adenocarcinoma (PDAC), including both unresectable locally advanced and metastatic PDAC, who were treated with chemotherapy.
    Conclusions: Pretreatment CT quantitative imaging biomarkers from texture analysis are associated with PFS and OS in patients with unresectable PDAC who were treated with chemotherapy, and the combination of pre- treatment texture parameters and tumor size have the potential to perform better in survival models than imaging biomarker alone.
    Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197
  • "CT texture analysis, a novel imaging post-processing tool, can reflect tumor heterogeneity through analyzing the distribution of pixel intensities in CT images and identifying relationships among those intensities. This may reveal subtle differences imperceptible to the naked eye, thereby compensating for the limitations of conventional CT.”
    Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197
  • “CT texture analysis relies on objective computer-aided evaluation of gray-level patterns within lesions to assess tumor heterogeneity quantitatively in terms of numerous relevant parameters, which has been used in the prediction of various cancer prognosis . In locally advanced rectal cancer, CT texture features have been associated with better neoadjuvant chemoradiotherapy response and higher disease-free survival . In pancreatic adenocarcinoma, CT-derived texture features of dissimilarity and inverse normalized differences may be promising prognostic imaging biomarkers of overall survival in patients undergoing surgical resection with curative intent.”
    Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197

  • Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197
  • "Notably, texture analysis was performed in the portal phase of the contrast enhanced CT in our present study according to previous studies. Although Bronstein et al. proved that the pancreatic phase was preferred to the portal phase, the quantitative assessment of McNulty et al. found that tumor conspicuity is equivalent in the pancreatic and portal phases. Furthermore, during the portal phase, the progressive accumulation of contrast medium within the tumor might provide more comprehensive information of the biological character- istics of tumors. Thus, the above reasons might explain why portal phase was chosen by previous studies for texture analysis.”
    Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197
  • "In this study, CT texture analysis was only performed on a single image which represent the largest area of the lesion. This may not exactly and comprehensively reflect disease characteristics, although prior studies reported that comparison of 2D vs. 3D measurements of single lesions showed fairly comparable results.”
    Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197
  • “In conclusion, instead of post-chemotherapy texture parameters or Δ value, pre-chemotherapy could provide more information about tumor biology. Therefore, using pre-chemotherapy texture of unresectable PDAC to predict survival is more accurate and reliable. Furthermore, texture analysis as a noninvasive image-processing tool has the potential to select patients with good prognosis before therapy, indicating a promising prospect of clinical application in the future.”
    Unresectable pancreatic ductal adenocarcinoma: Role of CT quantitative T imaging biomarkers for predicting outcomes of patients treated with chemotherapy
    S.-H. Cheng, et al.
    European Journal of Radiology 113 (2019) 188–197
  • Background: Texture analysis of medical images has been reported to be a reliable method for differential diagnosis of neoplasms. This study was to investigate the performance of textural features and the combined performance of textural features and morphological characteristics in the differential diagnosis of pancreatic serous and mucinous cystadenomas.
    Conclusions: In conclusion, our preliminary results highlighted the potential of CT texture analysis in discriminating pancreatic serous cystadenoma from mucinous cystadenoma. Furthermore, the combination of morphological characteristics and textural features can significantly improve the diagnostic performance, which may provide a reliable method for selecting patients with surgical intervention indications in consideration of the different treatment principles of the two diseases.
    Differential diagnosis of pancreatic serous cystadenoma and mucinous cystadenoma: utility of textural features in combination with morphological characteristics
    Jing Yang et al.
    BMC Cancer (2019) 19:1223 https://doi.org/10.1186/s12885-019-6421-7
  • “In conclusion, our preliminary results highlighted the potential of CT texture analysis to discriminate pancreatic serous cystadenoma and mucinous cystadenoma. Furthermore, the combination of morphological characteristics and textural features can significantly improve differential diagnostic performance, which may provide a reliable method for selecting pancreatic cystadenoma patients who need surgical intervention.”
    Differential diagnosis of pancreatic serous cystadenoma and mucinous cystadenoma: utility of textural features in combination with morphological characteristics
    Jing Yang et al.
    BMC Cancer (2019) 19:1223 https://doi.org/10.1186/s12885-019-6421-7
  • "Thus, surgical intervention should be proposed in a minority of patients with serous cystadenoma, and only for those who had uncertain diagnosis after systemic examinations or had symptoms. Given the risk of invasive disease and the relatively young age at diagnosis, surgical management is recommended for all mucinous cystadenoma patients who are medically fit for the surgery. Therefore, the differential diagnosis of the two diseases is clinically crucial for the choice of treatment regimen.”
    Differential diagnosis of pancreatic serous cystadenoma and mucinous cystadenoma: utility of textural features in combination with morphological characteristics
    Jing Yang et al.
    BMC Cancer (2019) 19:1223 https://doi.org/10.1186/s12885-019-6421-7
Practice Management

  • “Now, more than 100 trillion messages (includes text messages, comments, and shares) are sent each year, with more than 3.8 trillion of those having emojis, stickers, or GIFs attached. Messages are the most common digital activity, dwarfing the number of Google searches each year.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
  • "In live conversation, 7% of content is transmitted by words, 38% by tone of voice, and 55% by body language. The advent of text messaging took away 93% of conversational content. The emoticon helped bring back some of that context, and was then replaced by the much more versatile and information-rich emoji.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
  • “A smiling- face emoji with eyes directed down may be interpreted by many people in Western countries as an indication of happiness in a message. But that same emoji may be interpreted as a sarcastic put-down in some Eastern cultures. Furthermore, the emojis people use can evolve over time; older individuals often convey happiness with a “thumbs-up” emoji, whereas younger people will use smiling and laughing face. The more recently a given emoji has been released, the more common its use among younger individuals will be.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
  • “When properly deployed, the combination of conversational understanding, participant understanding, and appropriately recommended content allows AI to understand the nuance of context and leads to genuine conversational intelligence. Our approach at Holler has been to apply anonymized conversational intelligence to brands, which has allowed brands to reach consumers and improve their conversations without being intrusive.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
  • “Altogether, the manner in which we carry out conversations using messaging on digital platforms will continue to rapidly change and evolve. Our ability to reflect subtle feelings and emotions through context will expand, and AI will have a large role to play in that. Although allowing people to have great conversations is an important goal for all messaging platforms, we must not lose sight of the need to protect privacy.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
  • “Communication in medicine is evolving parallel to communication in our culture more broadly. Staying in contact with our patients and our colleagues is increasingly done through digital platforms and messaging. Developing improved digital communication methods that incorporate added context to more completely convey our feelings and ideas can be an important aspect of future communication in the medical field.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
  • “As the field of medicine inevitably incorporates more messaging into our daily work flow and processes, we will have to confront important considerations, as outlined in Mr. Montaque’s talk. For example, given the highly sensitive nature of protected health information, maintaining privacy will be of utmost importance. Furthermore, with the ability to incorporate brands into messaging in an unobtrusive way, hospitals and practices may be able to subtly insert reminders regarding important health maintenance procedures, such as mammograms or colonoscopies, into everyday conversation.”
    The Future of Digital Communication:Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)

  • The Future of Digital Communication: Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)

  • The Future of Digital Communication: Improved Messaging Context, Artificial Intelligence, and Your Privacy
    Travis Montaque, Elliot K. Fishman,Steven P. Rowe
    JACR 2020 (in press)
Quotes

Radiation Dose

  • “Instead because the volume CTDI is displayed on the scanner console before the initiation of a scan ( to allow the operator to confirm that the proper scanner output is programmed) and recorded as part of the patients examination information, many users incorrectly assume that it is the dose to that particular patient.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
  • “The CTDI values are included in either a screen captured “patient dose report” or a structured Digital Imaging and Communications in Medicine dose report, which reinforces the incorrect belief that CTDI is a measure of patient dose.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
  • “The CTDI is a standardized measure of the radiation output of a CT system, measured in a cylindrical acrylic phantom, that enables users to guage the amount of emitted radiation and compare the radiation output between different scan protocols or scanners.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
  • “The CTDI is a standardized measure of the radiation output of a CT system, measured in a cylindrical acrylic phantom, that enables users to guage the amount of emitted radiation and compare the radiation output between different scan protocols or scanners. Complex calculations are required to map scanner output to patient dose, taking into account the patients size , irradiated organs, body composition, and scan range.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
  • “Estimates of individual patient risk, and epidemiologic studies assessing potential late effects, must use patient size-specific dose estimates-they cannot use only scanner output (CTDI or DLP). Rather use of the known exponential relationship between patient size and absorbed dose will allow patient size specific dose estimates to be made from scanner output values.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
  • “CTDI provides a very useful way to compare the doses delivered by various scan protocols or to achieve a specific level of image quality for a specific size patient.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
  • “CTDI cannot be used as a surrogate for patient dose, either in epidemiologic assessments of potential late effects or for potential deterministic effects (eg, skin injury). Neither CTDI nor its derivative, dose length product (DLP, which is the product of CTDI and the irradiated scan length) should be used to estimate effective dose or potential cancer risk for any individual patient.”
    CT Dose Index and Patient Dose: They Are Not the Same Thing
    McCollough CH et al.
    Radiology 2011; 259:311-316
Small Bowel

  • “Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • "Cancer complications may be directly related to the tumor due to its local effect, or may be an indirect consequence related to its systemic manifestations including immune suppression, paraneoplastic syndromes or disorders of hemostasis. Cancer treatment including surgery, chemotherapy and/ or radiotherapy can also be associated with significant com- plications.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
    - Small bowel obstruction
    - Large bowel obstruction
    - Bowel ischemia
    - Bowel perforation
    - Enteritis (chemotherapy, radiation enteritis)
    - Thyphlitis
  • “Neutropenic enterocolitis or typhlitis is an acute life- threatening intestinal inflammation typically affecting the immunocompromised patients such as those with myeloproliferative disorders or those receiving myelo- suppressive therapy such as paclitaxel, idarubicin, fluorouracil, and carboplatin. It is most commonly associated with the treatment of acute leukemia. Patients usually present with fever, abdominal pain, and neutropenia. Although neutropenic enterocolitis may occur anytime during the course of the disease, it usually occurs 5–17 days after therapy initiation, often at the nadir of neutropenia, which is a later presentation compared to chemotherapy-induced ischemic enterocolitis.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • "Although abdominal oncologic emergencies are uncommon, their number are increasing, particularly so with advance- ments in oncologic management. Prompt detection and assessment are crucial for improving quality of life and survival. Various abdominal emergencies may occur in cancer patients and these can sometimes be due to benign or unrelated causes, in addition to expected malignant etiopathophysiology. Although imaging recognition could be a challenge, identification of key imaging findings with an awareness of the clinical scenario permits not only a timely diagnosis but also accurate management planning.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
    - Pancreatitis
    - Graft versus host disease
    - Pseudomembranous colitis
    - Treatment-induced enteritis
    - Acute liver failure
  • Genitourinary Etiology of the Acute Abdomen in Oncology Patients
    - Urinary obstruction
    - Acute pyelonephritis
    - Bladder perforation
  • Vascular Etiology of the Acute Abdomen in Oncology Patients
    - Vascular thrombosis and thromboembolic complications
    - Budd-Chiari syndrome (BCS) and Hepatic veno-occlusive disease
  • “Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • "Cancer complications may be directly related to the tumor due to its local effect, or may be an indirect consequence related to its systemic manifestations including immune suppression, paraneoplastic syndromes or disorders of hemostasis. Cancer treatment including surgery, chemotherapy and/ or radiotherapy can also be associated with significant com- plications.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
    - Small bowel obstruction
    - Large bowel obstruction
    - Bowel ischemia
    - Bowel perforation
    - Enteritis (chemotherapy, radiation enteritis)
    - Thyphlitis
  • “Neutropenic enterocolitis or typhlitis is an acute life- threatening intestinal inflammation typically affecting the immunocompromised patients such as those with myeloproliferative disorders or those receiving myelo- suppressive therapy such as paclitaxel, idarubicin, fluorouracil, and carboplatin. It is most commonly associated with the treatment of acute leukemia. Patients usually present with fever, abdominal pain, and neutropenia. Although neutropenic enterocolitis may occur anytime during the course of the disease, it usually occurs 5–17 days after therapy initiation, often at the nadir of neutropenia, which is a later presentation compared to chemotherapy-induced ischemic enterocolitis.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • "Although abdominal oncologic emergencies are uncommon, their number are increasing, particularly so with advance- ments in oncologic management. Prompt detection and assessment are crucial for improving quality of life and survival. Various abdominal emergencies may occur in cancer patients and these can sometimes be due to benign or unrelated causes, in addition to expected malignant etiopathophysiology. Although imaging recognition could be a challenge, identification of key imaging findings with an awareness of the clinical scenario permits not only a timely diagnosis but also accurate management planning.”
    Imaging of acute abdomen in cancer patients
    Morani AC et al.
    Abdominal Radiology 2019 https://doi.org/10.1007/s00261-019-02332-5
  • Gastrointestinal Etiology of the Acute Abdomen in Oncology Patients
    - Pancreatitis
    - Graft versus host disease
    - Pseudomembranous colitis
    - Treatment-induced enteritis
    - Acute liver failure
  • Genitourinary Etiology of the Acute Abdomen in Oncology Patients
    - Urinary obstruction
    - Acute pyelonephritis
    - Bladder perforation
  • Vascular Etiology of the Acute Abdomen in Oncology Patients
    - Vascular thrombosis and thromboembolic complications
    - Budd-Chiari syndrome (BCS) and Hepatic veno-occlusive disease
  • “The purpose of this retrospective medical audit was to evaluate the effect of discontinuing routine administration of oral contrast material to oncology patients undergoing follow-up multidetector computed tomography (CT) on reader evaluation of study adequacy. Analysis of 100 patients' experience of CT shows that positive oral contrast material was their least pleasant experience (P < .0001). Abandoning the routine use of positive oral contrast material for follow-up scans in general oncology patients undergoing multidetector CT, with section reconstruction thickness of 2.5 mm, was audited for 447 patents and included 5-13-month follow-up. The patient satisfaction study and clinical audit were performed according to local institutional audit guidelines. Since this was a clinical audit project, ethical approval was not required under UK National Health Service research governance arrangements. No patient needed to be recalled, no related diagnostic error has been reported, and follow-up CT, available in 285 of 447 cases (64%), revealed no error on the audited scan. We conclude that the routine use of positive oral contrast material is unnecessary for follow-up multidetector CT for general oncology indications.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • “The purpose of this retrospective medical audit was to evaluate the effect of discontinuing routine administration of oral contrast material to oncology patients undergoing follow-up multidetector computed tomography (CT) on reader evaluation of study adequacy. Analysis of 100 patients' experience of CT shows that positive oral contrast material was their least pleasant experience (P < .0001). Abandoning the routine use of positive oral contrast material for follow-up scans in general oncology patients undergoing multidetector CT, with section reconstruction thickness of 2.5 mm, was audited for 447 patents and included 5-13-month follow-up. The patient satisfaction study and clinical audit were performed according to local institutional audit guidelines. No patient needed to be recalled, no related diagnostic error has been reported, and follow-up CT, available in 285 of 447 cases (64%), revealed no error on the audited scan. We conclude that the routine use of positive oral contrast material is unnecessary for follow-up multidetector CT for general oncology indications.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • "The standard contrast material was barium sulfate suspension (4.9% wt/vol in 225 mL, E-Z-CAT; E-Z-Em, Lake Success, NY) diluted in 1000 mL of water, making a suspension of 1.1% wt/vol. In a previous study, this contrast agent was found to be tolerated similarly to Gastromiro (Bracco, Milan, Italy) and better than Gastrografin (Bayer Schering Pharma, Berlin, Germany).”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • "In our study, difficulties were encountered with thin patients (although not formally measured), peritoneal disease close to bowel loops, and in patients examined without the use of intravenous contrast material. Oral contrast material may be justified in some of these situations, although we do not routinely use oral contrast material in any of these groups. During the study, we also found positive oral contrast material may mask certain findings such as subtle mucosal deposits seen in carcinoid or melanoma and calcified peritoneal deposits, although a direct comparison of bowel delineation with and that without oral contrast material was not tested in this study.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • "On the basis of our findings, we suggest that if multidetector CT is available, positive oral contrast material should not be a routine requirement for follow-up abdominal pelvic scans in oncology patients. The requirement for routine positive oral contrast material should also be removed from research protocols (such as RECIST protocols) in these patients unless there is a specific indication for their use, such as known peritoneal disease or stage 3 ovarian tumors. This recommendation should not preclude using positive oral contrast material in certain situations, such as in patients who are very thin or are unable to have intravenous contrast material.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • OBJECTIVES:  To evaluate the diagnostic efficacy of different oral contrast media (OCM) for abdominopelvic CT examinations performed for follow-up general oncological indications. The objectives were to establish anatomical image quality criteria for abdominopelvic CT; use these criteria to evaluate and compare image quality using positive OCM, neutral OCM and no OCM; and evaluate possible benefits for the medical imaging department. quality by grading the fulfilment of 24 anatomical image quality criteria.
    RESULTS:  Visual grading characteristics (VGC) analysis of the data showed comparable image quality with regards to reproduction of abdominal structures, bowel discrimination, presence of artefacts, and visualization of the amount of intra-abdominal fat for the three OCM protocols.
    CONCLUSION:  All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.
    KEY POINTS:  • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • CONCLUSION:  All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.
    KEY POINTS:  • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • OBJECTIVE: The objective of our study was to compare the quality of bowel opacification from three different positive oral contrast agents-barium sulfate, diatrizoate, and iohexol-at abdominopelvic CT.
    CONCLUSION: The frequency of inhomogeneous bowel opacification was lower for iohexol than for diatrizoate or barium sulfate. Barium showed the highest frequency of bowel lumen heterogeneity. The iodinated agents showed greater increases in mean CT attenuation from the proximal bowel segments to the distal bowel segments than barium sulfate.
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • RESULTS: Fewer artifacts were detected with iohexol (4.3%) as the oral contrast agent than with diatrizoate (13.0%) and barium sulfate (14.3%) (each, p < 0.05). Barium showed a greater frequency of bowel lumen heterogeneity (388/831 segments, 47%) than iohexol (155/679, 23%) and diatrizoate (185/763, 24% segments) (p < 0.001). Barium showed higher CT attenuation than iohexol and diatrizoate in the stomach but lower CT attenuation in the ileum (each, p < 0.05).
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “We found that the frequency of nonuni- form opacification of bowel was higher with oral diatrizoate and barium sulfate than with iohexol at CT. The CT attenuation of all three types of positive oral contrast agents is lowest in the stomach and highest in the ileum, and the increase in CT attenuation from proximal to distal bowel is greater for diatrizoate and iohexol than for barium sulfate.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “There is a surprising paucity of published data on the comparative value of positive oral contrast material versus neutral or no oral contrast material for most general indications for abdominal CT. Nevertheless, in a consensus expert statement by the American College of Radiology and Society for Pediatric Radiology, positive oral contrast material is recognized to improve the delineation of bowel disease, such as abscesses or hypovascular tumors, from nonbowel disease and is also recognized to improve the delineation of bowel leaks.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “Although multiple studies of emergency department patients with relatively small sample sizes suggest that avoid- ance of oral contrast material may improve cost efficiency in that niche scenario, extrapolation of these narrowly staged studies to broader patient populations is not founded on solid evidence. Larger prospective multiinstitution studies that compare the value of positive, neutral, and no oral contrast material for the speed, accuracy, and confidence in diag- nosis of critical abdominal disease diagnoses in outpatients, oncology patients, and patients undergoing postoperative evaluations and in other scenarios are clearly needed.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • "In conclusion, we found that inhomoge- neous opacification of the bowel lumen was more frequently seen with oral diatrizoate or barium sulfate than with oral iohexol at CT of the abdomen and pelvis. The iodinated agents showed a greater progressive increase in CT attenuation in more distal bowel segments than the more proximal bowel segments than was seen with barium sulfate. Further study is warranted to assess for the effects of these differences in bowel opacification on disease detection.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy.
    CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy. , it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • “A disturbing recent trend, however, is the increasing decision to forego positive oral contrast material largely (or solely) for increased patient throughput, typically driven by nonradiologists such as emergency department (ED) physicians, surgeons, and even health system administrators. As radiologists, we need to ensure that such financially driven nonmedical justifications are in the best interest of our patients.”
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10

  • Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • Indications for Positive Oral Contrast
    - Suspected postoperative bowel leak
    - Suspected gastrointestinal fistula
    - Suspected interloop abscess or other fluid collection
    - Oncologic staging and surveillance
    - Nonspecific abdominal pain or other symptoms (subacute)
  • "I believe that there is definitely still a role for positive oral contrast material in modern state-of-the-art abdominal CT. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process.”
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • “Our Emergency physicians do not see that oral contrast administration for CT hampers operational efficiency; in fact, they have expressed gratitude to our department for care in diagnosis. They have stated that delays in patient turnaround are more frequently related to overall demand on the scanner and not to the oral contrast consumption period. They are all acutely aware of the serious consequences of missed or incorrect diagnoses (either leading to inappropriate hospital admission or discharge), and will always choose good medical care over time slashing, corner cutting methods that impress the dashboard monitors perhaps at the expense of excellence in patient care.”
    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
    Megibow A.J.
    Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
  • “In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”
    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
    Megibow A.J.
    Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
  • “The purpose of this retrospective medical audit was to evaluate the effect of discontinuing routine administration of oral contrast material to oncology patients undergoing follow-up multidetector computed tomography (CT) on reader evaluation of study adequacy. Analysis of 100 patients' experience of CT shows that positive oral contrast material was their least pleasant experience (P < .0001). Abandoning the routine use of positive oral contrast material for follow-up scans in general oncology patients undergoing multidetector CT, with section reconstruction thickness of 2.5 mm, was audited for 447 patents and included 5-13-month follow-up. The patient satisfaction study and clinical audit were performed according to local institutional audit guidelines. Since this was a clinical audit project, ethical approval was not required under UK National Health Service research governance arrangements. No patient needed to be recalled, no related diagnostic error has been reported, and follow-up CT, available in 285 of 447 cases (64%), revealed no error on the audited scan. We conclude that the routine use of positive oral contrast material is unnecessary for follow-up multidetector CT for general oncology indications.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • “The purpose of this retrospective medical audit was to evaluate the effect of discontinuing routine administration of oral contrast material to oncology patients undergoing follow-up multidetector computed tomography (CT) on reader evaluation of study adequacy. Analysis of 100 patients' experience of CT shows that positive oral contrast material was their least pleasant experience (P < .0001). Abandoning the routine use of positive oral contrast material for follow-up scans in general oncology patients undergoing multidetector CT, with section reconstruction thickness of 2.5 mm, was audited for 447 patents and included 5-13-month follow-up. The patient satisfaction study and clinical audit were performed according to local institutional audit guidelines. No patient needed to be recalled, no related diagnostic error has been reported, and follow-up CT, available in 285 of 447 cases (64%), revealed no error on the audited scan. We conclude that the routine use of positive oral contrast material is unnecessary for follow-up multidetector CT for general oncology indications.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • "The standard contrast material was barium sulfate suspension (4.9% wt/vol in 225 mL, E-Z-CAT; E-Z-Em, Lake Success, NY) diluted in 1000 mL of water, making a suspension of 1.1% wt/vol. In a previous study, this contrast agent was found to be tolerated similarly to Gastromiro (Bracco, Milan, Italy) and better than Gastrografin (Bayer Schering Pharma, Berlin, Germany).”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • "In our study, difficulties were encountered with thin patients (although not formally measured), peritoneal disease close to bowel loops, and in patients examined without the use of intravenous contrast material. Oral contrast material may be justified in some of these situations, although we do not routinely use oral contrast material in any of these groups. During the study, we also found positive oral contrast material may mask certain findings such as subtle mucosal deposits seen in carcinoid or melanoma and calcified peritoneal deposits, although a direct comparison of bowel delineation with and that without oral contrast material was not tested in this study.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • "On the basis of our findings, we suggest that if multidetector CT is available, positive oral contrast material should not be a routine requirement for follow-up abdominal pelvic scans in oncology patients. The requirement for routine positive oral contrast material should also be removed from research protocols (such as RECIST protocols) in these patients unless there is a specific indication for their use, such as known peritoneal disease or stage 3 ovarian tumors. This recommendation should not preclude using positive oral contrast material in certain situations, such as in patients who are very thin or are unable to have intravenous contrast material.”
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • OBJECTIVES:  To evaluate the diagnostic efficacy of different oral contrast media (OCM) for abdominopelvic CT examinations performed for follow-up general oncological indications. The objectives were to establish anatomical image quality criteria for abdominopelvic CT; use these criteria to evaluate and compare image quality using positive OCM, neutral OCM and no OCM; and evaluate possible benefits for the medical imaging department. quality by grading the fulfilment of 24 anatomical image quality criteria.
    RESULTS:  Visual grading characteristics (VGC) analysis of the data showed comparable image quality with regards to reproduction of abdominal structures, bowel discrimination, presence of artefacts, and visualization of the amount of intra-abdominal fat for the three OCM protocols.
    CONCLUSION:  All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.
    KEY POINTS:  • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • CONCLUSION:  All three OCM protocols provided similar image quality for follow-up abdominopelvic CT for general oncological indications.
    KEY POINTS:  • Positive oral contrast media are routinely used for abdominopelvic multidetector computed tomography • Experimental study comparing image quality using three different oral contrast materials • Three different oral contrast materials result in comparable CT image quality • Benefits for patients and medical imaging department.
    Routine use of positive oral contrast material is not required for oncology patients undergoing follow-up multidetector CT.
    Harieaswar S et al.
    Radiology. 2009 Jan;250(1):246-53
  • OBJECTIVE: The objective of our study was to compare the quality of bowel opacification from three different positive oral contrast agents-barium sulfate, diatrizoate, and iohexol-at abdominopelvic CT.
    CONCLUSION: The frequency of inhomogeneous bowel opacification was lower for iohexol than for diatrizoate or barium sulfate. Barium showed the highest frequency of bowel lumen heterogeneity. The iodinated agents showed greater increases in mean CT attenuation from the proximal bowel segments to the distal bowel segments than barium sulfate.
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • RESULTS: Fewer artifacts were detected with iohexol (4.3%) as the oral contrast agent than with diatrizoate (13.0%) and barium sulfate (14.3%) (each, p < 0.05). Barium showed a greater frequency of bowel lumen heterogeneity (388/831 segments, 47%) than iohexol (155/679, 23%) and diatrizoate (185/763, 24% segments) (p < 0.001). Barium showed higher CT attenuation than iohexol and diatrizoate in the stomach but lower CT attenuation in the ileum (each, p < 0.05).
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “We found that the frequency of nonuni- form opacification of bowel was higher with oral diatrizoate and barium sulfate than with iohexol at CT. The CT attenuation of all three types of positive oral contrast agents is lowest in the stomach and highest in the ileum, and the increase in CT attenuation from proximal to distal bowel is greater for diatrizoate and iohexol than for barium sulfate.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “There is a surprising paucity of published data on the comparative value of positive oral contrast material versus neutral or no oral contrast material for most general indications for abdominal CT. Nevertheless, in a consensus expert statement by the American College of Radiology and Society for Pediatric Radiology, positive oral contrast material is recognized to improve the delineation of bowel disease, such as abscesses or hypovascular tumors, from nonbowel disease and is also recognized to improve the delineation of bowel leaks.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • “Although multiple studies of emergency department patients with relatively small sample sizes suggest that avoid- ance of oral contrast material may improve cost efficiency in that niche scenario, extrapolation of these narrowly staged studies to broader patient populations is not founded on solid evidence. Larger prospective multiinstitution studies that compare the value of positive, neutral, and no oral contrast material for the speed, accuracy, and confidence in diag- nosis of critical abdominal disease diagnoses in outpatients, oncology patients, and patients undergoing postoperative evaluations and in other scenarios are clearly needed.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • "In conclusion, we found that inhomoge- neous opacification of the bowel lumen was more frequently seen with oral diatrizoate or barium sulfate than with oral iohexol at CT of the abdomen and pelvis. The iodinated agents showed a greater progressive increase in CT attenuation in more distal bowel segments than the more proximal bowel segments than was seen with barium sulfate. Further study is warranted to assess for the effects of these differences in bowel opacification on disease detection.”
    Comparison of Positive Oral Contrast Agents for Abdominopelvic CT.
    Winklhofer S, Lin WC, Wang ZJ, Behr SC, Westphalen AC, Yeh BM.
    AJR Am J Roentgenol. 2019 Mar 5:1-7. 
  • OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy.
    CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific consid- erations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy. , it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • “A disturbing recent trend, however, is the increasing decision to forego positive oral contrast material largely (or solely) for increased patient throughput, typically driven by nonradiologists such as emergency department (ED) physicians, surgeons, and even health system administrators. As radiologists, we need to ensure that such financially driven nonmedical justifications are in the best interest of our patients.”
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10

  • Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • Indications for Positive Oral Contrast
    - Suspected postoperative bowel leak
    - Suspected gastrointestinal fistula
    - Suspected interloop abscess or other fluid collection
    - Oncologic staging and surveillance
    - Nonspecific abdominal pain or other symptoms (subacute)
  • "I believe that there is definitely still a role for positive oral contrast material in modern state-of-the-art abdominal CT. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process.”
    Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy
    Perry J. Pickhardt
    AJR 2020; 215:1–10
  • “Our Emergency physicians do not see that oral contrast administration for CT hampers operational efficiency; in fact, they have expressed gratitude to our department for care in diagnosis. They have stated that delays in patient turnaround are more frequently related to overall demand on the scanner and not to the oral contrast consumption period. They are all acutely aware of the serious consequences of missed or incorrect diagnoses (either leading to inappropriate hospital admission or discharge), and will always choose good medical care over time slashing, corner cutting methods that impress the dashboard monitors perhaps at the expense of excellence in patient care.”
    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
    Megibow A.J.
    Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
  • “In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”
    Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
    Megibow A.J.
    Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
Vascular

  • “The etiology of fibromuscular dysplasia (FMD) remains largely unknown. It is well recognized that the incidence is higher in women and the most common clinical presentation is hypertension. It is estimated that the incidence in the general population is 2% to 3%. The incidence of FMD in potential living renal donors is reported to be 4% to 6%.”
    Renal Artery Fibromuscular Dysplasia in 2640 Renal Donor Subjects: A CT Angiographic Analysis
    Gavin A. McKenzie et al.
    J Vasc Interv Radiol. 2013 October ; 24(10): 1477–1480.
  • "Sixty-eight patients (2.6%; 59 female) with an average age of 52 ± 10 years were diagnosed with FMD according to the independent readers who evaluated the CTA. Unilateral FMD was observed in 46 patients (68%) and bilateral in 22 patients (32%). Three patients had aneurysms of the renal artery. The comorbidities included hypertension (n=21, 31%), dyslipidemia, (n=13, 19%), history of migraines (n=3, 4%), and history of smoking (n=14, 21%). No patients had diabetes mellitus, coronary artery disease, or family history of FMD. Twenty-one patients (31%) had a history of hypertension with 13 patients (62%) treated with antihypertensive medications.”
    Renal Artery Fibromuscular Dysplasia in 2640 Renal Donor Subjects: A CT Angiographic Analysis
    Gavin A. McKenzie et al.
    J Vasc Interv Radiol. 2013 October ; 24(10): 1477–1480.
  • “There are three types of FMD: intimal, medial, and adventitial. The majority of the FMD is the medial form typically described as the classic “string of beads sign” that has been observed in 65% to 90% of FMD lesions. The string of beads finding is easily detected using CTA. Several studies have compared DSA and CTA for detection of renal artery stenosis (RAS) and have showed slightly lower sensitivities and specificities for CTA ranging from 88% to 100% and 97% to 99%, respectively. In the present study, the incidence of FMD was 2.6% by CTA compared to 2% to 6.6% in DSA studies. The difference in incidence is likely a reflection of the imaging modality used for detection.”
    Renal Artery Fibromuscular Dysplasia in 2640 Renal Donor Subjects: A CT Angiographic Analysis
    Gavin A. McKenzie et al.
    J Vasc Interv Radiol. 2013 October ; 24(10): 1477–1480.
  • “The incidence of FMD in patients who underwent CTA for evaluation of living renal donor protocol is 2.6%.”
    Renal Artery Fibromuscular Dysplasia in 2640 Renal Donor Subjects: A CT Angiographic Analysis
    Gavin A. McKenzie et al.
    J Vasc Interv Radiol. 2013 October ; 24(10): 1477–1480.

“The etiology of fibromuscular dysplasia (FMD) remains largely unknown. It is well recognized that the incidence is higher in women and the most common clinical presentation is hypertension. It is estimated that the incidence in the general population is 2% to 3%. The incidence of FMD in potential living renal donors is reported to be 4% to 6%.”
Renal Artery Fibromuscular Dysplasia in 2640 Renal Donor Subjects: A CT Angiographic Analysis
Gavin A. McKenzie et al.
J Vasc Interv Radiol. 2013 October ; 24(10): 1477–1480.

 

 

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