Author: Logan Young

  • Magnetic Eyelashes: A New Source of MRI Artifacts

    Alexander Mamourian
    Coauthor

    With U.S. sales of false eyelashes having increased 31% since 2017 and magnetic eyelashes trending as the top beauty-related Google search of 2018, Einat Slonimsky and Alexander Mamourian at Penn State Health utilized a phantom to show that magnetic eyelashes worn during MRI can cause substantial artifact and that detachment of the eyelashes from the phantom can occur. Using two sets of magnetic eyelashes from the same manufacturer that were randomly selected and purchased online, the phantom was created by drilling multiple 2-mm holes in a plastic container and then running monofilament line through these holes to create a grid. The two sets of eyelashes were attached to single nylon strings, placed diagonally within the phantom. The phantom was then submerged in a container filled with distilled water, covered with a layer of plastic film to prevent free movement of the lashes, should they detach. MRI was performed using a 3-T scanner with T2-weighted images, FLAIR images, T1-weighted images, susceptibility-weighted images, DW images, T1-weighted magnetization-prepared rapid-acquisition gradient-echo images, and T2-weighted sampling perfection with application-optimized contrasts using different flip-angle evolutions. Ultimately, the magnetic eyelashes evidenced an artifact much larger than that created by the control aneurysm clips (two made of cobalt alloy, one made of titanium) using the same sequences—measuring 7 × 6 cm maximal on susceptibility-weighted images, obscuring the entire phantom. Although the eyelashes stayed attached to the strings during the scan, upon removal of the phantom from the bore, one set of eyelashes detached from its string. Restrained by the plastic covering, it became attracted to the other eyelashes still attached to the phantom. “We strongly recommend inserting a line about magnetic eyelashes on the MRI safety questionnaire and adding stops in the screening system to prevent the entry of anyone with these lashes, including staff, into the MRI scanner room,” Slonimsky and Mamourian wrote.

  • Aspirin and Embolization of Hepatocellular Carcinoma

    F. Edward Boas
    Corresponding Author

    Aspirin therapy is associated with both improved liver function test results and survival after transarterial embolization (TAE) for hepatocellular carcinoma (HCC), according to a retrospective review of 304 patients led by F. Edward Boas at Memorial Sloan Kettering Cancer Center in New York City. Among the 42 patients taking aspirin at the time of initial TAE for HCC, bilirubin level evidenced lower 1 day (0.9 vs 1.3, p < 0.001), 1 month (0.9 vs 1.2, p = 0.048), and 1 year (0.8 vs 1.0, p = 0.021) post-embolization. “Although the differences in liver function test results in the groups taking and not taking aspirin were small,” wrote Boas, “standard biochemical liver function tests are insensitive to early cirrhotic changes.” Clarifying further, Boas noted, “small changes in biochemical liver function test results might underestimate the degree of liver injury after embolization.” Whereas aspirin use indicated no disparity in initial response rate (88% vs 90% complete response or partial response, p = 0.59), median time to progression (6.2 vs 5.2 months, p = 0.42), initial site of progression (p = 0.77), or fraction of patients dying with disease progression (88% vs 89%, p = 1.00), the median overall survival period after TAE for HCC measured longer for the cohort taking aspirin (57 vs 23 months, p = 0.008). Despite comparable liver function, American Joint Committee on Cancer stage, comorbidities, and other clinical characteristics before embolization in both groups, because his study was retrospective, Boas acknowledged that a confounding variable may account for the improved survival among patients taking aspirin.

  • Quantifying the Severity of Parkinson Disease

    Pathologically, Parkinson disease is characterized by a loss of dopaminergic neurons in the substantia nigra pars compacta (SNpc) area of the brain, resulting in presynaptic nigrostriatal dopamine dysfunction. Whereas prior research into dopaminergic neuroimaging has illustrated the independent utility of neuromelanin MRI and dopamine transporter SPECT for evaluating the severity of Parkinson disease, Hiroto Takahashi and colleagues from Japan’s Osaka University Graduate School of Medicine aimed to explore the use of these two imaging biomarkers to quantify severity during the progression of Parkinson disease. Twenty men and 20 women (mean age 68.35 years) who underwent neuromelanin MRI and dopamine transporter SPECT were included in the study. Parkinson disease severity was assessed with the Hoehn and Yahr (HY) scale (HY stage 1, 4 patients; stage 2, 18 patients; stage 3, 8 patients; stage 4, 6 patients; stage 5, 4 patients). The signal-to-noise ratio (SNR) in the SNpc on neuromelanin MR images and the striatal specific binding ratio (SBR) on dopamine transporter SPECT images were calculated based on the value of each background region. The Mann-Whitney U test was used to assess the significance of differences between the early-stage group (HY 1 and 2) and the advanced-stage group (HY 3–5) for each SNR and SBR. Overall, both SNR and SBR measured much greater in early-stage patients compared to the advanced stage group (p < 0.05). Additionally, the AUC for differentiating early and advanced stage groups was 0.73 for SNR and 0.89 for SBR. The coefficient of correlation was −0.47 for SNR versus HY stage and −0.67 for SBR versus HY stage. As Takahashi acknowledged, “The current study shows that it is possible to quantify the degeneration of dopaminergic nigrostriatal transporters in Parkinson disease using striatal SBR derived from dopamine transporter SPECT with good correlation with the HY stage.”

  • Optimization of MRI Turnaround Times

    Michael Recht
    Corresponding Author

    One topic that has the potential to drastically improve the value of MRI (but has not been researched as thoroughly as hardware application and software innovation) is the optimization of MRI workflow. The construction of a new outpatient imaging center at NYU Langone Health to house 1.5- and 3-T scanners provided Dr. Michael Recht and colleagues an opportunity to reengineer their MRI turnaround time (i.e., “the interval between completion of the last sequence acquisition for one patient and initiation of the first sequence acquisition for the next patient”). A process improvement team comprised of different stakeholders—radiologists, MRI technologists, IT administrators, front desk personnel, real estate and development staff—met biweekly for several months to define the current workflow and its limitations and to determine optimizations, such as the use of dockable tables, dedicated patient preparation rooms, two doors in each MRI room, positioning the scanner to provide the most direct path to the scanner, and coil storage in the preparation rooms with duplication of the most frequently used coils. Once construction and a two-month training period were completed, mean and median turnaround times were measured for each scanner at NYU Langone’s new facility, as well as for six scanners with differing magnets at two existing outpatient centers from March 1, 2018 to June 30, 2018. When patients were properly prepared and on their docking tables, the authors found the difference in mean turnaround time was 328 seconds, “which is greater than the goal of five minutes of time saved,” Recht wrote. For all patients, including those who were not ready when the prior patient’s examination was finished, the improvement in mean turnaround time was 265 seconds. Interestingly, the difference in median turnaround times for all patients clocked in at 340 seconds. “Five minutes might not seem like much time,” Aunt Minnie added, “but taking 300 fewer seconds to turn around an MRI suite to accommodate the next case can improve workflow, better serve patients, and add to a facility’s coffers.”

  • Interreader Variability of PI-RADSv2 in Detecting and Assessing Prostate Cancer Lesions

    Matthew D. Greer
    Corresponding Author

    The use of prostate multiparametric MRI (mpMRI) and targeted biopsy increases detection of clinically significant cancers while decreasing the diagnosis of indolent disease. “One obstacle to broad application of prostate mpMRI is the lack of standardization and training necessary to interpret mpMR images,” wrote Matthew D. Greer, MD, department of radiation oncology at the University of Washington School of Medicine in Seattle. To evaluate agreement among radiologists across experience levels in the detection and assessment of prostate cancer at mpMRI using Prostate Imaging Reporting and Data System version 2 (PI-RADSv2), Greer’s team evaluated a total study population of 163 patients. Of these, 110 underwent prostatectomy after MRI, and 53 evidenced normal MRI findings and transrectal ultrasound–guided biopsy results. Of the nine radiologists representing six countries and eight institutions who volunteered for the study, three had a high level of experience in prostate mpMRI (> 2000 cases in the last two years), three had a moderate level (500–2000 cases in the last two years), and three had a low level of experience (< 500 cases in the last two years). The authors’ results found that sensitivity for index lesions was comparable among all radiologists (average, 92.2%; p = 0.360), but specificity proved experience-dependent. Highly experienced readers had 84.0% specificity versus 55.2% for all others (p < 0.001), suggesting that the decision to perform biopsy be set at a lower threshold for novice prostate mpMRI radiologists and in centers where prostate MRI is an uncommon examination. As Radiology Business noted, “radiologists were blinded to prostate-specific antigen level and previous biopsy results, and providing such information could have improved results.”

  • Implementing Abbreviated MRI Screening Into a Breast Imaging Practice

    Holly Marshall
    Corresponding Author

    MRI remains the most sensitive tool for detecting breast cancer, but cost and acquisition time continue to be deterrents for women at average risk. For patients at University Hospitals Cleveland Medical Center who received a digital mammography (DM) or digital breast tomosynthesis (DBT) screening examination, patients with heterogeneously dense or extremely dense breast tissue received their density notification and mammogram results by mail, alongside a pamphlet explaining a new supplemental screening option: abbreviated protocol MRI. Choosing to implement the EA1141 study protocol—localizer sequences, axial T2-weighted STIR sequence, axial T1-weighted sequence with fat saturation before and after IV administration of gadolinium contrast—a team led by Holly Marshall, MD maintained a schedule of three 10-minute examinations in a single one-hour time slot (i.e., the time allotted for a complete MRI exam). After presenting the concept of “Fast MRI” to her hospital’s leadership board of surgeons, pathologists, breast clinicians, and medical and radiation oncologists, Marshall created online educational resources for referring physicians and patients. Marshall’s colleagues noted that it took 10 months to establish pricing through their institution’s finance department, as abbreviated MRI is a self-pay procedure that cannot be billed to insurance because no CPT code exists for it. Relying upon radiology self-pay tests such as unenhanced lung cancer CT screening and cardiac scoring as precedents for cost determination, Marshall concluded that her institution’s price is “substantially lower than that of the full breast MRI protocol” and “many patients with high-deductible insurance plans have a lower out-of-pocket expense for [abbreviated protocol] breast MRI than for the full protocol.”

  • Cost-Utility Analysis of Imaging for Surveillance and Diagnosis of HCC

    An Tang
    Corresponding Author

    Utilizing a Markov model developed via TreeAge Pro software, Paulo Henrique Lima, An Tang, and a team of researchers at the University of Montreal simulated seven strategies for surveilling and diagnosing hepatocellular carcinoma (HCC) in patients with cirrhosis: ultrasound (US) for surveillance, CT for diagnosis; US for surveillance, complete MRI for diagnosis; US for surveillance, CT for inadequate or positive surveillance; US for surveillance, complete MRI for inadequate or positive surveillance; surveillance and diagnosis with CT, followed by complete MRI for inadequate surveillance; surveillance and diagnosis with complete MRI, followed by CT for inadequate surveillance; and surveillance with abbreviated MRI, followed by CT for inadequate surveillance or complete MRI for positive surveillance. For both compliance scenarios evaluated—optimal and conservative—the most cost-effective strategy was based upon a willingness-to-pay threshold of $50,000 (Canadian) per quality adjusted life year. Base-case analysis revealed that the most cost effective strategy when compliance was optimal was surveillance and diagnosis with CT, followed by complete MRI for inadequate surveillance. When compliance was conservative, the best option was surveillance with abbreviated MRI, followed by CT for inadequate surveillance or complete MRI for positive surveillance. Although sensitivity analyses supported the base-case analysis in the optimal compliance scenario, several parameters altered cost effectiveness in the conservative scenario. “North American guidelines currently recommend [US] surveillance every 6 months in patients at risk for HCC,” as noted by Health Imaging; however, Lima et al. pointed out that compliance is “suboptimal” with an overall rate of 52%.

  • Positive Predictive Value for Colorectal Lesions at CT Colonography

    Perry J. Pickhardt
    Corresponding Author

    Using optical colonoscopy as their reference standard for concordance, a trio of researchers from the United States and Italy demonstrated high positive predictive value for colorectal cancer screening using CT colonography (CTC), resulting in greater specificity and risk stratification for appropriate patient triage compared with other noninvasive screening tests. In an AJR online exclusive, University of Wisconsin School of Medicine and Public Health radiologist, Perry J. Pickhardt, evaluated the positive predictive value for detecting colorectal lesions using only CTC compared to common stool-based assessments like the fecal occult blood test, fecal immunochemical test, and stool DNA. Of the 877 men and 773 women (median age 59.7 years) with 2688 total CTC-detected lesions 6 mm or larger, the overall positive predictive values were 88.8% by polyp and 90.8% by patient. In addition, a positive CTC examination pointed to the likelihood of abnormal tissue growth, as per-patient positive predictive values were 72.3% (1193/1650) for any neoplasia 6 mm or larger and 38.8% (641/1650) for advanced neoplasia. Perhaps more importantly, as Aunt Minnie reported, “CTC enabled radiologists to identify critical information about the kind of condition behind each positive finding.” For example, only 5.8% of positive CTC studies at the CTC Reporting and Data System (C-RADS) C2 category will have advanced neoplasia at optical colonoscopy; however, this increases to 67.1% and 79.4% for the C3 and C4 categories, respectively. “Similarly,” wrote Pickhardt, “although none of the 781 patients whose CTC studies were positive at the C-RADS C2 category (the lowest level of positive) had cancer, the cancer rate increases to over 50% at the C4 category (the most concerning positive level). By comparison, there is generally no such weighted information available to physicians and patients for a positive stool-based test.”

  • Immunohistochemistry to Predict Thyroid Nodules

    Researchers have validated a first-of-its-kind machine learning– based model to evaluate immunohistochemical (IHC) characteristics in patients with suspected thyroid nodules, achieving “excellent performance” for individualized noninvasive prediction of the presence of cytokeratin 19, galectin 3, and thyroperoxidase based upon CT images. “When IHC information is hidden on CT images,” principal investigator Jiabing Gu explained, “it may be possible to discern the relation between this information and radiomics by use of texture analysis.” To assess whether texture analysis could be utilized to predict IHC characteristics of suspected thyroid nodules, Gu and colleagues from China’s University of Jinan enrolled 103 patients (training cohort– to-validation cohort ratio, ≈ 3:1) with suspected thyroid nodules who had undergone thyroidectomy and IHC analysis from January 2013 to January 2016. All 103 patients—28 men, 75 women; median age, 58 years; range, 33–70 years—underwent CT before surgery, and 3D Slicer v 4.8.1 was used to analyze images of the surgical specimen. To facilitate test-retest methods, 20 patients were imaged in two sets of CT series within 10–15 minutes, using the same scanner (LightSpeed 16, Philips Healthcare) and protocols, without contrast administration. These images were used only to select reproducible and nonredundant features, not to establish or verify the radiomic model. The Kruskal-Wallis test (SPSS v 19, IBM) was employed to improve classification performance between texture feature and IHC characteristic. Gu et al. considered characteristics with p < 0.05 significant, and the feature-based model was trained via support vector machine methods, assessed with respect to accuracy, sensitivity, specificity, corresponding AUC, and independent validation. From 828 total features, 86 reproducible and nonredundant features were selected to build the model. The best performance of the cytokeratin 19 radiomic model yielded accuracy of 84.4% in the training cohort and 80.0% in the validation cohort. Meanwhile, the thyroperoxidase and galectin 3 predictive models evidenced accuracies of 81.4% and 82.5% in the training cohort and 84.2% and 85.0% in the validation cohort, respectively. Noting that cytokeratin 19 and galectin 3 levels are high in papillary carcinoma, Gu maintained that these models can help radiologists and oncologists to identify papillary thyroid cancers, “which is beneficial for diagnosing papillary thyroid cancers earlier and choosing treatment options in a timely manner.” Ultimately, asserted Gu, “this model may be used to identify benign and malignant thyroid nodules.”

  • Leadership to Equitable Radiology

    Leadership to Equitable Radiology

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    Ruth C. Carlos
    2019-2020 ARRS Scholar

      According to the January issue of AJR, women occupy only 14% of available leadership positions in academic nuclear medicine departments, both at American and Canadian institutions. A recent Emory University assessment of gender disparity in labor divisions found that female general, abdominal, and musculoskeletal radiologists read fewer advanced imaging modalities like CT and MRI. Perhaps more lopsided is the male-to-female ratio, itself—approximately three men for every one woman among radiologists and radiology residents, as per ACR’s annual industry survey. Furthermore, according to the October edition of AJR, just 8% of all interventional radiologists in the United States are women.

      Like much of the news, health care headlines such as these can leave us asking ourselves, “How much progress have we made?” Dredging this sea of conspicuous data points and trends on gender inequality in medical imaging, men and women alike question, “What does ‘progress’ even look like?”

      One hundred years removed from the ratification of the Nineteenth Amendment to the U.S. Constitution that confirmed my right to vote, as the 119th ARRS president, I am proud to join the august ranks of Kay Vydareny, Theresa McLeod, Ella Kazarooni, and Melissa Rosado de Christenson—four previous female presidents who have served this oldest radiology society in North America. And now, for the first time ever, six major radiology organizations are all led by women—International Society for Magnetic Resonance in Medicine, Radiologic Society of North America, Society of Interventional Radiology, American Society of Neuroradiology, American College of Radiology, and, of course, the American Roentgen Ray Society.

      In the wake of this boom of female leadership in our specialty, why is it that more women continue to enter other specialties such as pediatrics and gynecology, while radiology remains a male-dominated field? The proportion of women in our specialty has remained static at 20–25%.

      Might this radiological gender gap present an opportunity for “failing up” in radiology, as described in my previous column for InPractice? Conversely, are there intrinsic differences in the practice of radiology compared to, say, pediatrics that will preferentially steer women toward non-radiology specialties? Although I can’t say that 20–25% is the right or wrong proportion, we must collectively work to reduce those barriers that we can control, such as increasing role-modeling, mentorship, and sponsorship and decreasing implicit and explicit bias.

      “And now, for the first time ever, six major radiology organizations are all led by women— International Society for Magnetic Resonance in Medicine, Radiologic Society of North America, Society of Interventional Radiology, American Society of Neuroradiology, American College of Radiology, and, of course, the American Roentgen Ray Society.”

      Ruth C. Carlos

      As an equal opportunity mentee, I have had the privilege of being supported and mentored by a wide variety of individuals such as Melissa Rosado de Christenson, who inspired my career-long affiliation with the ARRS, JACR Editor-in-Chief Emeritus Bruce Hillman, who shared his knowledge and love of scholarly publishing, and John Fennessy and Ruth Ramsey, to whom I owe considering radiology as a career. All those in a position to lead have a responsibility for closing the gender gap. This gap can be as obvious as the lagging proportion of women in radiology or as subtle as “manels,” all-male speaker panels. I applaud Francis S. Collins, director of the National Institutes of Health, for his resolution to no longer speak on all-male panels. “Breaking up the subtle (and sometimes not so subtle) bias that is preventing women and other groups underrepresented in science from achieving their rightful place in scientific leadership must begin at the top,” read his memo, “Time to End the Manel Tradition”.

      A radiologist’s gender is a fact, not a quota. Nevertheless, consistent, thoughtful attention to increasing diversity not just in gender but in all the axes of diversity benefits us all.

      The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

    • Moving from Peer Review to Peer Learning

      Moving from Peer Review to Peer Learning

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      Nadja Kadom
      Department of Radiology and Imaging Sciences Emory University; Pediatric Imaging Assistant Editor, AJR
      Cindy Lee
      Department of Radiology NYU Langone Health

        Competency of radiologists is an important factor in the delivery of high-quality patient care. To meet maintenance of certification (MOC) and Joint Commission requirements for ongoing professional performance evaluation (OPPE), radiologists are participating in peer review, a system that uses accuracy of interpretation as a surrogate marker for competency. A widely used example of such a system is RADPEER, a web-based product that was developed by the American College of Radiology (ACR).

        Benefits of peer review as a means of assessing radiologist competency include: Availability of commercial products; accreditation that is accepted by the Joint Commission; credit towards American Board of Radiology MOC part 4; and familiarity with established peer review systems. Existing peer review systems are generally set up to create as little additional workload as possible, which fosters compliance.

        There are, however, several issues regarding peer review systems, including great variability in how peer review data are collected. Some programs select cases randomly, whereas others allow physicians to select cases, which could introduce bias or result in case selections that are quick to review. There is also variability in how peer review is executed (i.e., the number of cases to review and the frequency of peer review).

        Systems that select cases for peer review—and that are not integrated in the daily exam reading workflow—carry a risk that participants will wait until the deadline and then hastily review a large number of cases, calling into question the quality of such reviews. Most peer review participants are never formally instructed on how to use the scoring system, and lack of examples for each scoring category can result in scoring inconsistencies Peer review participants prefer anonymous review, although in most practices, both the reviewer and the reviewed can identify each other. Friendly and unfriendly relationships may influence the scoring of agreement. There is often a stated peer review goal, such as achieving a less than 5–10% disagreement rate, which can create bias and result in under-reporting. Regarding the use of peer review data, as a ground rule, data should be collected and reported in a fashion that does not invite medicolegal action or repercussions at the local level. Allowing peer review data to be reviewed by other radiologists or officials at higher levels of the organization incites fear in participants that could lead to adverse effects on relationships within the department or the organization. Participants may need transparency regarding local and state policies and medicolegal safeguards in order to trust and honestly use the review system. Whereas some radiology practices have even used peer review data to terminate radiologists’ contracts, instead, peer review should serve to coach and judge at the same time. Moreover, there is no evidence to suggest peer review is an appropriate tool for identifying radiologists who are inadequate performers.

        It is not clear whether or not participation in peer review leads to performance improvement. This may be especially true for systems that do not provide feedback on reviewed cases, nor discuss relevant cases in a group setting. It should be noted that a disagreement does not equal an error or low-quality patient care. A discrepancy could simply be a difference of opinion on how a finding should be interpreted and reported. Peer review can underestimate the number, as well as the severity, of errors. Any discussion around such disagreement may be of little value in the absence of clinical follow-up or tissue-proven diagnoses. In traditional peer review, there can be a significant gap between the time the report was rendered for patent care and the time the report was reviewed and an error was identified, delaying any changes to patient care.

        To improve patient outcomes, we need to move from quality assurance to quality improvement. Our goal should be to reduce diagnostic errors, which contribute to 10% of patient deaths and 6–17% of adverse events in hospitals.

        Radiologists should be able to learn from their mistakes—an essential component of improving patient safety. Disclosing and discussing errors for learning and improvement purposes requires a so-called Just Culture that acknowledges human error, avoids blame, promotes fair accountability, and focuses on fixing system deficiencies. Just Culture often goes hand-in-hand with Safety Culture, which is found in high-reliability organizations, where error rates are very low. This culture entails, among other traits, embracing every opportunity to learn from mistakes and fix systems and processes for error prevention.

        Several sources are available for providing timely feedback. For example, during the read-out, a radiologist may find an error after reviewing the prior study. Consultation with a referring clinician and second review of studies for multidisciplinary conferences can reveal errors, comparison of pathology or surgical reports with imaging results can uncover errors, and complaints to radiology leadership or incident reporting systems can disclose errors. Radiologists may decide which system for feedback they prefer, be it a collegial email, a templated email, or if this information should be routed through third parties, such as section chiefs or quality officers. Many automated systems are available that facilitate peer feedback as part of the daily workflow rather than a separate activity, such as integration with PACS, dictation systems, or other apparatuses that automatically send surgical and pathology results to the radiologist who made the diagnosis. Each method has different ramifications regarding medico-legal discoverability, which may be an important consideration for practicing radiologists.

        Recommendations for best practices to raise learning opportunities to the group level include establishing a small committee to select cases with the highest learning potential, removal of all identifying case information and anonymity of the radiologist who interpreted a case, recording of peer learning conferences to enable asynchronous participation, avoiding blame or finding fault, encouraging discussion of pitfalls, mimics, and strategies for error prevention, and even providing relevant scientific references. Compliance with ongoing OPPE can be achieved in ways other than peer review discrepancy rates, such as recording participation in peer learning conferences, case submissions, or improvement initiatives that were completed as a result of peer case discussions.

        In 2019, the ARRS Performance Improvement Subcommittee decided to tackle the topic of transitioning from peer review to peer learning. The subcommittee assumed that most peer review programs focus on error detection, numerical scoring, and radiologist-specific error rates, with questionable effectiveness regarding learning and systemic improvement. The subcommittee created a 21-question, multiple-choice survey, and this survey was emailed to 17,695 ARRS members; 742 (4.2%) responded. Most respondents were in private practice (51.7%, 283/547) with a size of 11–50 radiologists (50.5%) and in an urban setting (61.6%). Significant diversity was noted in several aspects regarding peer review systems, including use of RADPEER (44.3%), selection of cases by commercial software (36.2%) versus manually (31.2%), and varying numbers of cases mandated for review per month (range < 10 to > 21). Interestingly, > 60% of respondents noted using peer review for group education. A great need for turning peer review into peer learning exists, as almost half (44.5%) of respondents reported being dissatisfied with their current process, stemming from insufficient learning (> 70%) and a sense of inaccurate performance representation (57.1%). Most respondents found the following peer review methods feasible in daily practice: incidental observation (65%), focused practice review (52.9%), professional auditing (45.8%), and blinded double reading (35.4%). Overall, it seems that a majority of practicing radiologists have already migrated toward peer learning systems and consider a variety of workflow-integrated review methods practicable. Establishing a peer learning system may require investments in staff and time, but as evidence continues to mount that peer learning—as opposed to traditional peer review—results in improved practice, better patient outcomes, and higher radiologist satisfaction, these investments appear to be justified.

        The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.

      • Vascular Imaging: Crossing Body Territories and Modalities

        Vascular Imaging: Crossing Body Territories and Modalities

        Imaging has become so engrained and valuable to the practice of medicine that sub-specialization has become necessary for radiology practices to manage the tremendous body of knowledge. This concentration has allowed us to practice diagnostic radiology at a high level to meet the needs of the many medical and surgical specialties. Clinical practices have shifted dramatically from utilizing imaging not only for surveillance and initial diagnosis, but also for surgical planning and long-term management of disease, which also requires greater understanding of the specific therapies in each field. Several medical and surgical specialties now rely on noninvasive vascular imaging to manage disease and for preoperative planning and postoperative observation.

        Although the current silos of subspecialization have been largely beneficial for radiology, some distinct areas of imaging cover the radiological spectrum and do not conform to our present subspecialty definitions. Vascular imaging is one such discipline, which has become somewhat orphaned because of its pervasive nature and tendency to cross body territories and imaging modalities.

        Clinical features of diseases with vascular etiologies frequently overlap with non-vascular diseases. For example, multiple diseases may present with post-prandial abdominal pain—though only a small fraction may end up benefiting from a course of steroids for vasculitis. A clinician’s preliminary diagnosis may be mesenteric ischemia, but the final judgment determined by MRI/MR angiography may be pancreatic cancer, or vice versa. An ulcerated plaque with a dangling thrombus may appear on a thoracic CT angiogram on one examination but disappear on the next—coinciding with a stroke, a bout of ischemic colitis, or a pulseless extremity. Rheumatologists, cardiologists, and surgeons do not terminate their attention to patients at the end of a body territory, though radiologists have largely broken down along territorial lines to improve our efficiency.

        As our specialty becomes increasingly subspecialized, clinical diagnosis has become progressively distributed among a larger number of physicians. This structural change has created a certain peril of failing to “connect the dots” and fading expertise for disciplines that “just don’t fit” into the existing framework of subspecialties. Vascular imaging champions are required, whether ordered into dedicated service lines or attached to conventional subspecialty silos. Complicating matters, indications for imaging examinations can be rather varied, including specific attention on the vessels themselves, (atherosclerotic disease to vasculitis) or diseases of the end-organs (stroke, myocardial infarct, mesenteric ischemia).

        Over that last 30 years, our field has witnessed tremendous advances in imaging technologies that have promptly changed the practice of cardiovascular imaging, shifting markedly from invasive catheter angiography to noninvasive imaging. Radiologist practices, for the most part, have seen noninvasive vascular imaging far outpace invasive imaging, especially as these techniques have improved in their reliability and effectiveness. Although imaging has recently been scrutinized as a cost center, noninvasive diagnosis is strikingly cost-effective, particularly compared to invasive angiography and surgical procedures undertaken without the benefit of the road map that imaging provides.

        These technologies continue to rapidly evolve with dramatic changes even in the last five years, which persist in shaping our clinical practices. However, the non-invasive technologies have not translated into all radiology practices with equal vigor. This non-adoption is due, in part, to the pervasive nature of vascular disease that impacts so many radiological subspecialties, as well as the roles that several imaging modalities play. Ultrasound, CT, and MRI each have complementary functions and strengths, such that screening, definitive diagnosis, and disease management often require more than one. It is difficult to find any subspecialty or individual radiologist with mastery of all these modalities, much less the ability to translate their latest advancements into practice.

        One prevailing question is how to achieve high-level vascular imaging across the wide range of clinical radiology. Ultimately, developing new service lines is exceedingly challenging, especially in the modern era where the pressures of relative value unit-based productivity dominate our practices. The activation barrier is high. Nevertheless, I believe that pursuit of diagnostic excellence is an endeavor worth committing a career to. Our patients count on it. No other specialties are prepared to carry this torch with imaging.

        I also believe radiologists possess a unique skill set and are well-positioned to be champions of multimodality imaging diagnosis. Many of us have been trained as master diagnosticians—to recognize and analyze disease, exploiting the strengths of and overcoming the weaknesses in individual imaging modalities. No, artificial intelligence doesn’t stand a chance without us.

        The opinions expressed in InPractice magazine are those of the author(s); they do not necessarily reflect the viewpoint or position of the editors, reviewers, or publisher.