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I n s I d e W e d n e s d a y Get more daily bulletin OnlineThe Daily Bulletin online edition fea-tures stories from our main news section and is offered in a mobile-optimized format for smartphones and other mobile

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Imaging PainMR neurography is an exciting new modality in pain detection and management 6A

The Aging radiologistExperts Weigh in on when to retire and why 17A

w e d N e S dAy

TechnologyTip of the daycorrect for aliasing artifacts on mr images by repeating the scan with a larger field of view or switching the phase encode and frequency encode directions.

American Association of Physicists in Medicine

Haffty Named to RSNA Board

b ruce G. Haffty, M.D., an interna-tional expert in breast radiation oncology known for his accomplish-

ments in the clinic and classroom, as well as for his groundbreaking cancer research, is the new-est member of the RSNA Board of Directors. Dr. Haffty will assume the position of Board Liaison for Science as Richard L. Ehman, M.D., becomes chairman of the Board of Directors. Since 2005, Dr. Haffty has served as profes-sor and chairman in the Department of Radiation Oncology at Rutgers Robert Wood John-son Medical School, Rutgers New Jersey Medical School and Rutgers Cancer Insti-tute of New Jersey. He also serves as asso-ciate director of Rutgers Cancer Institute. “RSNA provides the preeminent forum to advance the radiologic sciences through

its meeting, journals and education, all supported by its dedicated volunteers,” Dr. Haffty said. “By providing venues to pres-ent findings and exchange ideas, as well as

offering funding opportunities through its foundation, there is no other organization better positioned to shape the future of radiology than RSNA.” Dr. Haffty completed his medical school and residency training at Yale University School of Medicine in 1988 and spent the next 18 years specializing in breast and head and neck cancers in Yale’s Department of Therapeutic Radiology. Dr. Haffty served

on the faculty at Yale from 1988 through 2005, being promoted to professor of therapeutic radiology in 2000, serving as residency program director from 1992 through 2004, and vice-chairman and clini-cal director from 2002 to 2005.

Bruce G. Haffty, M.D.

Optimal medical Imaging Achievable for Patients with ebola

By Evonne Acevedo Johnson

while a hospital’s standards of practice for isolating and caring for patients

with Ebola virus infection are not likely to be directed toward radiology staff, an early point of contact might be an outpatient imaging clinic, according to a presenter of a special interest session on Tuesday. David A. Bluemke, M.D., Ph.D., direc-tor of radiology and imaging sciences and

senior investigator at the National Institute of Biomedical Imaging and Bioengineer-ing, spoke during a session “Radiology Preparedness and Ebola Virus Disease.” He cited a case in which a patient who later presented with Ebola virus disease had initially visited a local emergency department, where he underwent CT imag-ing to rule out appendicitis.

Radiologists Need to Take Action in Transition to Value-Based PracticeRadiologists must be willing to take meaningful action to transform and improve the way they practice in order to make a successful transition from volume-based to value-based practice, according to David C. Levin, M.D., the presenter of the RSNA 2014 Annual Oration in Diagnostic Radiology. By Paul LaTour“w e need to become better doctors—

real doctors, if you will—who provide real value to our patients,

our referring doctors and our hospitals,” said Dr. Levin, professor and chairman emeritus of the Department of Radiology at Jefferson Medical College and Thomas Jef-ferson University Hospital in Philadelphia. “We’ve let ourselves become the invisible doctors and that is something none of us are happy about.” Radiologists are their own worst enemies by allowing the perception to grow that radiology is a commodity rather than a true specialty, Dr. Levin said. That perception, he added, has led to threats to the profession from inside and outside healthcare, including declining reimburse-ments and the idea that much imaging is

inappropriate or unnecessary. Other threats include an increased emphasis on utiliza-tion management and termination of groups by hospitals that then turn to teleradiology companies. Fortunately, Dr. Levin continued, radi-ologists have plenty of opportunities to create a new perception—that they add real value to the patient-care process. Radi-ologists can act more like true consulting

physicians by supervising and moni-toring every advanced imaging exam, bolstering their input with guidelines such as American College of Radiology Appropriateness Criteria. Being a true consulting physician also means giving patients access to results, either verbally or via an electronic portal, he said.

radiologists must be Available to Patients, referring PhysiciansDr. Levin also advocated for radi-ologists being more available to their patients and referring physicians. The first step, he said, is to stop outsourc-ing to teleradiology companies, which Dr. Levin said devalues the work of radiolo-gists. “By outsourcing nights and weekends to teleradiology groups, we are shooting ourselves in the foot,” he said.

Developing and tracking internal qual-ity metrics—and then publicizing them—also adds value, Dr. Levin said. To prove value, you have to prove quality, he said.

David C. Levin, M.D.

continued on page 16a continued on page 16a

continued on page 4a

David A. Bluemke, M.D., Ph.D., Bruce S. Ribner, M.D., Carolyn C. Meltzer, M.D.

Look inside to see how attendees are celebrating the meeting of the century with shared stories and a look back through history.

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7:15–8:15Hot Topic and Controversy sessions RSNA Diagnosis Live™Body, Cardiac, MSK, Neuro, ENT Potpourri8:00–9:00ASRT@RSNA2014: Innovation and Translational Research8:30–10:00Refresher/Informatics Courses(BOOST) Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for Tomorrow: Oncology/Anatomy—CNSEssentials of UltrasoundRSNA/ESR Emergency Symposium: General Principles, Pediatric and ENT Emergencies8:30–NooNSeries CoursesInterventional, Neuroradiology9:20–10:20ASRT@RSNA2014: Shoulder Imaging10:30–NooNScientific Paper Sessions(BOOST) Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for Tomorrow: Integrated Science and Practice—CNSEssentials of Pediatric ImagingInformatics CoursesRSNA/ESR Emergency Symposium: CNS Emergencies

10:40–11:40ASRT@RSNA2014: Expanding the Role of the Radiographer in the Quality Assurance Triangle12:15–1:15 Poster Discussions12:30–2:00 Informatics Courses1:00–2:00ASRT@RSNA 2014: The Miracle of Breast MRI1:30–2:45Wednesday Plenary Session (Arie Crown Theater)Annual Oration in Radiation Oncology (See Page 6)'Error Bars' in Medical Imaging: Stealth and TreacherousLawrence B. Marks, M.D.1:30–3:00Essentials of Neuro ImagingRSNA/ESR Emergency Symposium: Chest Emergencies1:30–5:00Resident and Fellow SymposiumHospital Administrators Symposium Interventional Oncology Series: Mechanisms Matter2:20–3:20ASRT@RSNA 2014: Dual Energy Computed Tomography

2:30–4:00 Informatics Courses3:00–4:00 Scientific Paper Sessions3:00–4:15(BOOST) Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for Tomorrow: Case-based Review—CNS3:30–5:00Essentials of Musculoskeletal ImagingRSNA/ESR Emergency Symposium: Abdominal Emergencies3:40–4:40ASRT@RSNA 2014: Contrast Media5:00–7:00Sip & Savor

wednesday at a GlanceWednesday © 2014 RSNA

The RSNA 2014 Daily Bulletin is the official publication of the 100th Scientific Assembly and Annual Meeting of the Radiological Society of North America. Pub-lished Sunday, November 30–Thursday, December 4..

Salomao Faintuch, M.D., ChairHarald Brodoefel, M.D.Philip Costello, M.D.Abraham H. Dachman, M.D.Karen Hoffman, M.D.Joseph G. Mammarappallil, M.D., Ph.D.Edith M. Marom, M.D.Tejas S. Mehta, M.D., M.P.H.Michael L. Richardson, M.D.Elizabeth L. Hipp, Ph.D., AAPM LiaisonMary C. Mahoney, M.D., Board Liaison

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technology

Question of the dayQ why can’t i use my other

workstations to review mam-mograms?

[answer on page 13.]

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Integrating Radiology, Pathology Would Improve Diagnostics, Aid PatientsBy Paul LaTour

Integration between radiology and pathology would lead to an improved diagnostic system that would benefit

both the caregivers and patients, according to speakers at the Monday special interest session, “Radiology and Pathology Diag-nostics: Is it Time to Integrate?” The value proposition includes speedier and more accurate diagnoses, better patient outcomes, better management of diag-nostic and therapeutic resources and lower costs, according to presenter Mitchell D. Schnall, M.D., Ph.D. “Diagnostics really drive the clinical care path and the precision medicine agenda as we go forward,” said Dr. Schnall, the Eugene P. Pendergrass professor and chair in the radiology department at the University of Pennsylvania. He added that current diagnostics exist in individual silos (radiology, lab, molecu-lar diagnostics, histology, etc.) with no “grain elevator” working to facilitate coop-eration or sharing. Pathologist Michael D. Feldman, M.D., Ph.D., said the disciplines need to develop a common culture, adding that one imme-

diate opportunity exists in terms of lesion location reference. The first step is estab-lishing a shared workflow and integrated information systems, which means upgrad-ing from the antiquated paper requisition system most hospitals still use. “It’s a real boondoggle to get all the necessary data together for anatomic pathologists with paper requisitions,” said Dr. Feldman, an associate professor of pathology and laboratory medicine at the

Hospital of the University of Pennsylvania. “So there are opportunities with an integrated workflow for standards in imaging, ordering and reporting spaces that could go a long way.” To converge workflows,

it is critical to decide what capabilities can be supported for developing information technology and informatics.

Structured Reporting Template for Prostate on the HorizonDuring the panel discussion later in the session, Curtis P. Langlotz, M.D., Ph.D., said it’s unfortunate most institutions don’t already have a group interface between radiology and pathology, but added that it’s not an informatics issue.

“The reason it hasn’t been done is more about the business and resources being allo-cated for it,” said Dr. Langlotz, the associate director of the Institute for Biomedical Infor-matics at the Univer-sity of Pennsylvania. “One of the headwinds we face is trying to develop a mechanism to exchange templates.” But one such mecha-nism is nearing fruition with prostate reports, according to panelist Jeffrey C. Weinreb, M.D. He said radiology is moving toward creating a standard template for structured prostate reporting that will mirror what pathologists have already implemented. “This is an obvious area for radiol-ogy and pathology to work together,” said Jeffrey C. Weinreb, M.D., a professor of diagnostic radiology at the Yale School of Medicine. Responding to a question from the audi-ence, Dr. Schnall said both radiology and pathology need to get together in deciding issues such as defining a disease and how it is measured. “We have to redefine some of

One of the headwinds we face is trying to develop a mechanism to exchange templates.

Curtis P. Langlotz, M.D., Ph.D.

these issues together for them to be coher-ent,” Dr. Schnall said. Despite the barriers that exist to keep full integration between radiology and pathology from happening, the panelists were optimistic it can be done. The key is communication. “You’ll never get to a common culture unless you start sitting down and talking about it,” Dr. Feldman said. “We’re starting to hear some of that now.” The joint session was held by RSNA and the American Society of Clinical Pathologists, (ASCP) and followed up on a two-day workshop held last spring at RSNA Headquarters in Oak Brook, Ill.

Mitchell D. Schnall, M.D., Ph.D. Michael D. Feldman, M.D., Ph.D.

This year’s Annual Oration in Diagnostic Radiology was dedicated to the memory of Henry N. Wagner, Jr., M.D., a towering figure in nuclear medicine for over half a century. Dr. Wagner published more than 800 articles and many books and was a member of the Insti-tute of Medicine. His scientific contributions included the development of lung scanning to diagnose pulmonary emboli and pioneering studies to image neuro-receptors in the living human brain—the first brain imaged was his. Dr. Wagner was also a hugely influential educator. More than 500 physicians and scientists were educated through his programs in both medicine and radiation science at Johns Hopkins University School of Medicine, including David C. Levin, M.D., presenter of this year’s oration. “He was truly a superb educator and a superb scientist, so it’s a special privilege for me to be able to give this lecture in his memory,” Dr. Levin said.

Oration Dedicated to Wagner

Continued from page 1a

“You can’t just beat your breast and proclaim to the rest of the world that you provide high-quality imaging,” he said. “Every-body says that. So those words don’t mean a damn thing.” Finally, radiologists must build closer ties with not only pri-mary care physicians, but with nurse practitioners, physician assistants and others who are going to become more influential under Accountable Care Organizations, bundled payments and capitation. Dr. Levin concluded with a prediction: if radiology groups follow these steps, in five years the specialty will no longer be viewed as a commodity—referring doctors will see radiologists as contributing value and look for guidance on imaging and patients will come to respect radiologists as “real doctors.” “This could be our future—just think of that,” he said. “But it’s only going to happen if we change the way we do business. It’s not going to happen if we just sit back and opt for the status quo.”

Radiologists Need to Take Action in Transition to Value-Based Practice

By Mike Bassett

R obot-assisted CT-guided biopsy of lung lesions can be used safely and accu-

rately, particularly compared to conventional CT-guided biopsy techniques, according to a study presented Tuesday. While CT-guided lung biopsy has become the standard proce-dure for obtaining a diagnosis of pulmonary lesions that are suspicious for malignancy, the two ways in which this proce-dure is usually performed—the “step-and-shoot” and fluoro-scopic techniques—have their limitations, said presenter Andrea Porfiri, M.D., of the Department of Radiological Sciences, Sapienza Uni-versity of Rome, in the session, “Preliminary Clinical Experience with a Dedicated Interventional Robotic System for CT-guided Biopsies of Lung Lesions: A Comparison with the Conventional Manual Technique.” According to Dr. Porfiri, the step-and-shoot tech-nique relies on the operator’s subjective assessment of needle path and positioning, which could result in lon-ger procedure times with an increased risk of compli-cations. On the other hand, the fluoroscopic technique is more accurate than the step-and-shoot technique when targeting smaller nodules, is of shorter dura-tion and yields significantly lower complication rates. However, it is associated with a significant increase in radiation dose to both operator and patient. “In both of these manual techniques, successful application depends significantly on the operator’s manual skill and experience,” Dr. Porfiri said. Conse-quently, he and his colleagues at Sapienza University wanted to assess the clinical performance of a dedi-cated robotic system compared to these conventional manual techniques. For purposes of the study, 100 patients (63 males and 37 females between the ages of 48 and 88) who were referred for CT-guided lung biopsy of previously diagnosed lung lesions were randomly assigned to undergo a robot-assisted procedure or a conventional biopsy using the step-and-shoot technique.

According to Dr. Porfiri, the dura-tion of the robot-assisted procedure ranged between 10-31 minutes—signif-icantly less than the 18-42 minutes for the conventional procedure. Radiation dose was significantly reduced with the robot-assisted procedure, as well. Dr. Porfiri and his colleagues deter-mined that the diagnostic performance of robot-assisted procedure was similar to the manual procedure, with four patients requiring re-biopsy after the robotic procedure and three patients requiring re-biopsy after the manual procedure. They also found that the complication rates were similar. “The result of our study demon-

strates that the robot-assisted lung biopsy is accurate and safe, and the robot-assisted procedure can also reduce procedure duration and radiation dose com-pared to the conventional approaches,” Dr. Porfiri said. “Our study was performed by two operators (with 2 and 8 years experience performing CT-guided lung biopsies), and although a statistical analysis has not been performed to evaluate differences between the two operators, what impressed us was the reduction in time needed by both operators to complete the proce-dure with in the robot-assisted approach, compared to the unassisted technique,” said Michele Anzidei, M.D., also of the Department of Radiological Sciences, Sapi-enza University, and the study’s lead author. While he expected to see that reduction in time for a less experienced operator, he was surprised to see a reduction in time for the experienced operator as well. “Future research should be aimed at evaluating how operators with different levels of experience may ben-efit from robot assistance in daily clinical routine, and to assess potential differences in the clinical perfor-mance of robot-assisted procedures between expert and non-expert radiologists,” Dr. Anzidei said. “While we obtained encouraging results, these should be verified and reproduced on a larger number of patients, preferably in a multi-centric study,” Dr. Anzidei concluded.

Robotic System for CT-guided Biopsies of Lung Lesions Shows Promise

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Annual Oration in Radiation Oncology Presented TodayBenefits, Liabilities of Imaging in Radiation Therapy are Focus

while medical imaging has markedly improved

radiation therapy, limita-tions remain and excessive over-reliance on imaging can be detrimental, according to Lawrence B. Marks, M.D., who will present “‘Error Bars’ in Medical Imaging: Stealth and Treacherous.” Dr. Marks combines expertise in radiation therapy-induced normal tissue injury and human-factors engineering to detail specific errors that can occur when applying medical images to radiation therapy. The Dr. Sidney K. Simon Distinguished Profes-sor of Oncology Research in the Department of Radiation Oncology at the University of North Car-olina at Chapel Hill School of Medicine, Dr. Marks has conducted several imaging-based prospective clinical trials to better understand radiation-induced lung and heart injury and was the lead physician for the QUANTEC (Quantitative Analyses of Normal Tissue Effects in the Clinic) initiative sponsored by the American Society for Radiation Oncology and the American Association of Physicists in Medi-cine.

Lawrence B. Marks, M.D.

mr neurography an emerging modality in musculoskeletal PainIn a few short years, MR neurography—a fairly new imaging technique for the direct imaging of spinal and peripheral nerves—has emerged as an exciting new modality in pain detection and management.By Mike Bassett

The subject of a Tuesday refresher course, MR neurography has “emerged as the poster child for innovation in

the area of musculoskeletal pain and is one of the leading developments in our subspe-cialty over the last four or five years,” said Sandip Biswal, M.D., an associate profes-sor of radiology at the Stanford University Medical Center, who pre-sented a session on “PET and MR Methods to Image Pain.” Chronic pain is now affecting approximately 116 million American adults and results in hundreds of billions of dollars annu-ally in treatment costs and lost productivity, said Dr. Biswal. For example, according to a report issued by the Institute of Medicine in 2011, the annual cost of chronic pain in the U.S. is estimated to be $560-635 billion, including health care expenses and lost productivity—more than the annual costs associated with heart disease, cancer, and diabetes combined. But the “ugly truth,’ Dr. Biswal said, is that the conventional methods of finding pain generators are “just not adequate,” which is one of the reasons why MR neu-rography is generating so much interest. According to Amelie Lutz, M.D., a colleague of Dr. Biswal who presented the session, “MR Neurography of the Bra-chial Plexus and Upper Extremities,” with

improved scanner and coil techniques, and advances in pulse sequences, “we are now capable of directly imaging nerves with a very high resolution. This has become a really exciting—and evolving—field in radiology.” What MR neurophraphy does is “to really lay out the nerve beautifully,” Dr. Biswal said. “We can reconstruct these

images in a variety of dimensions or even trace them like we do with the vascular system. You can really lay out a pretty look-ing nerve and see if any-thing looks like a mass or inflammation, whether there are neuromas in it, or areas of clumping with the nerve root or intrinsic pathology in the nerve, rather than something compressing it.”

mr neurography breaks Ground with brachial PlexusIn her presentation, Dr. Lutz discussed the anatomy and

normal MR imaging appearance of the brachial plexus and upper extremity nerves and how to recognize the most commonly encountered pathologies and their differen-tial diagnoses in these regions. “With the more central or proximal nerves like the brachial plexus it can be very challenging for physicians to really nail down the specific location and prob-lem with nerve conduction studies or electromyographies,” Dr. Lutz said. “The brachial plexus is probably one of the first

areas in which people focus on this type of imaging.” And while the complexity of this ana-tomic region can appear “daunting,” she said, with the proper tools to systematically analyze and break down anatomy “then suddenly it all makes sense.” Dr. Biswal discussed a number of new approaches to imaging pain involving PET and MRI. He is currently working on developing a biomarker that targets and helps measure the mechanisms of pain at the molecular level. “This PET tracer looks for markers of inflamed nerves,” he said. “So whether it’s increased ion channels in that nerve or increased pain receptors, or increased cellularity, that’s what we’re trying to mark.” That, combined with MR techniques, will provide both a molecular readout along with an anatomic readout that will identify where pain is originating “with great specificity and sensitivity,” Dr. Biswal said. “Basically, what we are all doing is responding to that fact that conventional approaches to imaging pain just haven’t been very good,” said Dr. Biswal. One example of that has been the use of MR and CT to image patients with non-specific back pain. A number of medical organizations have issued recommendations advising against lumbar MRI, mainly because it has not been very predictive or helpful in the acute setting, Dr. Biswal said. Ultimately, Dr. Biswal said, improving ways to use imaging to find the source of pain will not only help patients by improv-ing outcomes, but will serve to improve

their quality of life. “We probably all have friends or relatives who are in chronic pain, and they get labeled as crazy or depressed, and it turns out that patients who have chronic pain are unfortunately difficult to deal with,” he said. “Something like this can dominate their existence and we can help them on the route to recovery.” Tuesday’s session also covered, “MR Neurography of the Lumbar Plexus and Lower Extremities” by presenter Avneesh Chhabra, M.D., who discussed current state-of-the-art techniques available for LS plexus evaluation and shared normal and abnormal imaging appearances of various common and uncommon pathologic states involving LS plexus and its branch nerves. The talk also addressed new 3D techniques that suppress vessel signal effectively while preserving effective nerve visualization. The session, “DTI of the Peripheral Nervous System,” presented by Gustav Andreisek, M.D., covered the basic prin-ciples of diffusion-tensor imaging (DTI), the challenges and limitations for imaging protocols, as well as the evaluation of DTI images quantitatively and qualitatively.

Basically, what we are all doing is responding to that fact that conventional approaches to imaging pain just haven’t been very good.

sandip biswal, m.d.

default mode network connectivity associated with schizophrenia severityBy Elizabeth Gardner

An imaging marker that measures the severity of chronic schizophre-

nia could have a significant impact on risk prediction, detection and treatment. Such a marker, discovered through using functional MR imaging to study the brain’s resting state, was described Tuesday morning by a team of German researchers. The research, led by presenter Sophia Mueller, M.D., from Ludwig-Maximilians University, Munich, included members from the Institute of Clinical Radiology and the Depart-ment of Psychiatry and Psychotherapy. “Despite [being an] enormous public health burden, treatments for schizophrenia still rely on a handful of mechanistic insights that date back to the 1960s,” Dr. Mueller noted in her abstract. “There is an urgent need to develop more effective clinically applicable strategies for treatment, risk prediction, and prevention. In order to make an imaging marker use-ful for therapy monitoring and risk prediction, the association [of default mode network, or DMN, connectivity changes] with symptom severity has to be established.” Studying the brain’s default mode network, the team obtained functional MRI (fMRI) data from 23 chronic

schizophrenia patients and 25 healthy controls. Each subject was scanned for six minutes while awake with eyes shut, and holding the head as still as possible. The subjects were interviewed using the Positive and Nega-tive Symptom Scale (PANSS), a 45-minute clinical assessment that measures symptom severity. Positive symp-toms include delusions, hallucinations and gran-diosity; negative symp-toms include emotional and social withdrawal and difficulty in abstract thinking. The scans showed distinct differ-ences in DMN connectivity between chronic schizophrenia patients and healthy patients and also differences that correlated to variations in the severity and type of symptoms. Within the DMN, patients with more severe positive symptoms and more severe anxiety had less connectivity in the medial prefrontal cortex. Specifically, positive symptoms were correlated with DMN connectivity of the dorso-medial prefrontal cortex, while trait anxiety was correlated with DMN

connectivity of the ventromedial pre-frontal cortex. Connectivity between the DMN and the right striatum was negatively correlated with general symptom severity as measured by the

PANSS total score. No cor-relation between severity of negative symptoms and DMN connectivity was detected. DMN connectivity could serve as an imaging marker to monitor the effects of schizophrenia treatment and also help measure the pres-ence of the disease in patients who carry genes associated with a risk of schizophrenia. The next step in the research is to correlate the MRI find-

ings with the genetic variations that predispose patients to develop schizo-phrenia. “This is an important link that we have to make,” Dr. Mueller said. The two departments are currently begin-ning a follow-up study to compare fMRI studies of 100 schizophrenia patients with those of their unaffected relatives who carry genetic risk fac-tors for schizophrenia, and also with a group of healthy controls. Results should be available within the next two years.

Sophia Mueller, M.D.

Sandip Biswal, M.D.

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D A I L Y B U L L E T I N C O M M E M O R A T I V E C E N T E N N I A L E D I T I O N

“Getting an Education” RSNA Refresher Course Chairs Reflect on Keeping Pace with Their Rapidly Changing SpecialtyBy Paul LaTourCarol B. Stelling, M.D., was a junior medical student at Northwestern University when she attended her first RSNA annual meeting in 1970 at Chicago’s Palmer House. Dr. Stelling recently recalled her first impressions of the meeting, which included seeing an exhibit on hilar anatomy shown on plain radiographs that she said opened her eyes to the wonders of diagnostic radiology. “Subsequently, the RSNA annual meeting became an annual pilgrimage for me and my fellow residents and faculty colleagues as we advanced in our chosen specialties,” Dr. Stelling said. Dr. Stelling didn’t just attend annual meetings, however. She went on to volunteer in the planning process, particularly when it came to the refresher courses—among the longest standing and well-attended types of sessions at the annual meeting. Dr. Stelling eventually chaired the refresher course committee from 1994 to 1997. “Being asked to join with the many talented individuals who participate in the RSNA annual meeting was a unique honor for me,” she said. “Service to the RSNA is a duty and a privilege in whatever capacity one is asked.”

Courses Designed to Provide Comprehensive StudyOffered for the first time at the 1938 annual meeting, the refresher courses gave attendees an opportunity to explore topics in more depth than the journals could provide. “Our journals tended to publish articles related to specific subjects, but often did not have space to collate and review related topics,” said O. Wayne Houser, M.D., refresher

course chair from 1979 to 1982 and RSNA president in 1994. “The aim of the refresher courses was to do that, and even create an updated field, and end the discussion at the cutting edge of knowledge.” RSNA past-president Michael A. Sullivan, M.D., who chaired the refresher course committee from 1984 to 1987, summarized the courses’ importance succinctly: “It’s where people go who really want to get an educa-tion.” Such glowing reviews date back to the courses’ origins. “Since it was started three years ago, the outstanding scientific achieve-ment of the Society has been the series of Refresher Courses,” Zoe A. Johnston, M.D., RSNA Third Vice-President in 1944, wrote in Radiology in 1941. Refresher course committee chairs spend four years in the position. Their role is to orchestrate the committee as a whole as it decides what courses to offer, and which experts to invite as instructors. As the years have gone on, the committee has grown as new tracks are introduced. “When I was the chair, radiology was becoming much more specialized, even sub-specialized,” said Donald R. Kirks, M.D., chair from 1991 to 1994. “I tried to align the refresher courses along those areas of

specialization. I gave the subcommittee chairs freedom to develop the courses in their discipline because they understood it better than I did.”

Specialty Expansion Increased Number, Types of CoursesThrough the years, the refresher course offerings have grown substantially, experienc-ing their greatest surge after the annual meeting moved to Chicago’s McCormick Place in 1975. That year there were 72 offerings; by the 75th annual meeting in 1989 there were 185. There are now more than 300 refresher courses from which attendees can choose each year. Ronald J. Zagoria, M.D., recalled how he proposed pulling some topics together into vertical courses called Essentials in Radiology, to be held each meeting day. In previous meetings, those topics were sprinkled throughout the meeting. Not knowing what to expect in terms of interest in the new offerings, Dr. Zagoria reserved a room that could hold 300 people. Registration maxed out the first day it was available, so Dr. Zagoria worked with RSNA staff to secure a room that held 450 registrants. After that room also quickly filled up, a 1,200-seat capacity room was eventually reserved to meet the demand. “We didn’t know what the interest was going to be like,” said Dr. Zagoria, who was refresher course chair from 2000 to 2003. “It was an absolute sellout for every one of those courses. It was a huge success.” Robert A. Novelline, M.D., followed on Dr. Zagoria’s heels by introducing new formats to the courses, including case-based and audience-response presentations. “We realized the audience wants to participate and think out problems,” said Dr. Novelline, who served as chair from 2003 to 2006.

Carol B. Stelling, M.D.

O. Wayne Houser, M.D.

Michael A. Sullivan, M.D.

Listening to the former committee chairs, it becomes clear how much they valued the experience and the opportunity. Many of them called their service an honor or privilege. “It certainly was one of the highest honors and most enjoyable roles I had in all my voluntary years working with the RSNA,” said Glenn Forbes, M.D., the chair from 1997 to 2000. “Knowing the tremendous impact our work had on the practice, both nationally and worldwide, on professional career develop-ment and on patient care created a level of gratification not easily matched elsewhere.”

Offered for the first time at RSNA 1938, refresher courses promised the opportunity to explore topics more in depth than the journals could provide.

See menus and event details: RSNA.org/Sip-and-Savor

Wednesday, December 3, 5:00 pm – 7:00 pmSkyline Ballroom, McCormick Place, West BuildingPurchase Tickets at:• Professional Registration, Lakeside Center-Level 3, Hall D• Exhibitor Registration, Grand Concourse-Level 3• Sip & Savor Social Desk, Grand Concourse-Level 2.5

Raise a glass to toast RSNA! Celebrate our 100th annual meeting with:• Beer, wine, and cocktails• Food from 18 Chicago restaurants • Live music from Matt Stedman Band $40

TICKETS ONLY

WHILE THEY LAST!

Cases of the Century Offer Challenges, History LessonsAll week in the Centennial Showcase, attendees are flocking to the Cases of the Century, which challenge visitors to test their skills at diagnosis and anatomy using vintage radiologic images. Participants must submit their answers with only the images to provide information. The Cases also feature trivia questions about journal publications and other related historic facts. “This is excellent,” said a first-time attendee from India. “This is our first meeting and we didn’t want to miss the chance to see the showcase. The Cases of the Century give us a chance to see cases we would never have seen elsewhere.” Attendees can try their hands at Cases of the Century during Centennial Showcase hours, 7:30 a.m. to 7:30 p.m. today and Thursday and until 12:30 p.m. on Friday.

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RSNA Centennial Recalls Commemorations of Roentgen’s DiscoveryBy Richard S. Dargan The legacy of Wilhelm Roentgen was very much in evidence at the RSNA 1995, the cen-tennial anniversary of his discovery of X-rays: meeting organizers honored the father of radi-ology by issuing commemorative medals in his name and sealing a time capsule with items from the early days of radiology. Even the meeting’s one disruption—a brief power outage at McCormick Place—seemed a fitting tribute to the man who made his discovery after turning off the lights and drawing the shades in his laboratory. Roentgen discovered X-rays on the afternoon of Nov. 8, 1895, while working with Crookes tubes, sealed glass tubes used to look

at cathode rays, in his lab at the University of Wurzberg in Wurzberg, Germany. “He was a 50-year-old assistant professor who was paid very little and so, like a lot of his peers, he had to moonlight,” said 1996 RSNA president Ernest J. Ferris, M.D., who

visited Roentgen’s lab in 1995. “He bought these Crookes tubes and studied them after work.” After Roentgen darkened the lab and activated the tube, he noticed something strange: a glimmer coming from a fluorescent screen at the end of his lab table. Roentgen discovered that the glimmer remained even when he blocked the tube with a 1,000-page book. Sensing he was on the trail of something profound, Roentgen worked feverishly over the next month to refine and expand his findings. He submitted his paper, “On A New Kind Of Rays,” just after Christmas and it was published in the Dec. 28, 1895, issue of the Proceedings of the Wurzberg Physical Medical Society. The international press picked up the story within days and it created a sensation across the globe. Radiology, the medical specialty birthed from Roentgen’s discovery, grew rapidly in the first half of the 20th century, rising from a

province of physicists and reluctant medical students to a thriving medical specialty with diagnostic and therapeutic applications. The evolution of the profession stirred an enhanced appreciation for Roentgen, who died in 1923. “People who went into radiology recog-nized that because of Roentgen’s discovery, they had increased diagnostic acumen that regular clinicians didn’t have,” Dr. Ferris said.

RSNA 1945 Reflected on Implications of DiscoveryRSNA honored Roentgen at its 1945 annual meeting—which took place exactly 50 years to the day of Roentgen’s discovery—with a keynote address by Robert S. Stone, M.D. Dr. Stone, who had served RSNA as president two years earlier, was a World War I veteran from Canada who knew well the promise and danger of radiation. During World War II, he led radiation safety and protection programs for workers at the metallurgical laboratory of the Univer-sity of Chicago, where much of the development of the atomic bomb took place. In his address, “Radiology from Roentgen to the Eve of Atomic Energy,” Dr. Stone credited Roentgen’s work for inspiring key figures from the early days of radiology, like Henri Becquerel, a French physicist who researched uranium salts and discovered radioactivity, and Marie and Pierre Curie, whose discovery of radium provided the first source of nuclear energy for medical and biological uses. “A new age has begun for medicine,” Dr. Stone told an audience of 900 people in the banquet hall at Chicago’s Drake Hotel. “The pioneering spirit of those physicians who created the specialty of radiology under the stimulus of Roentgen’s discovery must enter into their professional descendants and their fellow physicians so that medicine will advance into new fields.”

Dr. Stone’s words were prophetic, as radiology advanced into new areas over the next 25 years. Medical ultrasound, computer-based image reconstruction and nuclear magnetic resonance expanded the possibilities of imaging.

75th Anniversary Honored Radiology’s RootsThe profession was poised for further dramatic growth in 1970 when the 56th Annual Scientific Assembly took place at the Palmer House Hotel in the heart of the Chicago’s Loop District. RSNA honored the 75th anniversary of Roentgen’s discovery with a symposium, “American Radiology: Then and Now,” featuring 10 of the leading radiologists of the day. Discussions centered on latest trends, including computers, medical cyclotrons and the shift away from gas tubes to electronic image intensification. One speaker, radiologist and historian Emmanuel Grigg, M.D., summed up the importance of honoring Roentgen and the other radiology pioneers: “I wish to remind everybody that a society, any society, if it is to survive in stormy surround-ings, needs its historic tradition for the same reason for which a tree needs its roots.”

Discovery Centennial Marked Amid Technological BoomThe next 25 years were a boom time for radiology as CT, PET and MR imaging became established modalities. RSNA 1995, the organi-zation’s 81st meeting, was the setting for the centennial celebration of Roentgen’s discov-ery. As part of the celebration, themed “Architects of the Future,” RSNA created the Roentgen Centennial Commemorative Medal to honor individuals who had made significant contributions to radiology: medical physicist

and bone densitometry pioneer John R. Cameron, Ph.D., osteopathic physician John H. Juhl, M.D., radiation therapy pioneer Juan del Regato, M.D., and Swedish radiologist Olle Olsson, M.D. On Nov. 29, 1995, 3M Medical Imaging Systems and Radiology Centennial, Inc., an organization created to honor the anniversary, sealed a time capsule commemorating the first 100 years of medical imaging technology.

Among the items sealed in the time capsule in a ceremony in the Arie Crown Theater were glass

X-ray plates and old X-ray tubes, as well as contemporary print and electronic materials on medical radiology. The time capsule is scheduled to be reopened in the year 2095. There is no telling where the profession—that grew from one professor’s discovery—will be by then. “The history of radiology portends the future,” Dr. Ferris said. “We live in an age when we look back at the mistakes and good things that have occurred, and we learn from these things.”

Ernest J. Ferris, M.D.

Robert S. Stone, M.D.

Curiosity of Old Equipment Draws a CrowdFor some RSNA 2014 attendees, nothing tells the story of how radiology has evolved quite like the collection of vintage radiology equipment on display in the Centennial Showcase.Equipment donated by RSNA exhibitors includes:• X-ray tubes from Dunlee• Ultrasound System from Siemens• Conventional X-ray table from Philips• Diagnostic X-ray unit and R39 Generator Control from GE• Remote-Controlled X-Ray R/F System and Aurora X-ray Apparatus from Shimadzu Also on display is the original CT unit displayed by EMI at RSNA 1972. Attendees of that meeting recall the milestone event with words like “stunning” and “enormous breakthrough,” leaving today’s attendees to wonder what watershed moments they’re witnessing. As one RSNA attendee wrote in the Memory Book, “A Century of Radiology, a century being in the “top of the wave,” a century bringing innovation, information and knowledge to all of us.” See the equipment in the Showcase today and Thursday from 7:30 a.m. to 6:00 p.m. and Friday from 7:30 a.m. to 12:30 p.m.

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Daily Bulletin, the Source for Meeting News Since 1990For almost a quarter century, RSNA annual meeting attend-ees have relied on the Daily Bulletin to learn about the hot topics being addressed, sci-entific breakthroughs being unveiled and luminaries being honored. As the meeting has grown so too has the publi-cation—attendees need not worry about not being able to see everything, as the Daily Bulletin offers coverage of all the latest developments. “The thousands of visitors who attend the RSNA annual meeting have a huge selection of lectures and presentations to choose from and a wide array of interests,” said Hedvig Hricak, M.D., Ph.D., Dr. h.c.

Prior to serving as RSNA President in 2010, Dr. Hricak oversaw the Daily Bulletin as Board Liaison for Publica-tions and Communications. “Amidst this tremendous diversity, the Daily Bulle-tin helps to create a sense of community and shared excitement,” she said. As the images show, the look of the Daily Bulletin has evolved since its debut in

1990. Addition of an online version in 2010 extended the reach of the Daily Bulletin, particularly to professionals who couldn’t make it to the meet-ing but still wanted to experience the thrill of radiology’s cutting-edge.

Hedvig Hricak, M.D., Ph.D., Dr. h.c.

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Professionalism Course Examines Ethics/Technology Balance Through the YearsAs RSNA enters its second century, and into an age of molecular and genomic imaging, reviewing the ethical implications of radiological technologies developed in the past century may offer insights into ethical dilem-mas that new imaging technologies may create in the future. An RSNA 2014 RSNA Professionalism Commit-tee refresher course, “The Ethical Power of Radiologic Technology: Reviewing the Past to Prepare for the Future,” will examine the interface of ethics and radio-logical technology. RSNA Professionalism Committee Chair Stephen D. Brown, M.D., will lead interactive sessions on assessing imaging technologies from a bioethical perspective, in particular the ethical challenges that have arisen from prenatal imaging and neuroimaging technologies. The course will be held Thursday, 4:30–6:00 p.m., in Room S103CD.

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Stephen D. Brown, M.D.

The Celebration Continues at RSNA 2015RSNA’s Centennial activities don’t end this year. While 2014 marks the society’s 100th annual meet-ing, next year the RSNA community will celebrate the 100th anniversary of RSNA’s founding. Now that we have looked back through the history of medical imaging, RSNA 2015, will showcase fascinating predictions for radiology’s future.

RSNA 2015 will feature:• An interactive centennial pavilion of radiologic history• Lectures from global leaders in medical imaging• Hundreds of the finest-quality courses and sessions• Thousands of exhibits and presentations of the latest science and

education• The world’s most spectacular exhibition of medical imaging

products and services

Keep up on RSNA 2015 developments at

RSNA.org/AnnualMeeting

Thanks for the Memories Attendees Share Their RSNA Stories Onsite and OnlineDuring RSNA’s Centennial celebration this week, attendees have limitless opportunities to tell their stories, both onsite and online. Many are taking the time to fill out RSNA’s Memory Book with fond recollections and well-wishes for the future of the society and the specialty.By Evonne Acevedo-Johnson“Without the members there would be no RSNA,” wrote attendee Peter from Seattle. “Congratulations to all the members for believing in RSNA for 100 years.” All attendees are encouraged to sign and share their thoughts in the Memory Book located inside the Centennial Showcase at the entrance to Hall D in the Lakeside Center, just north of RSNA Services. Anmar Chaudrhy, M.D., of Stony Brook Radiology wrote, “Thank you to the founding members of RSNA, and leaders that have developed and grown the field and afforded us this amazing opportunity to work and enjoy the fields of diagnostic and interventional radiology. Hopefully we can further the missions and ambitions of RSNA in the years to come.”

Attendee Judith Marinelli Godfrey said that she was attending RSNA 2014 in honor of her father, Leonidas D. Marinelli, Ph.D., (1906 – 1974), who introduced studies of human popu-lations exposed to high levels of internal radiation, measured with a fast-neutron gamma camera that he invented in 1950. Dr. Marinelli was among several groundbreaking physicians—including those evaluating the potential effects of what is known as the Manhattan Project—who advanced the field now known as medical physics. Dr. Marinelli continued to develop pioneering inventions throughout his career. “Thank you, RSNA,” Godfrey wrote, “for continuing the computer research and development transforming Marinelli’s methods and techniques in spectroscopy to the

remarkable instruments showing the internal composi-tions of the human body today!” Members of the RSNA community who aren’t onsite at McCormick Place can still share their stories online at RSNA.org/Centennial. The Interactive Timeline features the opportunity for visitors to add their own milestones. Submitted milestones range from hopeful to inspiring to hilarious. One example: “The first superconductive MR machine installed in Bogotá, Colombia, in the first trimester of 1989, a 0.5 T magnet, did not make it to the local news. Our magnet was installed where the morgue used to be, and the first reporter that visited our site was jokingly led to believe by my colleague, Dr. César Maldonado (RIP), that we had witnessed paranormal activity around the magnet,” wrote Anibal Morillo, M.D., institu-tional radiologist at University Hospital Fundacion Santa Fe de Bogota. “When the reporter approached this cutting-edge magnetic contraption, new to our country, he was so in awe to see his camera levitate as it hanged from his neck, that he freaked out,” continued Dr. Morillo. “Perhaps remembering that he stood where dead patients used to be, he ran away, not finishing his news report. We did have other opportunities to appear in radio and TV news programs. We never heard from this first reporter again.”

It has been a remarkable journey indeed! Edwin von Beek, M.D., Ph.D

Attendees can sign the Memory Book in the Centennial Showcase, open from 7:30 a.m. to 7:30 p.m. through Thursday and until 12:30 p.m. on Friday. The online experience at RSNA.org/Centennial, which includes the interactive timeline, submissions from RSNA’s image contest and a parallel Centennial Showcase, will remain open to all members of the RSNA community for exploring and sharing.

“It has been a remarkable journey indeed!” said Edwin von Beek, M.D., Ph.D., Chair of Radiology at the University of Edinburgh. “Here is to many more years of advancing the field to better patient care.”

(1.) Attendees are filling the RSNA 2014 Memory Book with fond recollections and well-wishes. Add yours by visiting the Centennial Showcase, today and Thursday, 7:30 a.m.–6:00 p.m. and Friday, 7:30 a.m.–12:30 p.m. (2.) From fascinating sessions to prestigious awards to selfies with 3D Wilhelm Roentgen, RSNA’s Twitter community is bringing its best #RSNA100. See the feed in Mobile Connect in RSNA Services. (3.) The 100th RSNA annual meeting, like its 99 predeces-sors, has been a place for great conversation. Richard E. Sharpe Jr, M.D., M.B.A. (center), chair of the RSNA Resident and Fellow Committee, relaxes with his constituents in the Residents Lounge. The lounge is open today and Thursday, 8:00 a.m.–6:00 p.m.

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Baron is President-ElectRichard L. Baron, M.D., is RSNA president-elect. Dr. Baron is a professor of radiology at the University of Chicago Medical Center, where he has been since 2002, serving as chair of the Department of Radiology from 2002 to 2011 and dean for clinical practice from 2011 to 2013.

A s president-elect, Dr. Baron will continue to place a priority on organization and opti-mization of RSNA's educational offerings,

given that lifelong learning is now so essential to the radiology community. Bringing together the RSNA international members and participants to maximize their educational opportunities and experiences will be an important emphasis. “Through its journals, annual meeting, educa-tion programs, and the invaluable contributions of its members, RSNA has been inextricably tied to the evolution of radiology worldwide,” he said.

“RSNA members and contributors produce a broad array of scientific and educational content that collectively provides an unmatched resource for the imaging community. We would like to continue to grow the communications between radiologists worldwide.” Dr. Baron has been principal investigator on a dozen research projects and has earned research awards from numerous national radiology societies, especially in the area of diagnostic imaging of liver disease. The RSNA has presented Dr. Baron with two Magna Cum Laude Awards and the American

Roentgen Ray Society (ARRS) awarded him gold and silver medals for educational exhibits. An RSNA member since 1978, Dr. Baron has served on numerous committees including the Scientific Program Committee, Public Informa-tion Advisors Network, Finance Committee and the Education Exhibits Committee, of which he served as chairman from 2006 to 2009. In 2008, he was elected to the RSNA Board of Directors and served as the Liaison for Education and then as the Liaison for International Affairs. He served as Board Chairman from 2013 to 2014. Richard L. Baron, M.D.

Technology

Answer[Question on page 3.]

Amost modalities require only a 3 megapixel monitor, but 10 megapixel monitors

are necessary for mammography. Be sure your viewing station has a 10 megapixel monitor if you want to use it to review mammograms as well as other studies. Q&A courtesy of AAPM.

Surgical Cap Protects Against RadiationAn inexpensive, disposable surgical cap effectively reduces radiation exposure to the brains of interventionalists and assistants, according to new research presented Tuesday.By Richard S. Dargan

radiologists and technologists involved in interventional proce-dures are chronically exposed to ion-

izing radiation, the only unequivocal risk factor for developing brain tumors. Irra-diation of the cranium, even at low doses, can increase the incidence of all cerebral neoplasms, including meningioma. A 2013 study identified 31 interventionalists who developed brain cancer and found that 85 percent of cases were left-sided tumors—the physician’s left side is typically closer to the radiation source during interven-tional procedures. Imgen, the Las Vegas-based research arm of the Nevada Imaging Centers, recently evaluated the radioprotective properties of the No Brainer®, a cranial radiation protection surgical cap manu-factured by RADPAD of Kansas City. The disposable surgical caps are available in four levels of protection based on the thickness of the heavy metal shielding. At 0.375 millimeters, the Red level provides the thickest lead equivalent shield, while

the Blue level’s 0.07-millimeter-thick shield is the thinnest. Researchers tested the cap on phantoms before studying them during actual fluoro-scopic procedures. The caps were used to protect the craniums of one interventional-ist and one assistant during 45 fluoroscopic procedures. Radiation monitoring during the fluoroscopic procedures was accom-plished using real-time radiation detectors. Simultaneous monitor recordings were performed with radiation detectors posi-tioned identically above and below the protective material at the level of the ante-rior left cranium above the left eye. Dose reductions for the procedures ranged from 83 percent for the Blue level to 100 percent for the Red and Orange levels. “Both the phantom study and the actual procedures demonstrated statistically significant ionizing dose reductions to cra-nium when using the protective caps,” said presenter Luke A. Byers, D.O. “Increased protection correlated with increasing thick-ness of radiation shielding material.” The interventionalist and the assistant

reported that the surgical caps were minimally dif-ferent from those typically worn for interventional procedures and there was no reported discomfort even after a full day of wear. “The study results show you can use dispos-able surgical caps in an interventional setting to significantly reduce or completely negate the amount of radiation that the cranium is exposed to,” Dr. Byers said. “Hopefully, this device will stem the increasing number of intervention-alists reported with cerebral malignancies.” The caps cost about $5 each and can be used for multiple procedures before disposal, according to radiologist and study co-author William W. Orrison, M.D., M.B.A. The thinner, lighter caps are ideal for brief procedures, while the thicker ones would be recommended for longer inter-ventions, Dr. Orrison said.

Luke A. Byers, D.O.

In the next phase of the research, the investigators plan to see if the caps can help reduce cranial dose to patients during interventional procedures.

see scientific Poster Vis235 today through thursday 7:30 a.m. – 7:30 p.m. and Friday 7:00 a.m. – 12:30 p.m., Vi community learning center.

added ct risk for limited-stage Hodgkin’s lymphoma is minimalDoes the value of surveillance CT scans in cancer patients outweigh the risk of additional cancers caused by the CT’s radiation? By Elizabeth Gardner

A study using mathematical modeling, presented Tuesday during a session on practice guidelines and outcomes

research, suggests that the additional risk posed by CT imaging for limited-stage Hodgkin’s lymphoma is extremely low. “There is growing con-cern about the use of CT for surveillance in young patients with a favorable prognosis, such as those with Hodgkin’s lymphoma, due to the risk of radiation-induced cancers,” said presenter Kathryn Lowry, M.D., of the Institute for Technology Assessment at Massachusetts General Hospital. “We wanted to estimate the magnitude of the risk of radiation-induced malignancies, to quantify what the magnitude of the ben-efit of CT needs to be to offset this risk.” Dr. Lowry’s research was awarded an

RSNA Trainee Research Prize, Resident. The team’s modeling found that the risk of death from a radiation-induced cancer in 35-year-old patients undergoing regu-

lar CT surveillance for Hodgkin’s lymphoma was no more than 0.3 percent, which translates to an average life expectancy loss of 12 days. The risk of death from recurrent lymphoma was more than 10 times higher. “This result suggests that even a very small mortality benefit of CT surveillance would justify its use,” Dr. Lowry said. The research team used several formulas together to model hypothetical Hodgkin’s lymphoma patients who were 35

years old, in remission after chemotherapy, and undergoing seven surveillance CT scans of the chest, abdomen and pelvis over five years. They modeled radiation-

said the benefit would not have to be large to justify doing the studies–at least from the standpoint of mortality risk. She cautioned that since the research is based on hypothetical patients, it should not be applied to any individual case.

Kathryn Lowry, M.D.

induced cancer risks and mortality for 17 different organ systems, to account for specific organs that were exposed during the scans. For comparison, they also mod-eled cohorts of patients at ages 20, 50 and 65. They based their analyses on published studies, and on data from publicly available sources, including the U.S. life-expectancy tables available from the Centers for Dis-ease Control and Prevention, the BEIR-VII study (Biological Effects of Ionizing Radi-ation) from the National Academies, and the National Cancer Institute’s SEER (Sur-veillance, Epidemiology and End Results Program) database, which includes cancer registry data from nine states that represent about a quarter of the U.S. population. The CT protocols modeled are those currently in use at Massachusetts General Hospital. Projected life expectancy losses from lymphoma were 428 days in men and 482 days in women, whereas life expectancy losses from radiation-induced cancers were less than 12 days in men and less than 16 days in women. The next step is to quantify the benefit of the imaging studies, though Dr. Lowry

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Pakistani Hospital’s “Attitude” Project Improves Patient ServiceWhile staff in a busy multimodality radiology department are rightly focused on providing the right diagnostic and interventional services, patients expect more than that, said an RSNA presenter.By Felicia Dechter“While patients come for ‘care’ solution of their health problems, there is no denying the fact that what they daily observe and usually assess and respond to in patient sat-isfaction survey is the ‘caring’ part—was the communication polite, were the staff, nurses, and doctors exhibiting positive attitudes, were my needs met timely and in efficient manner, was I handled well and with respect during my stay in the hospital?” said Muhammad Akbar Khan, M.B.A., manager of radiology at Aga Khan University Hospital (AKUH), a 650-bed philanthropic, not-for-profit, private teach-ing institution in Karachi, Pakistan. “This makes service excellence, and hence the patient’s experience, and satisfac-tion of utmost importance.” On Tuesday at RSNA 2014, Khan presented a quality storyboard detailing AKUH’s initiative to improve the patient experience by focusing on service excel-lence within the radiology department. “The idea was to do a measureable assess-ment of where we were in the eyes of those whom we serve and then act upon the assessment to improve the four dimensions of service excellence: communication, atti-tude, responsiveness, respect and caring,” Khan said. Those modes of behavior are as important as patients’ healthcare needs, he added. While the baseline assessment identified improvement opportunity in all four cat-egories, the Attitude rating in the radiology department was estimated at 64 percent. The hospital set a goal to bolster the Atti-tude rating to at least 80 percent within a 12-to-16 month period by using a system-atic approach to ensure a “delightful patient experience.” The approach included timely guidance upon entry, complete informa-tion with courteous communication, quick processing of test formalities, positive and welcoming staff, radiographers and radiolo-gists, and an easy-to-approach leadership for addressing their concerns.

An analysis of patient satisfaction findings and patient complaints yielded expected behaviors from staff, including radiographers. Staff training sessions incor-porated role modeling and video records of actual interactions between patients and staff to identify “do’s” and “don’ts.” In addition, supervisors more frequently monitored interactions with patients, and a “meet-and-greet service” was created to welcome and guide patients. Special din-ners, breakfast gatherings and other events served to keep staff motivated.

“attitude” Goal metThe hospital’s interventions were imple-mented in early 2013. By December, the Attitude rating had improved from 64 to 82 percent. While changing attitudes is a chal-lenging task, small and focused actions with continuous reinforcement help create desired improvements, Khan said. “When the team started exploring why our Attitude rating was so low, the striking finding was that the staff had an emotional disconnect within the team,” he said. “There was some basis for such feeling—lack of positive attitude within the team both when mis-

takes are used to reprimand staff without addressing the ‘system’ part of the cause and when good work is ignored without praise. “With deliberate efforts to ensure that mistakes are used as learning opportunities

and good work is publicly praised, we saw the most remarkable change in the Attitude rating,” Khan continued. “You plant wheat to get wheat …you give service excellence to get service excellence.”

With deliberate efforts to ensure that mistakes are used as learning opportunities and good work is publicly praised, we saw the most remarkable change in the Attitude rating.

muhammad akbar Khan, m.b.a.

More than 480 participants braved the 23-degree Chicago weather to take part in the RSNA 2014 5k Fun Run along Lake Michigan on Tuesday, raising $37,130 for the RSNA Research & Education (R&E) Foundation. The run along the Lake Michigan shore started Tuesday at 6:30 a.m. in Arvey Field at Chicago’s South Grant Park.

Fun Run Draws 480 on Brisk Chicago Morning

Muhammad Akbar Khan, M.B.A.

Congratulations to the top finishers:FEMALE

Gold Medalist: Mari Vaananen, Finland Silver Medalist: Jennifer Kemp, U.S. (Colorado) Bronze Medalist: Ashley Prosper, U.S. (California)MALE

Gold Medalist: Jonathan Kraas, U.S. (Indiana)Silver Medalist: Aaron Snolnik, U.S. (Pennsylvania)Bronze Medalist: Romain Labas, France

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In preparing for dealing with patients with Ebola, Dr. Bluemke said, imaging staff should consider which staff to train and how imaging equipment will be dis-tributed—whether it will be transported, used once and immediately decontami-nated, or remain in an isolation unit for the duration of the patient’s care. “When you take a unit and park it there, you have to consider how that will affect the rest of the hospital,” he said. The potential effects of decontaminant agents like isopropyl alcohol, bleach and vaporized hydrogen peroxide on valuable radiologic equipment should also be considered, he said. Also presenting during Tuesday’s ses-sion was Bruce S. Ribner, M.D., M.P.H., a professor of medicine at the Emory School of Medicine and Department of Medicine, Division of Infectious Diseases, in Atlanta. Hailed last month in TIME magazine as “America’s Top Ebola Doctor,” Dr. Ribner has spent 12 years oversee-ing the development of Emory’s serious com-municable disease unit, funded by the Centers for Disease Control (CDC). His team has cared for Emory’s four patients with Ebola, all of whom have survived the disease. “The key to survival is aggressive sup-portive care, but this is extremely labor-intensive,” Dr. Ribner said. “We have one nurse to one patient so they can respond rapidly to changes and adjust their care

accordingly. These nurses support patients with nutrition, physical therapy, self-care and—I cannot emphasize this enough—emotional support.” With the high mortality rates in West Africa, depression is very common in patients with Ebola virus disease, Dr. Rib-ner explained. “Patients have told us, ‘I thought you were just bringing me back here to the U.S. so I could die on American soil.’”

donning, doffing of Protective equipment Presents High riskCentral venous catheters for controlling fluid loss are crucial in treating Ebola patients, Dr. Ribner said. At a minimum, radiology support would include ultrasound to aid in catheter placement and chest radiography for evaluation of tip location. Chest radiography also is used to distin-

guish acute respiratory distress, fluid overload and infectious or chemi-cal pneumonia. “We believe one of the highest risks occurs during donning and doffing of personal protective equipment,

or PPE,” Dr. Ribner said. All donning and doffing of PPE is observed by another team member, he said, and there are checklists posted in the affected rooms to remind staff of the proper protocols. In addition, Emory’s model dic-tates that ancillary staff are not permit-ted in patient’s room unless absolutely

required—they remain in the anteroom and guide nurses through the process of using equipment, including ultrasound and radiography units. Session moderator Carolyn C. Melt-zer, M.D., Associate Dean for Research at Emory University School of Medicine, noted that educating the healthcare team is as important as educating the public. “Ini-tially, some of the staff who were parking patients’ cars chose to wear face masks, and that was probably not the best way to welcome them to the hospital,” Dr. Meltzer

said. “There were also vendors who refused to service the equipment at our unit. These personnel can be made part of the team with proper communication so it’s a little less dramatic.” “There’s perception and there’s sci-ence,” Dr. Ribner said. “Our message is that we have expertise in treating patients with serious infectious diseases, we are trained and prepared for these patients and we will protect our patients, our staff and our communities.”

Optimal medical imaging achievable for Patients with ebola

The key to survival is aggressive supportive care, but this is extremely labor-intensive.

bruce s. ribner, m.d.

Continued from page 1a

At Rutgers Robert Wood Johnson Medical School and Cancer Institute of New Jer-sey, Dr. Haffty spearheaded the expansion of the Radiation Oncology Program and developed a residency program in radiation oncology and medical physics—the only such programs in the state of New Jersey. Through his extensive work with the American Society for Radiation Oncol-ogy (ASTRO), Dr. Haffty served as the founding president of the Association of Directors of Radiation Oncology Programs (ADROP) in 2000, providing tools and resources to advance the quality of resi-dency training and education in radiation oncology. He served as ADROP president from 2000 to 2003. Dr. Haffty’s research has focused on developing novel methods of delivering radiation therapy targeting breast can-cer and exploring novel molecular targets that may enhance the effects of radiation. In a recent project, Dr. Haffty and col-leagues demonstrated that combining radiation with BCL-2 inhibitors results in better response rates than with radiation alone and discovered molecular path-ways of resistance to the combination of BCL-2 inhibitors and radia-tion. During the course of this research, one of Dr. Haffty’s medical students was awarded a grant from the RSNA Research & Education (R&E) Foundation to work on a portion of the project. Dr. Haffty said he has watched how R&E-funded pilot projects in his depart-ment have inspired students and junior faculty to further their academic careers. RSNA also advances radiologic science, he said, through innovative programs like the

Bolstering Oncoradiologic and Oncoradio-therapeutic Skills for Tomorrow (BOOST) program, designed to forge ties between radiology and radiation oncology, and spe-cial collaborations such as the Quantitative Imaging Biomarker Alliance. “By facilitat-ing these forums to exchange ideas and provide education, RSNA will continue to help to support the future of the field,” he said. In addition to editing the comprehen-sive Handbook of Radiation Oncology, Dr. Haffty served as co-editor of The Cancer Journal from 2005 to 2007 and is currently associate editor of the Journal of Clini-cal Oncology, a position he has held since 2007. He has served on the RSNA News Editorial Board since 2009. Dr. Haffty has volunteered with RSNA in a number of roles, including as third vice-president from 2013 to 2014 and as

co-chair of the BOOST program. At RSNA 2009 he delivered the Annual Oration in Radiation Oncology, “Genetic Fac-tors in the Diagnostic Imaging and Radio-therapeutic Manage-ment of Breast Cancer.” Dr. Haffty was named RSNA Outstanding Edu-cator in 2013.

Among his other leadership positions, Dr. Haffty served as president of ASTRO from 2013 to 2014, American Board of Radiology from 2010 to 2012 and Ameri-can Radium Society from 2008 to 2009. He served as chairman of the Accredita-tion Council for Graduate Medical Educa-tion Residency Review Committee, Radia-tion Oncology, from 2007 to 2010.

Haffty named to rsna board

By facilitating these forums to exchange ideas and provide education, RSNA will continue to help to support the future of the field.

bruce G. Haffty, m.d.

Prior to Tuesday’s Annual Oration in Diagnostic Radiology, 2014 RSNA President N. Reed Dunnick, M.D. (second from left), presented the Society’s highest honor, the Gold Medal, to (from left) Allen S. Lichter, M.D., Etta D. Pisano, M.D., and Gary J. Becker, M.D.

Gold Medals Presented

said. “Pursuing a long standing interest or avocation is critical to a happy retirement.” Dr. Casarella said his “major message” to radiologists is to invest some time in developing an exciting post-retirement activity during their career. “The scope of activities is limitless…photography, wood working, tutoring children, medical work abroad, writing, are just a few,” he said. There is no doubt maintaining excellent vision is a problem after 65, Dr. Casarella said. “However, the abilities of some radi-ologists are well-maintained until later 70s and 80s,” he said. Nevertheless, there will come a time when reality sets in, Dr. Schmidt said.

Stamina wanes, it’s hard to stand all day doing biopsies, hands shake a bit, concentration can wander, he said. “I did a lot of breast biopsies in my time, but in later years I developed a mild tremor, which I

could overcome, but it made it just a stitch harder when targets were very small, which was my special talent before,” Dr. Schmidt said. “The AMA in 1999 gave a number for MDs over 90 still working: 1,200 in the U.S. And your feeling about a sound mind might not correspond with what your col-leagues objectively think. “Some doctors need to be apprised that they’re no longer meeting the mark—dif-ficult, but real,” Dr. Schmidt continued. “Many may keep working as they need the money, or would feel diminished if they gave up the status of their positions. I feel gratified when one of my fellows goes on to best me at something.”

17Ad a i l y b u l l e t i n • w e d n e s d a y , d e c e m b e r 3 , 2 0 1 4

Watch for stories in the national media generated by RSNA press conferences:

tuesday’s Press conferences

even mild coronary artery disease Puts diabetic Patients at risk Using the CONFIRM Registry, developed to examine the prognostic value of cardiac CT angiography (CCTA) for predicting adverse cardiac events related to coronary artery disease, researchers studied data on 1,823 diabetic patients who underwent CCTA to detect and determine the extent of coronary artery disease. Major adverse cardiovascular event (MACE) data was available on 973 patients and 30.3 percent experienced a MACE during the follow-up period. The study indicated that both obstructive and mild, or non-obstructive, coronary artery disease were related to patient deaths and MACE and that the rela-tive risk for death or MACE for a patient with mild coronary artery disease was comparable to that of patients with single vessel obstructive disease.

dbt improves cancer detection in dense breasts Digital breast tomosynthesis (DBT) has the potential to significantly increase the cancer detection rate in mammography screening of women with dense breasts. Research-ers compared cancer detection using full-field digital mammography (FFDM) versus FFDM plus DBT in 25,547 women between the ages of 50 and 69. Of 257 can-cers detected, 82 percent were detected with

FFDM plus DBT, a significant improve-ment over the 163 detected with FFDM alone. FFDM plus DBT pinpointed 63 per-cent of the 132 cancer cases in women with dense breasts, compared to only 59 percent for FFDM alone. The findings showed an overall relative increase in the cancer detec-tion rate with DBT of about 30 percent, and an increase in detection of invasive cancers of about 40 percent.

risk-based screening misses breast cancers in women in their Forties This study found that using a risk-based approach to screening mammography could potentially miss more than 75 percent of breast cancers in women in their 40s. The retrospective study included 136 women between the ages of 40 and 49 with breast cancer identified by screening mammog-raphy between 1997 and 2012. Of the 136 breast cancer cases identified, 50 percent were diagnosed as invasive and 50 percent were diagnosed as ductal carcinoma in situ (DCIS). A very strong family history was absent in 90 percent of patients, and extremely dense breast tissue was absent in 86 percent. Seventy-eight percent of patients had neither strong family history nor extremely dense breasts, including 79 percent of the cases of invasive disease.

Patients take control of their medical exam recordsResearchers set out to evaluate patient and provider satisfaction with RSNA Image Share, an Internet-based interoperable image exchange system that gives patients owner-ship of their imaging exams and control over access to their imaging records. Patients undergoing any radiologic exams in four aca-demic centers were eligible to establish online patient health record (PHR) accounts using the network. Between July 2012 and August 2013 the study enrolled 2,562 participants, who were provided a brief survey to assess patient and physician experience with the exchange of images. Ninety-six percent of sur-vey respondents valued having direct access to their medical images. In addition, a greater percentage of Internet users reported being able to access their images without difficulty, compared to CD users.

Today’s Press ConferenCesRSNA invites members of the medical news media to attend its annual meeting each year so that, through stories in print, broad-cast and Internet media, the public gains a greater understanding of radiology and its role in their healthcare.Three press conferences will be held today:• Interventional Radiology Procedure Pre-

serves Uterus in Patients with Placenta Accreta

• Common Knee Surgery May Lead to Arthritis and Cartilage Loss

• Many Chest X-rays in Children Are Unnecessary

RSNA 2014 press releases are available online at RSNA.org/press14.

Strategies for Coping, Retirement Planning, Critical to the Aging RadiologistWhile the practice of radiology presents physical, cognitive and personal challenges to every radiologist, age-related changes provide further domain-specific challenges.By Felicia Dechter

Dealing with those challenges and grappling with issues including when to retire were covered by presenters

of Tuesday’s session, “The Aging Radi-ologist: How to Cope, When to Quit,” an interactive session sponsored by the RSNA Professionalism Committee. Presenters spoke on issues such as iden-tifying the physiological and psychological manifestation of aging specific to performance as a radiologist, understanding economic, health, emotional and professional factors that stimulate radiologists to either continue working or retire, and identifying strategies for insti-tuting meaningful and satisfy-ing activities after retirement from active radiology practice. Presenter Stephen Chan, M.D., an associate professor of Clinical Radiology at Columbia University in New York City, asked attendees to think about the barriers that may arise as they age. “What are the physiological and psy-chological challenges to a radiologist’s performance that increasingly manifest themselves as a radiologist ages?” Dr. Chan asked. They are: Visual (cataracts are the No. 1 problem for aging radiologists), hear-ing, strength/flexibility/endurance, burden of illness/risk of disability—over a lifetime, and not necessarily just among older radiol-ogists, he said. The most common physical

challenge for radiologists is visual. Cogni-tive challenge can be ameliorated by techni-cal and work environment changes, he said. Nevertheless, there is no mandatory retirement age for radiologists, Dr. Chan said. “As long as a radiologist of sound mind and body retains the competence, desire and personal/professional integrity to prac-

tice radiology, there is no phys-ical or mental basis for anyone to insist upon retirement,” Dr. Chan said. “Of course, there may also be personal choices, economic reasons and other professional options that affect this decision.” In fact, many older radi-ologists are functioning just as well as their younger col-leagues, Dr. Chan said. “Older radiologists have the advantages of greater experi-

ence and wider breadth of knowledge in their field,” Dr. Chan said. “Younger radi-ologists have the advantage of more recent exposure to prolonged periods of intensive study, especially to new developments in the field being promulgated by their profes-sors and teachers.”

Preparing for retirement Policies for addressing the potential for health or age-related impairments are rare, but there are a number of ways to plan for retirement, said Bruce Barron, M.D., a professor of radiology and chief of Nuclear

Medicine at Emory Crawford Long Hospi-tal in Atlanta. Those include: Figuring out power of attorney; tilting of assets; wills; trusts; ben-eficiary designation; getting information on Medicare and seeking out alternative living options, among other things, said Dr. Barron. “Make sure you and your spouse are on the same page,” said Dr. Barron, whose presentation focused on why people retire, how to deal with people that are aging, and preparing for retirement. Of the 36,000 practicing radiologists, 7,000 radiologists age 56 to 65 are working fulltime, Dr. Barron said. “There is some notion of discrimination,” said Dr. Barron. “I’ve seen it happen.” The average retirement age for a radi-ologist has dropped from 70 to 64, said Robert Schmidt, M.D., a retired professor of radiology at the University of Chicago. Dr. Schmidt spoke about retirement issues that may be unexpected such as savings and healthcare costs including Medicare and Social Security timing. Many radiologists feel lost without their daily focus and routine, Dr. Schmidt said.To that end, the importance of activities to keep radiologists busy and productive in retirement was the focus of a presentation by William Casarella, M.D., an Emeritus Professor at Emory University in Atlanta. “A radiologist should only retire if there is something to retire to,” Dr. Casarella

“…the abilities of some radiologists are well-maintained until later 70s and 80s.”

william casarella, m.d.

Stephen Chan, M.D.

A study of breast cancers detected with screening mammography found that strong family history and dense breast tissue were commonly absent in women between the ages of 40 and 49 diagnosed with breast cancer. Results of the study were presented by Bonnie Joe., M.D., at a Tuesday press conference.

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ACR at RSNA 2014 Leading Radiology Into the Future

Experts Debate Options for Head and Neck ImagingExperience and expertise are key when weighing decisions about imaging the structures of the head and neck, according to head and neck imaging experts who on Tuesday discussed and debated available imaging options for three clinical scenarios: parathyroid surgery, cancer surveillance and hearing loss in one ear due to a suspected tumor.By Richard S. Dargan

T he first scenario involved localization of the parathyroid tissue for mini-mally invasive parathyroid surgery

(MIPS). At one time, surgeons would open up and explore the neck to localize the often-difficult-to-locate glands, but improvements in surgical technique and imaging technology have enabled a more focused approach—important consider-ing that in most people with hyperpara-thyroidism only one gland of the four is diseased. With the help of 4DCT, surgeons can access the parathyroid through a tiny inci-sion and remove a single lesion, said C. Douglas Phillips, M.D., of Weill-Cornell Imaging at New York-Presbyterian Hos-pital in New York City. The exam can be learned quickly, is easily interpretable and offers a volumetric study, which is very important when imaging parathyroid dis-ease, he said. “You need to have every millimeter of the parathyroid evaluated,” Dr. Phillips said. “The problem with ultrasound and nuclear medicine is that you may not see every lesion.” Dose reduction measures from manu-facturers have helped mitigate the con-cern over radiation exposure from CT, Dr. Phillips added. “Our dose for a three-phase exam today is lower than the dose

we previously had for a single-phase CT exam,” he said. Laurie A. Loevner, M.D., from the University of Pennsylvania Medical Cen-ter in Philadelphia, argued against the use of 4DCT. Surgery has become much easier for patients, she said, with shorter operating times and no general anesthesia requirement. “The take home message is that we have a 95 percent success rate without any imaging, and only a minority of cases requires any imaging other than sestamibi and ultrasound,” she said.

PET/CT Valuable for Surveillance of Squamous Cell CarcinomaThere was considerably less controversy in the second segment of the session, as pre-senters Barton F. Branstetter, M.D., from the University of Pittsburgh Medical Cen-ter, and Hugh D. Curtin, M.D., of Mas-sachusetts Eye and Ear in Boston, largely agreed on the value of PET/CT for surveil-lance of treated head and neck squamous cell carcinoma. PET/CT detects cancer recurrence sooner than other methods and is cost-effective in part because it prevents unnecessary surgery, Dr. Branstetter said. Expense, availability and patient toler-ance are the chief problems with PET, Dr. Curtin said. The leading alternatives are CT with contrast and MRI with contrast, he said. He described how his institution

stratifies patients into different risk categories, and those at medium risk for recurrence undergo PET/CT. The final seg-ment of Tuesday’s session consid-ered the use of gadolinium-based contrast agent in MRI of the inter-nal auditory canal (IAC) for suspected vestibular schwan-noma, a benign tumor of the nerve that conducts hearing and balance information from the inner ear to the brain. MRI with contrast is considered the best imaging option, but gadolinium has been associated with side effects in patients with compro-mised kidney function. A T2-weighted approach is now available that enables visualization of the nerve without contrast. William P. Dillon, M.D., of the Uni-versity of California in San Francisco, said the non-contrast approach requires experience and a “good eye,” as it can miss lesions outside of the IAC and has a high potential for false-negative findings. “In some cases you can’t identify a very tiny tumor or other pathology without con-trast,” he said. “If I want a quick, defini-

tive answer and I don’t want to have to bring people back for additional imaging, I’m going to use contrast.” In addition to the gadolinium exposure, added time and expense are drawbacks of contrast-enhanced MRI, said Franz J. Wippold II, M.D., from Washington Uni-versity School of Medicine in St. Louis. The T2-weighted approach takes only 4.5 minutes—compared to 25 for a limited gadolinium-enhanced scan—and improve-ments in the approach have reduced the rate of false-negative findings. In addi-tion, the T2-weighted MRI eliminates “the small but real chance of adverse effects from contrast,” he said.

Barton F. Branstetter, M.D.

Hugh D. Curtin, M.D. William P. Dillon, M.D.

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