Highlights from the scientific and educational abstracts presented at the ASER 2016 annual scientific meeting and postgraduate course

The annual meeting of the American Society of Radiology (ASER) took place in San Francisco, California on September 14 through September 17, 2016. Attendees represented the USA as well as international emergency radiology communities, including those from academic, private practice, and teleradiology settings. There were several “members in training” in attendance as well. The meeting again featured the “Trauma Head to Toe” 2-day didactic course, highlighting various important topics on imaging of traumatic injuries. Scattered throughout the 4 days were several poster and case of the day presentations, scientific sessions, and self-assessment modules. The following is a summary of the educational posters and scientific papers.     

Highlights from the scientific and educational abstracts presented at the ASER 2017 annual scientific meeting and postgraduate course

The annual meeting of the American Society of Emergency Radiology (ASER) took place in Toronto, Canada, on September 6 through September 9, 2017. Attendees represented the USA as well as international emergency radiology communities, including those from academic, private practice, and teleradiology settings. There were several “members in training” in attendance as well. The meeting again featured the “Trauma Head to Toe” 2-day didactic course, highlighting various important topics on imaging of traumatic injuries. Scattered throughout the 4 days were several poster and case of the day presentations, scientific sessions, and self-assessment modules. The following is a summary of the educational posters and scientific papers.     

Swiss teleradiology survey: present situation and future trends

The purpose of this study was to obtain a survey about the present situation including the usage pattern, technical characteristics and the anticipated future of teleradiology in Switzerland. An internet-based questionnaire was made available to all members of the Swiss Society of Radiology. Questions concerning current teleradiology usage, the type of transmitted modalities, the technology employed, security, billing issues and the anticipated future of teleradiology were addressed. One hundred and two (22.67%) of 450 radiologists responded to the survey. Of the total, 41.2% (42) were teleradiology users, 35.3% (36) planned to use teleradiology in the near future and 24.5% (25) did not use or plan to use teleradiology. The mean number of examinations transmitted per month was 198 (range 1–2,000) and the mean distance was 33 km (range 1,250 km). An emergency service was considered the most important purpose (mean score 6.90; minimum 1, maximum 10) for the use of teleradiology, followed by image distribution (mean 6.74) and expert consultation (mean 6.61). The most commonly transmitted modality was computed tomography (mean 8.80), followed by conventional X-rays (8.40) and magnetic resonance imaging (8.32). The most commonly transmitted format was Digital Imaging and Communications in Medicine (DICOM) (66.7%), followed by bitmap/Joint Photographic Experts Group (jpg) (38.1%), using the DICOM send/receive protocol (52.4%), followed by the hypertext transfer protocol (26.2%) and e-mail (21.4%). For security a secure connection (54.8%) followed by encryption (14.3%) and anonymization (9.5%) was used. For the future, image distribution was rated the most important aspect of teleradiology (7.88), followed by emergency (7.22) and expert consultation (6.53). Development of legal regulations is considered most important (8.17), followed by data security guidelines (8.15). Most radiologists believe that insurance companies should pay for the costs of teleradiology (37.3%), followed by the radiologist (33.3%). In conclusion, in Switzerland a wide spectrum of teleradiology applications and technologies is in use. Guidelines and reimbursement issues remain to be solved.     

Teleradiology applications with DICOM-e-mail

For the connection of several partners to a Dicom-e-mail based teleradiology network concepts were developed to allow the integration of different teleradiology applications. The organisational and technical needs for such an integration were analysed. More than 60 institutions including 23 hospitals in the Rhein-Neckar-Region, Germany were connected. The needed functionality was grouped in six teleradiology applications (emergency consultation, tele-guided examinations, expert consultations, cooperative work, scientific cooperations and homework with on call services) and their technical and organisational needs according to availability, speed of transfer, workflow definitions and data security needs was analysed. For the local integration of teleradiology services the setup and workflow is presented for a standalone teleradiology workstation and a server based teleradiology gateway. The line type needed for different groups of applications and users is defined. The security concept and fallback strategies are laid out, potential security problems and sources of errors are discussed. The specialties for the emergency teleradiology application are presented. The DICOM-e-mail protocol is a flexible and powerful protocol that can be used for a variety of teleradiology applications. It can meet the conditions for emergency applications but is limited if synchronous applications like teleconferences are needed.     

Arbeitstagung „Radioonkologie und Recht”

From 25 to 27 Sept 1997, a workshop was organized at the Essen Medical School (Universitätsklinikum Essen), at which radiooncologists and jurists from universities and courts as well as lawyers contributed their views on mutual problems. The following topics were discussed by papers and in round table meetings: “Requirements on the patient’s information”, “definition of therapeutic guidelines — limits of clinical research and standard treatments”, “treatment documentation”, “liability of the physician for treatment faults” and “technical standard and preserve of quality”. The consensual guidelines to the topics “patient’s information”, “therapeutic guidelines” and “liability” are presented here.     

Offshore teleradiology

Radiologists are responsible for providing prompt emergency radiology interpretations 24 hours a day, every day of the year. As a result of the increasing use of multidetector computed tomography, emergency radiology has increased significantly in volume over the past 5 years. Simultaneously, radiologists are working harder during the day because of the workforce shortage. Although teleradiology services located in the continental United States have been providing efficient coverage until recently, they are now having increasing difficulty recruiting radiologists who are willing to work at night. Addressing this problem is “offshore teleradiology.” With the increasing use of several enabling technologies—Digital Imaging and Communication in Medicine, the picture archiving and communication system, and the Internet—it is now possible to cover a domestic radiology practice at night from any location in the world where it is daytime. Setting up such a practice is nontrivial, however. The radiologists must all be American trained and certified by the American Board of Radiology. They must have medical licenses in every state and privileges at every hospital they cover. This article describes some of the details involved in setting up an offshore teleradiology practice. It also attempts to make a financial case for using such a practice, particularly in the current economic environment.     

Picture archiving and communication system (PACS) networking: three implementation strategies

This paper outlines the diverse Picture Archiving and Communication Systems (PACS) networking implementation strategies at the University of California at Los Angeles, the University of Florida, and the University of Kansas. At the University of California at Los Angeles, a very high-speed network has been integrated into a hierarchical networking strategy, resulting in an entirely customized network for the local transmission of images. The University of Florida has chosen to implement networks for local transmission of images using commercially available equipment. The University of Kansas, specializing in teleradiology applications, uses commercial telecommunication circuits to implement long distance referral services to small hospitals.     

Strategic uses of teleradiology.

The most frequently cited benefits of image communications systems (teleradiology) are: (1) a reduction in the travel time of radiologists, and (2) an improvement in access to services, especially in rural areas. The benefits of teleradiology services for hospitals are, however, potentially much greater. Teleradiology services could alter the competitive positions of organizations in the market for imaging services and change the nature of the competition. In this article we examine how a small community hospital and a large referral hospital might each use teleradiology strategically to improve their respective competitive positions.     

Comparison between intensity normalization techniques for dynamic susceptibility contrast (DSC)-MRI estimates of cerebral blood volume (CBV) in human gliomas

Purpose:

To compare “standardization,” “Gaussian normalization,” and “Z‐score normalization” intensity transformation techniques in dynamic susceptibility contrast magnetic resonance imaging (DSC‐MRI) estimates of cerebral blood volume (CBV) in human gliomas. DSC‐MRI is a well‐established biomarker for CBV in brain tumors; however, DSC‐MRI estimates of CBV are semiquantitative. The use of image intensity transformation algorithms provides a mechanism for obtaining quantitatively similar CBV maps with the same intensity scaling.

Materials and Methods:

The coefficient of variance (CV) in normal‐appearing white matter and relative contrast between tumor regions and normal tissue was compared between the three CBV transformations across five different MR scanners in 96 patients with gliomas.

Results:

The results suggest all normalization techniques improved variability and relative tumor contrast of CBV measurements compared with nonnormalized CBV maps. The results suggest Gaussian normalization of CBV maps provided slightly lower CV in normal white matter and provided slightly higher tumor contrast for glioblastomas (WHO grade IV) compared with other techniques.

Conclusion:

The results suggest Gaussian normalization of leakage‐corrected CBV maps may be the best choice for image intensity correction for use in large‐scale, multicenter clinical trials where MR scanners and protocols vary widely due to ease of implementation, lowest variability, and highest tumor to normal tissue contrast. J. Magn. Reson. Imaging 2012;35:1472–1477. © 2012 Wiley Periodicals, Inc.     

Teleradiologie – Update 2014

Due to economic considerations and thanks to technological advances there is a growing interest in the integration of teleradiological applications into the regular radiological workflow. The legal and technical hurdles which are still to be overcome are being discussed in politics as well as by national and international radiological societies. The European Commission as well as the German Federal Ministry of Health placed a focus on telemedicine with their recent eHealth initiatives. The European Society of Radiology (ESR) recently published a white paper on teleradiology. In Germany §3 section 4 of the Röntgenverordnung (RöV, X-ray regulations) and DIN 6868-159 set a framework in which teleradiology can also be used for primary reads. These possibilities are already being used by various networks and some commercial providers across Germany. With regards to cross-border teleradiology, which currently stands in contrast to the RöV, many issues remain unsolved.     

Focusing on functional knee parameter determination to develop a better clinical gait analysis protocol

BackgroundAttempts to improve protocol standards of marker-based clinical gait analysis (CGA) have been one of the main focuses of research to enhance robustness and reliability outcomes since the 1990s. Determining joint centres and axes constitutes an important aspect of those protocols. Although the hip joint is more prominent in such studies, knee joint center (KJC) and axis (KJA) directly affect all outcomes.Research questionWhat recommendations arise from the study of the scientific literature for determining knee joint parameters (KJP) for protocols of CGA?MethodsA systematic, electronic search was conducted on November 2018 using three databases with the keyword combination (“functional approach” OR “functional method” OR “functional calibration”) AND (“hip joint” OR “knee joint” OR “ankle joint”) and analyzed by four reviewers. Given the existence of a recent review about the hip joint and the lack of material about the ankle joint, only papers about the knee joint were kept. The references cited in the selected papers were also screened in the final round of the search for these publications.The quality of the selected papers was assessed and aspects regarding accuracy, repeatability, and feasibility were thoroughly considered to allow for a comparison between studies. Technical aspects, such as marker set choice, KJP determination techniques, demographics, and functional movements, were also included.ResultsThirty-one papers were included and on average received a rating of about 75 % according to the quality scale used. The results showed that functional methods are superior or equivalent to predictive methods to estimate the KJA, while a regression method was slightly better for KJC prediction.SignificanceCalibration methods should be applied to CGA whenever feasibility is reached. No study to date has focused on evaluating the in vivo RoM required to obtain reliable and repeatable results and future work should aim in this direction.     

Questionnaire survey on teleradiology for radiological technologists: analyses by age group and facility type in Hokkaido

A questionnaire survey was given to 1,951 radiological technologists in Hokkaido to examine their views on teleradiology. The questionnaire consisted of questions about their understanding of teleradiology and interest in it as well as examining the need for teleradiology and problems with it. A total of 1,275 radiological technologists responded to the survey, a response rate of 65.4%. The returned questionnaires were analyzed according to different groups categorized by age of the radiological technologists and type of medical facility. Almost all radiological technologists knew about teleradiology. Among the different age groups, the higher age groups showed greater recognition and understanding of teleradiology. About 60% of radiological technologists were interested in teleradiology (no significant differences among age groups). When it was assumed that a teleradiology system would be introduced, (1) the working load for radiological technologists was estimated to be about 17,820 (+/-24,233) yen per month. (2) Sixty percent of the respondents considered that the system should be used for the reading and diagnosis of difficult cases. (3) Fifty percent of them thought that the system should be managed and operated by radiological technologists. (4) Many radiological technologists pointed out problems concerning initial costs and the facility's management system.     

体部CT和磁共振学会双能量CT白皮书(下)

体部CT和磁共振学会于2016年末陆续推出了双能量CT系列白皮书,这是该学会首次推出的关于双能量CT专家共识之系列白皮书。本文介绍了该系列白皮书的第三和第四部分,分别描述了双能量CT在血管、心脏、肺部、肌肉骨骼系统和腹盆部的临床应用并提出专家共识意见。     

A “scoping” review of prostate brachytherapy and immune responses

PurposeWhether prostate brachytherapy (BT) results in opportunistic biological changes that can improve clinical outcomes is not well studied. We sought to investigate the impact of prostate BT on the immune system.Materials and MethodsA scoping review was performed using PubMed/Scopus for papers published between 2011-2021. Search terms were “brachytherapy” AND “immune” AND “prostate”. A total of 81 records were identified and 6 were selected for further review.Results2 low-dose-rate BT papers (n=68) evaluated changes in the peripheral blood following I-125 monotherapy. Both showed significant increases in peripheral CD3+ and CD4+ T cells post-BT. One also demonstrated significant increases in Treg subsets up to 150 days post-BT. 4 high-dose-rate (HDR) studies (n=37) were identified, and all were done in combination with EBRT. The largest study (n=24) showed a single 10 Gy fraction of HDR converted 80% of “cold” tumors into an “intermediate” or “hot” state, based on a tumor inflammation signature when comparing a pre-BT biopsy to one prior to a second HDR fraction.ConclusionProstate BT can invoke an immune activating phenotype; however, changes in immunosuppressive cells are also seen. Additional data is needed to understand how to promote synergy between BT and the immune system.     

From shared data to sharing workflow: Merging PACS and teleradiology

Due to a host of technological, interface, operational and workflow limitations, teleradiology and PACS/RIS were historically developed as separate systems serving different purposes. PACS/RIS handled local radiology storage and workflow management while teleradiology addressed remote access to images. Today advanced PACS/RIS support complete site radiology workflow for attending physicians, whether on-site or remote. In parallel, teleradiology has emerged into a service of providing remote, off-hours, coverage for emergency radiology and to a lesser extent subspecialty reading to subscribing sites and radiology groups.When attending radiologists use teleradiology for remote access to a site, they may share all relevant patient data and participate in the site's workflow like their on-site peers. The operation gets cumbersome and time consuming when these radiologists serve multi-sites, each requiring a different remote access, or when the sites do not employ the same PACS/RIS/Reporting Systems and do not share the same ownership. The least efficient operation is of teleradiology companies engaged in reading for multiple facilities. As these services typically employ non-local radiologists, they are allowed to share some of the available patient data necessary to provide an emergency report but, by enlarge, they do not share the workflow of the sites they serve.Radiology stakeholders usually prefer to have their own radiologists perform all radiology tasks including interpretation of off-hour examinations. It is possible with current technology to create a system that combines the benefits of local radiology services to multiple sites with the advantages offered by adding subspecialty and off-hours emergency services through teleradiology. Such a system increases efficiency for the radiology groups by enabling all users, regardless of location, to work “local” and fully participate in the workflow of every site. We refer to such a system as SuperPACS.     

Analysis of the painting “Gioventú” (Eliseu Visconti) using EDXRF and computed radiography

In this work, the painting “Gioventú” (Eliseu Visconti, 1898) was analyzed by means of energy dispersive X-ray fluorescence and computed radiography. A portable EDXRF system was employed to identify the pigments used by the artist: yellow, red and brown ocher; umber; vermilion; cobalt blue; lead white and viridian (or chromium oxide). The CR analysis revealed that the painting was in a good state of conservation and also a previous composition hidden under the painting.     

Gibbs tracking: A novel approach for the reconstruction of neuronal pathways

Reconstruction of neuronal fibers using diffusion‐weighted (DW) MRI is an emerging method in biomedical research. Existing fiber‐tracking algorithms are commonly based on the “walker principle.” Fibers are reconstructed as trajectories of “walkers,” which are guided according to local diffusion properties. In this study, a new method of fiber tracking is proposed that does not engage any “walking” algorithm. It resolves a number of inherent problems of the “walking” approach, in particular the reconstruction of crossing and spreading fibers. In the proposed method, the fibers are built with small line elements. Each line element contributes an anisotropic term to the simulated DW signal, which is adjusted to the measured signal. This method demonstrates good results for simulated fibers. A single in vivo result demonstrates the successful reconstruction of the dominant neuronal pathways. A comparison with the diffusion tensor imaging (DTI)‐based fiber assignment with continuous tracking (FACT) method and the probabilistic index of connectivity (PICo) method based on a multitensor model is performed for the callosal fibers. The result shows a strong increase in the number of reconstructed fibers. These almost fill the total white matter (WM) volume and connect a large area of the cortex. The method is very computationally expensive. Possible ways to address this problem are discussed. Magn Reson Med 60:953–963, 2008. © 2008 Wiley‐Liss, Inc.     

半月板下表面撕裂的MRI影像学表现

目的 探讨半月板下表面撕裂(meniscus lower surtace tear,MLST)的MRI影像学表现及与半月板撕裂传统分型的差异.方法 以"桶柄状撕裂""水平撕裂""复杂撕裂"为关键词,检索2018-06至2021-06在医院影像归档系统(picture archiving and communicatio...     

Standardization of teleradiology using Dicom e-mail: recommendations of the German Radiology Society

Until recently there has been no standard for an interoperable and manufacturer-independent protocol for secure teleradiology connections. This was one of the main reasons for the limited use of teleradiology in Germany. Various teleradiology solutions have been developed in the past, but the vast majority have not been interoperable. Therefore an ad hoc teleradiology connection was impossible even between partners who were already equipped with teleradiology workstations. Based on the evaluation of vendor-independent protocols in recent years the IT Working Group (AGIT) of the German Radiology Society set up an initiative to standardize basic teleradiology. An e-mail based solution using the Dicom standard for e-mail attachments with additional encryption according to the OpenPGP standard was found to be the common denominator. This protocol is easy to implement and safe for personalized patient data and fulfills the legal requirements for teleradiology in Germany and other countries. The first version of the recommendation was presented at the 85th German Radiology Convention in 2004. Eight commercial and three open-source implementations of the protocol are currently available; the protocol is in daily use in over 50 hospitals and institutions.     

The Current State of Teleradiology Across the United States: A National Survey of Radiologists’ Habits,Attitudes, and Perceptions on Teleradiology Practice

PurposeTo explore the current state of teleradiology practice, defined as the interpretation of imaging examinations at a different facility from where the examination was performed.MethodsA national survey addressing radiologists’ habits, attitudes, and perceptions regarding teleradiology was distributed by e-mail to a random sample of ACR members in early 2019.ResultsAmong 731 of 936 respondents who indicated a non-teleradiologist primary work setting, 85.6% reported performing teleradiology within the past 10 years and 25.4% reported that teleradiology represents a majority of their annual imaging volumes; 84.4% performed teleradiology for internal examinations and 45.7% for external examinations; 46.2% performed teleradiology for rural areas and 37.2% for critical access hospitals; 91.3% performed teleradiology during weekday normal business hours and 44.5% to 79.6% over evening, overnight, and weekend hours. In all, 76.9% to 86.2% perceived value from teleradiology for geographic, after-hours, and multispecialty coverage, as well as reduced interpretation turnaround times. The most common challenges for teleradiology were electronic health record access (62.8%), quality assurance (53.8%), and technologist proximity (48.4%). The strategy most commonly considered useful for improving teleradiology was technical interpretation standards (33.3%). Radiologists in smaller practices were less likely to perform teleradiology or performed teleradiology for lower fractions of work, were less likely to experience coverage advantages of teleradiology, and reported larger implementation challenges, particularly relating to electronic health records and prior examination access.ConclusionDespite historic concerns, teleradiology is widespread throughout modern radiology practice, helping practices achieve geographic, after-hours, and multispecialty coverage; reducing turnaround times; and expanding underserved access. Nonetheless, quality assurance of offsite examinations remains necessary. IT integration solutions could help smaller practices achieve teleradiology’s benefits.