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Borgstede Named to RSNA BoardJames P. Borgstede, M.D., an accomplished clinician and educator whose expe-rience and expertise in radiology economics, quality and safety, and healthcare politics have made him a voice for the specialty, is the newest member of the RSNA Board of Directors. Dr. Borgstede will assume the position of Board Liai-son for International Affairs as Richard L. Baron, M.D., becomes chair of the Board of Directors.

“The RSNA as an organization is vision-ary and outstanding in both education

and research in imaging and image-guided therapies,” Dr. Borgstede said. “The annual meeting is the venue for educa-tion and research presentations and for radiologists around the world to meet face to face and discuss issues relevant to the future of our specialty for the benefit of our patients.” A professor of radiology and vice-chair of professional services, clinical operations and quality at the University of Col-orado, Denver, Dr. Borgstede is president of the American Board of Radiol-ogy and president-elect of the International Society of Radiology. Dr. Borgstede’s career has included both private practice and academic radiol-

ogy. He has spent his teaching career at the University of Colorado. For more than 25 years he also has worked to advance radiol-ogy through his service to and leadership

of numerous national and local radiologic and medical organi-zations. Dr. Borgstede served on many American College of Radiology (ACR) committees and task forces before becom-ing ACR chairman of the Board of Chancellors in 2004 and president in 2006. Since his presidency he has continued to work with ACR in capacities

such as the Committee on Inter-national Service, with which he traveled to Grace Children’s Hospital Port au Prince as part of the Haiti Radiology Project.

James P. Borgstede, M.D.

continued on page 4a

coronary cTA Administered at Lower radiation with Iterative reconstruction

Presented Tuesday afternoon by Bin Lu, M.D., the research, “Effect of

Reduced X-ray Tube Volt-age, Low Iodine Concentra-tion Contrast Medium and Iterative Reconstruction on Image Quality and Radia-tion Dose at Coronary CT Angiography: A Prospective Multicenter Study,” was conducted at nine hospitals in China and spearheaded by researchers at Fuwai Hospital, Beijing, and the Chinese Academy of Medi-cal Sciences. Dr. Lu and colleagues compared image quality for two CTA protocols. The first protocol used a tube voltage of 120kVp, a contrast agent of

370mgI/ml iopromide and filtered back projection reconstruction; the second used

100kVp, a contrast agent of 270mgI/ml iodixanol and sinogram affirmed iterative reconstruction (SAFIRE). The two groups, 115 in the reduced dose group and 116 in the control group, were comparable in size, age, body mass index and con-trast volume. Images were read by radiologists who had attended training sessions to enable them to assign image quality scores consistently.

Image quality scores in the two groups were comparable, and there were no

Bin Lu, M.D.

Iterative image reconstruction allows coronary CT angiography (CTA) to be administered at lower radiation exposure and with less iodine than con-ventional filtered-back projection reconstruction, and with no loss of image quality, according to a prospective study of more than 200 patients at several imaging centers.

continued on page 4a

medicine is model for Progress in 21st centuryProgress in the 21st century will come from harnessing human innovation and creativity, and the global gathering of physicians at RSNA 2013 exemplifies that phenomenon, former U.S. Secretary of State Condoleezza Rice, Ph.D., told a packed Arie Crown Theater on Tuesday.

“T hat creation and transmission of knowledge, the ability to use the talents of people across the globe, is really an extraordinary aspect of medicine,” said Dr. Rice her Spe-

cial Lecture, “Mobilizing Human Potential.” While the 19th century belonged to coun-tries that relied on resources for their wealth and their strength, and the 20th century to those with superior manufacturing, the 21st century will belong to those who can mobilize human poten-tial, Dr. Rice said. “Whether you are talking about how we protect the envi-ronment and still grow economies, or how to deal with the extraordinary information that you as physicians see every

day to give you a better chance to deal with crippling, chronic diseases, to extend life and to find a cure for the worst of diseases, or technolo-gies to reach out to people in remote parts of the world who just want a better life, it’s all going to come from innovation, creativity, and human potential,” she said. In a question and answer session

with lecture attendees, Dr. Rice noted she has always admired the global community of the sciences, and particularly the medical profession. Reading faculty folders as a provost at Stanford, she was always struck by the number of citations in science or medical papers that came from around the world.

Condoleezza Rice, Ph.D.

“That creation and transmis-sion of knowledge, the ability to use the talents of people across the globe, is really an extraor-dinary aspect of medicine.”

condoleezza rice, Ph.d.

continued on page 4a

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NeuroLogica December 3 & 4, 2013.pdf 1 10/28/2013 10:42:45 AM

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7:15–8:15Hot Topic Sessions8:30–10:00Refresher Courses and WorkshopsAssociated Sciences Refresher Course: Navigating the Regulatory, Reimburse-ment and Compliance Landscape or Land Mines!(BOOST) Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for Tomorrow: Anatomy and Contouring—GenitourinaryEssentials of Neuro ImagingRSNA/ESR Emergency Symposium: General Principles, Pediatric and ENT Emergencies

8:30–12:00Series CoursesCardiac, Interventional, Neuroradiology

10:30–12:00Scientific Paper SessionsAssociated Sciences Refresher Course: Clinical Imaging (Image Guided)(BOOST) Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for Tomorrow: Integrated Science and Prac-tice—GenitourinaryEssentials of Musculoskeletal ImagingInformatics CoursesRSNA/ESR Emergency Symposium: CNS Emergencies

wednesday at a GlanceWednesday © 2013 RSNA

The RSNA 2013 Daily Bulletin is the official publication of the 99th Scientific Assembly and Annual Meeting of the Radiological Society of North America. Published Sunday, December 1–Thursday, December 5.

Gary J. Whitman, M.D., ChairSalomao Faintuch, M.D., Vice-chairPhilip Costello, M.D.Karen Hoffman, M.D.Joseph G. Mammarappallil, M.D., Ph.D.Edith M. Marom, M.D.Maitray D. Patel, M.D.Michael L. Richardson, M.D.Pamela W. Schaefer, M.D.Benjamin M. Yeh, M.D.Sharon L. White, Ph.D., AAPM LiaisonWilliam T. Thorwarth Jr., M.D., RSNA Board Liaison

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Evonne Acevedo Johnson, M.F.A. Mike BassettEvelyn Cunico, M.A., M.S.L.I.S.Richard DarganFelicia Dechter, M.A.Elizabeth GardnerMary HendersonPaul LaTour

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12:15–1:15Scientific Informal (Poster), Quality Storyboard and Education Exhibit Pre-sentations (Lakeside Learning Center and Subspecialty Campuses)12:30–2:00Informatics Courses1:00–2:00ASRT@RSNA 2013: Musculoskeletal Imaging: New Ways to Image the Same Old Bones1:30–2:45Wednesday Plenary Session (Arie Crown Theater)Annual Oration in Radiation Oncology (See Page 9A)Beneficial Liaisons: Imaging and TherapyPaul M. Harari, M.D.1:30–3:00Essentials of Chest ImagingRSNA/ESR Emergency Symposium: Chest Emergencies1:30–3:30Resident and Fellow Symposium: Career 101: Planning for Success After Residency1:30–5:30Hospital Administrators Symposium 1:30–6:00Interventional Oncology Series: Prog-ress, Challenges and Opportunities2:20–3:20

ASRT@RSNA 2013: Pediatric CT/CTA: Techniques and Applications

2:30–4:00Informatics Courses3:00–4:00Scientific Paper Sessions3:00–4:15(BOOST) Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for Tomorrow: Case-based Review— Genitourinary

3:30–5:00Essentials of Breast ImagingRSNA/ESR Emergency Symposium: Abdominal Emergencies3:40–4:40ASRT@RSNA 2013: The Role of the Radiologic Technologist in Patient Safety (HCIAC)4:00–5:45Resident and Fellow Symposium: Career 102: Survival Skills for Your Job4:30–6:00RSNA Diagnosis Live™: Neuroradiology and Musculoskeletal RadiologyControversy SessionsInformatics Courses4:45–6:00BOOST: Bolstering Oncoradiologic and Oncoradiotherapeutic Skills for TomorrowHands-on Contouring: Genitourinary5:00–6:00ASRT@RSNA2013: The Patient Experience—Our Shared Journey

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Borgstede Named to RSNA Boardcontinued from cover

continued from cover

continued from cover Dr. Borgstede’s work with ACR also included testimony before the U.S. House of Representatives Ways and Means Health Subcommittee “Managing the Use of Imaging Services” hearing in 2005 and the U.S. House Rural Health-care Caucus, “Utilization Rates of Medi-cal Imaging Equipment” hearing in 2009. A member of RSNA since 1976, Dr. Borgstede has been a familiar face as part of the annual meeting refresher course faculty for many years. Dr. Borg-stede has served in numerous positions with the RSNA Research & Education (R&E) Foundation, including chair of the R&E Board of Trustees for the past year. He has also served on the RSNA Qual-ity Committee from 2009 to 2011. He is currently the R&E liaison to the RSNA

International Radiology Education Com-mittee. RSNA was the first organization he joined, Dr. Borgstede said, and he looks forward to helping the Society continue to extend its high-quality educational opportunities to people across the globe. “I joined during my first year of resi-dency and I still remember how I was immediately captivated by the organiza-

tion and the quality and breadth of the educational opportunities,” he said. Dr. Borgstede served on the editorial board of the Journal of the American College of Radiology (JACR) from 2004 to 2008 and currently serves on the edi-torial advisory board of American Family Physician and as a reviewer for JACR. He is a past-president of the Colorado Physician Health Program, the Colorado peer assistance program for physicians, and a past-president of the Colorado State Board of Medical Examiners. ACR has awarded Dr. Borgstede its William T. Thorwarth Award for Excellence in Economics and Health Policy and its gold medal. Dr. Borgstede received the first gold medal awarded by the Colorado Radiological Society.

Virtual Hysterosalpingography is Effective in Gynecologic Disorder EvaluationCombining the benefits of multidetector CT with traditional hysterosalpingography, virtual hysterosalpingography (V-HSG) provides a more detailed modality for evaluating the reproductive system.

T he emerging modality provides an integral evaluation of the cervix, fal-lopian tubes and uterine cavity and is

beneficial in discovering the specific cause of female infertility and other gynecologic disorders, said presenter Patricia M. Carras-cosa, M.D., Ph.D., in her presentation on Tuesday, “Virtual Hysterosalpingography in 10000 Cases.” The technology, which achieves many goals that conventional techniques can-not, is beginning to gain acceptance, Dr. Carrascosa said. “It is very feasible, it’s fast, it’s non-invasive, the patients in gen-eral don’t have any discomfort, it uses very low radiation dose, and it doesn’t have many complications,” said Dr. Carrascosa, head of the CT and MR Imag-ing Department and the Research Depart-ment at Diagnostico Maipu in Buenos Aires, Argentina. “In many cases, one study is enough for the physician to determine which treatment to use, or to determine how well treatment is going,” she added. Dr. Carrascosa began researching V-HSG as an alternate modality in 1998, and technological advancements since

2006 have allowed her to make substantial progress. Since 2006, the technique has upgraded from using 64-row multislice CT to 128- and 256-row, cutting scanning time from 3.6 seconds to 1.3 seconds. The technology also reduced the radiation dose from 0.9 mSv to 0.3 mSv. Unlike conventional modalities, V-HSG does not require cervical clamping, which can cause bleeding and irritation. In the 10,000 cases Dr. Carrascosa studied, there were no complications reported and 80 per-cent of the patients said they experienced

statistically significant differences in mean attenuation, image noise, or contrast-to-noise ratio. The mean iodine dose was 27 percent lower with the 100kVp protocol, and the mean effective radiation dose was 35 percent lower. Dr. Lu cited two limitations for the study. The first was that the body mass index (BMI) of the Chinese study sub-jects was, on average, significantly lower than that of the general population in both Europe and North America, and further study is needed to determine whether higher BMI might affect the results. The second was that the protocol wasn’t designed to measure whether the lower iodine load would translate to a reduced risk of contrast-induced nephropathy.

coronary cta administered at lower radiation with iterative reconstruction

From 2005 to 2009, Dr. Rice served as the 66th Secretary of State of the United States, the second woman and first African American woman to hold the post. She also served as national security advisor for President George W. Bush from 2001 to 2005, the first woman to hold the position. Dr. Rice is currently the Denning Professor in Global Business and the Economy at the Graduate School of Business; the Thomas and Barbara Stephenson Senior Fellow on Public Policy at the Hoover Institution; and a professor of Political Science at Stanford University. She is also a founding partner of RiceHadleyGates LLC.

nurturing innovation and creativity creates better lives for all

mild or no discomfort during the procedure. “There are no complications, no rash or infection, because of the noninvasive nature,” Dr. Carrascosa said. Some patients are allergic to the iodine used in the contrast, which includes 18 ml of saline solution and 2 ml of contrast, Dr. Carrascosa noted. If an individual suffers from an iodine allergy, the contrast can be made with gadolinium instead. “We don’t use gadolinium every day because of the cost,” she said. “So there are no limitations for patients who are allergic.”

The results demonstrated the variety of gynecologic disorders that can be discov-ered using V-HSG. In the cervical region, disorders included wall irregularities (25 percent), fold thickening (13 percent), cer-vical polyps (11 percent), cervical stenosis (8 percent), diverticulae (5 percent) and cervical synechiaes (1 percent). Findings in the uterus were divided into uterine cavity and uterine wall abnormali-ties. Uterine cavity findings included pol-yps (43 percent), synechiaes (13 percent) and submucous myomas (12 percent). Uterine wall abnormalities included intra-mural and suberous myomas (7 percent), uterine malformations (6 percent), adeno-myosis (4 percent) and C-section scars (8 percent). Fallopian tube findings included uni-lateral hydrosalpinx (10 percent), bilateral hydrosalpinx (4 percent), tubal obstruction (5 percent) and tubal synechiae (1 percent). “Many people can be helped by this technique,” Dr. Carrascosa said. “We began with many limitations, but then with technology improvements we could begin modifying V-HSG into a very non-invasive technique with very low radiation dose.”

Condoleezza Rice, Ph.D. (left), joined RSNA President Sarah S. Donaldson, M.D., for a question and answer session following her lecture.

In many cases, one study is enough for the physician to determine which treatment to use, or to determine how well treatment is going

Patricia m. carrascosa, m.d., Ph.d.

“The RSNA as an organiza-tion is visionary and out-standing in both education and research in imaging and image-guided therapies.

James P. borgstede, m.d.

Overheard on the WebYour colleagues are talking about #RSNA13 on Facebook, Twitter and beyond. Join the conversation and dis-cover new happenings at the meeting and around Chicago. Today at noon, be sure to watch Twitter for a TweetChat on how social media can be used for imaging edu-cation. Meet the hosts, Journal of the American College of Radiology Deputy Editor Ruth Carlos, M.D., and Geraldine McGinty, M.D., at the American College of Radiology booth 3123A, South Building, Hall A.

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Medical Ozone Improves Condition of Patients with Herniated Disks

Injections of medical ozone improve symptoms in almost 75 percent of patients with herniated disks in their

lower backs, according to new research from Germany presented Tuesday. Ozone is a structurally modified form of oxygen present in small amounts in the atmosphere. Research has shown that it has a destructive effect on substances called proteoglycans that make up a major com-ponent of the nucleus pulposus, the jelly-like substance in the middle of a spinal disk. The nucleus pulposus can be forced out of the disk, exerting pressure on the nerve located nearby, leading to sciatica. “The water binding capacity of the proteoglycans is the main force that holds water to the nucleus pulposus,” said study author Thomas Lehnert, M.D., from the Department of Diagnostic and Interven-tional Radiology at the Goethe University in Frankfurt, Germany. “Destruction of the proteoglycans reduces the hold water and therefore diminishes the size of herniation.” Ozone also has an effect on disk inflammation by altering the breakdown

of arachidonic acid, a fatty acid found in tissues, to inflammatory prostaglandins. “Therefore, by reducing the inflamma-tory components, there is a corresponding reduction of pain,” Dr. Lehnert said. Dr. Lehnert and colleagues recently evaluated the effects of ozone on 371 patients with lumbar radiculopathy, a con-dition in which compressed nerves in the spine cause pain and numbness. The patients received one injection of a 97-percent oxygen, 3-percent ozone mixture into the disk, and another perian-glionically, or around a mass of nerve cells known as a ganglion. The ozone injections were performed under CT guidance and were followed by corticosteroid and anes-thetic injections in the same session. The researchers assessed clinical out-comes six months after treatment and used MR imaging to evaluate disk matrix and disk volume. Treatment was successful in 268 patients, or slightly more than 72 per-cent. Among those patients, outcome was excellent in 133 patients (49.6 percent) and good in the remaining 135 patients.

“The ozone did not cause any complications in patients,” Dr. Lehnert said. MR imaging find-ings revealed that the majority of patients had a statistically significant reduction of volume in their herniated lum-bar disks. On average, patients with excellent outcomes experienced a 20 percent reduc-tion in disk volume, while those with good outcomes had a 7 percent volume reduc-tion. This volume-reduction effect corre-lated negatively with the patient’s age and positively with initial disk volume. “Our study shows that the combined intradiskal and periganglionic injection of medical ozone and periganglionic injec-tion of steroids affects both the mechanical and the inflammatory components of pain caused by disk herniation,” Dr. Lehnert said. “For this reason, oxygen-ozone injections are a therapy option for treat-

Thomas Lehnert, M.D.

Spectral ct improves image Quality, reduces radiation exposureRecent technological advances have contributed to the development of photon-counting detectors (PCD), which are now able to discriminate between photons based on energy level, providing information about the composition of an object in a single scan. “PcDs are the next big thing in ct,” said Radin A. Nasirudin, Dipl.-Ing, of the Department of Diagnostic and Interven-tional Radiology, Technische Universitat München, Munich, Germany, in a presenta-tion Tuesday. Incorporating photon-counting detector technology into CT—a technique called spectral CT—not only relays this addi-tional information in a single scan, but due to quantum efficiency, noise can be drastically reduced. This means that better image quality can be achieved with lower radiation dose, Nasirudin said. “Current estimates on dose reduc-tion suggest a decrease by a factor of two or more.” In his study, “Applica-tion of Photon-counting CT: Metal Artifact Reduc-tion,” Nasirudin and colleagues investigated the advantages this technique provides in reducing metal artifacts. “Artifacts caused by metal objects are common and can significantly reduce the diagnostic quality in daily clinical prac-tice,” Nasirudin said. “Although there are many well-established methods for metal artifact reduction, most involve segmenta-tion and thresholding for detection of the metal object, which is prone to reintro-duce new artifacts.“ With this in mind, Nasirudin and colleagues developed an algorithm—spectral-driven iterative reconstruction (SPIR)—that utilizes spectral information to reduce metal artifact in CT. Researchers used a Monte Carlo simu-lator to simulate spectral CT projection data of a jaw phantom consisting of bone, soft tissue, teeth and gold implants. The resulting spectral projection data were

decomposed to determine the spatial location and density of the gold. That information was then incorporated into a penalized maximum likelihood iterative reconstruction algorithm. “The results from our investigation into the reduction of metal artifacts are promising,” Nasirudin said. “The mate-rial decomposition technique is able to detect the metal implant from other com-ponents of the phantom.” When compared

to a known shape, the error from detecting the implant by material decomposition is less than 2 pixels, he said, which “strongly sug-gests” the technique is able to accurately detect the spatial location and density of any dental implant. Use of the technique

resulted in in a reduction of streaking artifacts without compromising any other anatomical information, Nasirudin said. When visually compared to other tech-niques like filtered-back projection or standard penalized maximum likelihood iterative reconstruction, “our method delivers superior image quality while preserving the details around the metal implant,” he said. It’s significant that this technique seems to work well with any shape of dental implant, he said. For example, researchers first used the technique with a jaw phantom that had a circle-shaped metal implant, but later tested the algo-rithm with more realistic dental implants that produced images with high diagnos-tic quality. In addition, he said the parameters for the iterative reconstruction (such as number of iterations and the strength of

the penalty) didn’t change from one shape to another, indicating that “our method can be extended to other parts of the body such as the lower extremity or the spine.” The study demonstrates that informa-tion provided by spectral CT “will be a central key to overcoming image quality issues in current clinical CT,” Nasirudin said. “We foresee that the clinical intro-duction of spectral CT will lead to more clinically relevant applications while pos-sibly reducing radiation exposure to the general population.”

Spectral CT “will be a central key to over-coming image quality issues in current clinical CT”.

radin a. nasirudin, dipl.-ing

Radin A. Nasirudin, Dipl.-Ing

Receiving RSNA’s highest honor, the Gold Medal, during Tuesday’s plenary session were (from left): J. Frank Wilson, M.D., of Milwaukee; Harvey L. Neiman, M.D., of Reston, Va.; and Theresa C. McLoud, M.D., of Boston.

2013 RSNA Gold Medalists

ing lumbar disk herniation that has failed to respond to conservative management, before recourse to surgery or when surgery is not possible.” The ease of execution and noninvasive-ness of medical ozone therapy make it a potentially useful tool for outpatient proce-dures, Dr. Lehnert said. Because of its tox-icity, medical ozone is currently approved only for research purposes in Europe and the U.S., though Dr. Lehnert added that approval for clinical use may be only a few years away.

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tuesday’s Press conferencesnew research Shows Promise for Possible HiV cureResearchers have used radioimmunotherapy (RIT) to destroy remaining HIV-infected cells in the blood samples of patients treated with highly active antiretroviral therapy (HAART). HAART has transformed the outlook for patients infected with HIV. However, reservoirs of latently infected cells persist in the body after HAART, preventing the possibility of a permanent cure. In the study, research-ers administered RIT to blood samples from 15 HIV patients treated with HAART. The researchers found that RIT was able to kill HIV-infected lymphocytes previously treated with HAART, reducing the HIV infection in the blood samples to undetectable levels.

breast tomosynthesis increases cancer detection and reduces recall ratesUsing digital breast tomosynthesis (DBT) led to reduced recall rates and an increase in cancer detection in a large breast cancer screening program. The researchers com-pared imaging results from 15,633 women who underwent DBT beginning in 2011 to those of 10,753 patients imaged with digital mammography the prior year. Compared to digital mammography, the average recall rate using DBT decreased from 10.40 percent to 8.78 percent, and the can-cer detection rate increased from 3.51 to 5.24 (per 1,000 patients).

breast cancer risk related to changes in breast density as women ageA new study compared breast density and cancer risk between younger and older women and analyzed how the risk relates to changes in breast density over time. The study group included 282 breast cancer cases and 317 healthy control participants who underwent full-field digital mammography, with breast density measured separately using an automated volumetric system. Breast cancer patients showed higher mammographic density than healthy participants up to the age of 50, as well as consid-erably more variability in density regression with age.

international Study Finds Heart disease Similar in men and womenAn analysis of data from an international multicenter study of coronary computed tomography angiography (CCTA) reveals that men and women with mild coronary artery disease and similar cardiovascular risk profiles share similar prognoses. Researchers identified 11,462 patients from the CON-FIRM registry, matched for age, risk factors and extent of coronary artery disease. Con-trolling for all cardiovascular risk factors, non-obstructive coronary artery disease con-ferred a similar adverse risk of death or heart attack in both men and women. Conversely, the absence of plaque on CCTA conferred a good prognosis for both men and women.

Jonathon Leipsic, M.D., F.R.C.P.C.

Nick Perry, F.R.C.S., F.R.C.R.

Ekaterina Dadachova, Ph.D.

Emily F. Conant, M.D.

Today’s Press ConferenCesRSNA invites members of the medical news media to attend its annual meeting each year so that, through stories in print, broadcast and Internet media, the pub-lic gains a greater understanding of radiology and its role in their healthcare.Three press conferences will be held today. They are:• MR-guided Ultrasound Offers Noninvasive Treatment for Breast Cancer• Blood Vessels Reorganize after Face Transplantation Surgery• Mammography Screening Intervals May Affect Breast Cancer PrognosisRSNA 2013 press releases are available online at RSNA .org/press13.

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wednesday Plenary Session: crossing the threshold in radiation therapyAdvancements in tumor visualization, tracking and treatment is the topic of today’s lecture.a n n u a l O r at i O n i n r a d i at i O n O n c O l O gyBeneficial Liaisons: Imaging and Therapy

Not long ago, external anatomy and plain X-rays served as the primary guide for radiation therapy. Broad field design was the prevailing paradigm with

the knowledge that the tumor surely resided within. Collat-eral normal tissue damage was a necessary accompaniment of treatment and tumor dose was largely limited by normal organ tolerance. Today, ablative radiation doses are delivered to complex 3D tumor shapes virtually anywhere in the body, says Paul M. Harari, M.D., who will present the Annual Oration in Radiation Oncology, “Beneficial Liaisons: Imaging and Therapy.” Sharp dose gradients are created between tumor and critical normal tissues and high precision is sought for daily treatment across thousands of patients. We are poised to move well beyond “see the tumor, treat the tumor,” Dr. Harari says, as we cross the threshold of unparalleled visualization within tumors, tracking indi-vidual tumor cells, developing diapeutic agents to simul-taneously image and treat, and harnessing early response

profiles to shape more personalized and effective future therapies. Dr. Harari is the Jack Fowler Professor and chair of the Depart-ment of Human Oncology at the University of Wisconsin School of Medicine and Public Health. Early career development awards from the American Cancer Society and the RSNA Research & Education (R&E) Foundation helped launch Dr. Harari’s career as a physician scientist. His clinical and laboratory research focuses on treatment advances for head and neck cancer patients with emphasis on the interaction of molecular growth inhibitors combined with radiation. His clinical work emphasizes the highest quality imaging for cancer patients and the advancement of new imaging modalities that enhance our ability to assess both tumor anatomy and biology.

Oration dedicated to ang

Paul M. Harari, M.D.

numerous new cancer treat-ment regimens,particularly for head and neck cancer. His research focused on developing novel therapy strategies through various in vitro and xenograft models and using specimens collected from patients enrolled into prospective phase II-III trials.His latest studies included the role of inhibitors of the epidermal growth fac-tor receptor or other signaling pathways

in selective enhancement of tumor radiation response in preclinical models. As chair of the Head and Neck Commit-tee of the Radiation Therapy Oncology Group between 1999 and 2012, Dr. Ang introduced several new regi-mens—such as radiation plus chemotherapy or Cetuximab,

resulting from laboratory studies into clinical trials—which established sev-eral standard treatments.

RSNA is dedicating this year’s Annual Oration in Radiation Oncology to the memory of K. Kian Ang, M.D., Ph.D., a renowned expert in radiation oncol-ogy research. Dr. Ang was to deliver the Annual Oration in Radiation Oncology at RSNA 2013. Dr. Ang was the Gilbert H. Fletcher Distinguished Memorial Chair and a professor in the Department of Radia-tion Oncology at The University of Texas MD Anderson Cancer Center in Houston. Dr. Ang was responsible for establishing

K. Kian Ang, M.D.

Thanks to the more than 650 people who registered for the RSNA 2013 5k Run, which raised $26,960 for the RSNA Research & Education Foundation. The run along the Lake Michigan shore started Tuesday at 6:30 a.m. in Arvey Field at Chicago’s South Grant Park, where the temperature was a brisk 40 degrees.

Fun Run Raises Almost $27,000

CongrAtulAtions to tHe toP finisHers:

Female1. Kara Waters2. Kathleen Anderson3. Tanya Tivorsak

Male1. Haakon Hjemly 2. Roque Oca3. David Palma

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9:00 a.m.• iOS 7 Overview; RSNA Staff• MITK Pocket—The Lightbox to Go; mbits

9:45 a.m.• Transforming Financial Data into Action-

able Insights with Mobile Business Intelligence; McKesson

10:00 a.m.• Health Apps; RSNA Staff

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11:15 a.m.• VitreaView—Accessing Images on Your

Tablet; Vital, A Toshiba Medical Systems Group Company

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12:45 p.m.• 3D Printing—DICOM Utilization of HTML5 on Your

Mobile Device; Vizua

1:30 p.m.• Health Companion; DR Systems

2:00 p.m.• RSNA Mobile; RSNA Staff

2:15 p.m.• Diagnose on the Go: Quickly, Confidently and

Securely; Calgary Scientific

3:00 p.m.• Productivity Apps; RSNA Staff• Fast, Simple, Secure Image Share; Carestream Health3:45 p.m.• Lightning Bolt Mobile App; Lightning Bolt Solutions

Code Bundling Among Factors Driving Decrease in UtilizationUtilization rates for CT, MR imaging and nuclear medicine have leveled off since experiencing rapid growth in the early part of the 2000s that drew concern due to cost, potential overuse and, in the case of CT, the cancer risk associated with radiation dose.

David C. Levin, M.d., presented “Nationwide Medicare Data Show the End of Growth in Utilization

Rates of Advanced Imaging” during a sci-entific session Tuesday at RSNA 2013. Dr. Levin, professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University, led a team in using the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2000-2011 to examine utilization rates. According to the study, the CT utiliza-tion rate per 1,000 beneficiaries skyrock-eted from 325 in 2000 to its peak of 637 in 2009, a 96 percent increase. The nuclear medicine rate per 1,000 rose from 193 in 2000 to 320 in 2006, a 66 percent increase. Meanwhile, the MR rate per 1,000 jumped from 95 in 2000 to 185 in 2006, a 95 per-cent increase. “Imaging was the most rapidly growing of all physician services,” Dr. Levin said. “That led to a lot of concern, and that was partially responsible for the reimbursement cuts that have followed since then.” The results of Dr. Levin’s study, how-ever, showed that the rates began leveling

off from 2009 until 2011, the most recent year with available data. CT dropped a small amount to 626 in 2010, and took a dramatic plunge to 500 in 2011, mostly the result of code bundling for CT of the abdo-men and pelvis. Nuclear medicine also saw a gradual decline to 303 by 2009, then a sharp decline to 135 in 2010, again largely due to code bundling for primary myocar-dial perfusion imaging and its two add-on codes for left ventricle wall motion and

ejection fraction. In 2011, the number fell again, to 128. MR imaging rates remained steady since 2006, hitting 184 in 2011. MR imaging experienced no code bundling. Despite code bundling appearing to have a dra-matic effect on the trend lines for utilization rates, Dr. Levin said even without that development the growth had ended. He attributed the drop off to a variety of fac-tors beyond code bundling,

including higher co-pays for patients and the growth of radiology benefits manage-ment companies (RBMs). Among other factors are reimbursement cuts and physi-cian concerns about costs and radiation, and appropriateness criteria. The recession was also a factor, though the slowdown began before the recession hit. All factors contributed to the leveling off, but Dr. Levin said RBMs played a major role. “RBMs have basically changed

David C. Levin, m.D.

the way a lot of the ordering physicians think about ordering imaging,” Dr. Levin said. “They know they’re going to have to go through this preauthorization process. That has probably discouraged a lot of inappropriate use.” Dr. Levin said it’s too soon to predict what the 2012 data will show, but he doesn’t believe the rates will increase. “There might be a little bit of growth, but it’s not going to be near the rate we saw in the early 2000s,” he said. “In fact, there may be no further growth.”

special recognition for in-Kind supportRSNA would like to recognize the following company for contribut-ing equipment to the Refresher Courses at RSNA 2013:

laurane medical

11Ad 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 4 , 2 0 1 3

Patient-centered care Goes beyond image interpretation

“I t’s not just about giving results to patients,” said Mary C. Mahoney, M.D., chair of RSNA’s Patient-Cen-

tered Radiology Steering Committee. “It’s about considering and optimizing the entire patient experience.” The committee sponsors the RSNA Radiology CaresTM: The Art of Patient-centered Practice campaign. The initiative facilitates radiologists’ meaningful engage-ment in the patient experience and encour-ages radiologists to take the “Radiology Cares” pledge. “We must portray radiologists as knowledgeable physicians—the imaging experts—and show that we’re patient advo-cates by demonstrating concern and knowl-edge about safety and risks,” Dr. Mahoney said. She and Bibb Allen Jr., M.D., vice-chair of the American College of Radiol-ogy (ACR) Board of Chancellors addressed attendees during the session, “Imaging in a New Dimension: Radiologists Add Value,” detailing efforts by RSNA and the ACR to make radiology more patient-centered. “Many patients don’t even know we exist,” Dr. Mahoney said. “We can’t just be a name on a bill.” One obvious way to become more vis-ible to patients is to deliver results in per-son, Dr. Mahoney added. “It is a privilege and a responsibility, and an important pro-fessional opportunity,” she said. But patient-centered radiology involves more than delivering results, Dr. Mahoney emphasized. She presented a video clip of a referring physician saying she is pleased when a radiologist takes the time to call

and question an order and make recom-mendations for a more appropriate proce-dure. Scheduling, results reporting, billing and even design of the reception room, along with interactions with the radiol-ogy team, have an impact on the patient experience, Dr. Mahoney said. Registra-tion, scheduling and instructions should be a one-stop process, she said, encouraging radiologists to consider options like Web-based scheduling. “You can create a ‘patient lounge’ rather than a ‘waiting room,’” Dr. Mahoney explained. “There may be little difference in principle, but providing a comfortable experience can go a long way.” For example, during peak times, radi-ologists can create a concierge-like experi-ence with a greeter who could also handle issues like unanticipated delays and make sure the patients are comfortable, she said.

radiologists should “Own all aspects of medical imaging” Optimizing the entire patient experience means that radiologists need to go beyond image interpretation and get involved in the imaging process before and after exams, Dr. Allen said in his presentation, “Imag-ing 3.0: A Framework for Radiologists’ Future.” But for a number of reasons, most radiologists are not providing that full spectrum of care, he said. “If we did that, the results would be improved patient safety and outcomes, more cost-effective care, and an increased relevance for radiologists in the healthcare

system,” Dr. Allen said. “We would have a measurable role for radiologists in improv-ing population health and we would have a calculation of radiology’s value in reducing per capita cost.” Session moderator William T. Thor-warth Jr., M.D., RSNA Board Liaison for Publications and Communications, observed, “We have the most sophisticated tools ever available to care for our patients, yet these tools make abnormalities so conspicuous and display them in such ana-tomic detail, that other specialties believe that they too can do what we do.” Dr. Allen added, “Radiologists need to own all aspects of medical imaging, pro-viding all care that is necessary and no care that is not.” He explained that “Imaging 3.0” is a blueprint for high-value care. “It goes beyond interpretations,” he said. “It’s about assuring appropriateness, document-ing the quality and safety radiologists pro-vide, actionable reporting with evidence-based follow-up, and empowered patients.” Dr. Mahoney encouraged radiologists to utilize resources that will improve the patient experience, like RadiologyInfo.org, the RSNA-ACR public information web-site that provides patients with easy access

to understandable descriptions of complex radiology procedures, and to get involved in patient-focused projects like RSNA Image Share, which enables patients to take control of sharing their medical imaging reports via a cloud-based edge server. Dr. Allen started Monday’s question-and-answer session with a challenge. “We more or less developed these ideas—Radi-ology Cares and Imaging 3.0—indepen-dently. We think this is a good vision for our specialty. But I’d like to ask you: Are we wrong? Is this the direction you’d like the specialty to take?” One audience member responded that the ideas and the values are sound, but that at his institution there was “not much trac-tion” for developing a value case for radi-ology. Dr. Allen acknowledged that insti-tutional boundaries can make it difficult for radiologists to change their culture. To help spur change, radiologists must achieve the imperatives of healthcare reform, he said. He urged radiologists to avail them-selves of point-of-care IT tools like ACR Select, which can make standards-based recommendations within a report, helping radiologists deliver reports that result in measurable outcomes.

Bibb Allen Jr., M.D.Mary C. Mahoney, M.D. William T. Thorwarth Jr., M.D.

Richard L. Baron, M.D.ChairmanChicago

William T. Thorwarth Jr., M.D.Liaison for Publications and CommunicationsHickory, N.C.

Richard L. Ehman, M.D.Liaison for ScienceRochester, Minn.

Vijay M. Rao, M.D.Liaison for Information Tech- nology and Annual MeetingPhiladelphia

Valerie P. Jackson, M.D.Liaison for EducationIndianapolis

James P. BorgstedeLiaison for International AffairsColorado Springs, Colo.

N. Reed Dunnick, M.D.PresidentAnn Arbor, Mich.

Ronald L. Arenson, M.D.President-elect/Secretary- TreasurerSan Francisco

2014 RSNA BoARd of diRectoRS

N. Reed Dunnick, M.D.PresidentAnn Arbor, Mich.

Ronald L. Arenson, M.D.President-elect/Secretary- TreasurerSan Francisco

G. Scott Gazelle, M.D., Ph.D.First Vice-PresidentBoston

Satoshi Minoshima, M.D., Ph.D.Second Vice-PresidentSeattle

Bruce G. Haffty, M.D.Third Vice-PresidentNew Brunswick, N.J.

Richard L. Baron, M.D.ChairmanChicago

2014 RSNA officeRS

Practicing patient-centered radiology can show the health-care industry—and, most importantly, patients—the value of a radiologist, according to speakers during a special interest session on Monday.

arenson named rsna President-electRenowned diagnostic radiologist Ronald L. Arenson, M.D., is RSNA president-elect.

D r. Arenson is the Alexander R. Mar-gulis Distinguished Professor and chair of the Department of Radiology

and Biomedical Imaging at the University of California, San Francisco. As president-elect, Dr. Arenson will focus on the value and improvement of patient-centered care initia-tives at the annual meeting and throughout the year. “As we enter an unprecedented period of change in our healthcare system, radiology must adapt in fundamental ways,” he said. Having served in the past as RSNA Board Liaison for Information Technology and Annual Meeting, Dr. Arenson is committed to the use of informatics to develop the future of patient service. “In addition to its usual roles in education and research, the RSNA is in a unique position to give practicing radiolo-gists tools to improve the services we pro-vide our patients and referring physicians,” Dr. Arenson said. Dr. Arenson was a founding member of the Radiology Information System Consor-tium (RISC), now the Society for Imaging Informatics in Medicine (SIIM). He is past-president of the Association of University Radiologists, Society of Chairs of Academic

Radiology Departments and the Academy of Radiology Research, and served on the National Advisory Council of the National Institute of Biomedical Imaging and Bio-engineering of the National Institutes of

Health (NIH), as well as the NIH Council of Councils. Dr. Arenson’s research achievements include the development of a catheter that can be steered in a magnetic field, allowing interventional radiologists to reach further into smaller blood vessels. Dr. Arenson and fellow research-ers filed a patent on the invention in 2001. The patent was recently nominated for a national fair on technology, and Dr. Arenson is now work-ing with faculty on the next stage prototype.

A member of RSNA since 1974, Dr. Arenson has served on numerous commit-tees, including the Publications Council, Public Information Advisors Network, Research Development Committee and the Radiology Informatics Committee (formerly Electronic Communications Committee), which he chaired from 1999 to 2005. He was elected to the RSNA Board of Directors in 2007 and served as Board chairman from 2012 to 2013.

Ronald L. Arenson, M.D.

radiation exposure

Question of the dayQ what are some techniques for minimizing patient radiation expo-

sure in fluoroscopy?[answer on page 13a.]

12A d 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 4 , 2 0 1 3

World Radiology Leaders Seek to Match Resources with NeedsCT scanners sometimes end up in remote areas of a developing nation, due to the ambitions of its government, the donations of well-meaning foreign philanthropists, or the tireless activity of vendor representatives. But unless those machines come with someone to operate and maintain them, and someone to interpret the images, they quickly turn into expensive doorstops.

“There is a huge need for educa-tion in those regions where the technology is coming very fast,”

said Richard Baron, M.D., RSNA Board Liaison for International Affairs and co-chair of this year’s International Trends meeting, which took place Tuesday morn-ing and focused on radiology education in developing nations. “The Internet lets them read about [the latest imaging tech-nology]; economic development lets them buy it. In many ways we’ve been handing out loaves of bread and we have to teach them how to cook.” The meeting was an international sum-mit of professional radiology, and attendees included the heads of major professional societies: the Asian Oceanian Society of Radiology; the Interamerican College of Radiology; the European Society of Radiology and the International Society of Radiology. The presidents of many individual coun-tries’ societies attended as well, including Canada, Great Britain, China, France, Spain, Germany, Japan, Korea, the Neth-erlands, Italy, Australia and New Zealand. In addition to Dr. Baron, RSNA was rep-resented by President Sarah S. Donaldson, M.D., President-elect N. Reed Dunnick, M.D., and Board Chairman Ronald L. Arenson, M.D. The co-chair was Byung Ihn Choi, M.D., of South Korea, chair of

the RSNA International Advi-sory Committee. Dramatic changes in radiol-ogy education are needed to bring adequate capabilities to developing nations. Meeting speakers focused on the needs of developing nations and the resources available in developed nations, and how the two might be aligned. “No one has taken a step back to look at the library of opportunities out there, or to ask whether we’re duplicat-ing efforts,” Dr. Baron said. “Do we have five teams going to the same small town while we ignore other areas? Do we know that the techniques we use to teach in the U.S. or Europe will work well in these countries? Have we asked them what they want?” Gloria Soto, M.D., of Chile, president of the Interamerican College of Radiology, cautioned against regarding the “develop-ing world” as a monolith. “Five billion people live in ‘developing nations,’ or 80 to 85 percent of the world population, and somewhere between 104 and 152 countries, out of 206, are developing or underdevel-oped, depending on the definition,” she said. “They are not homogeneous. There are great differences in their infrastructure,

The RSNA 2013 International Trends meeting was a summit of professional radiology.

their technologies, their work forces, their national policies. Any educational pro-grams must be focused to specific needs and support local conditions.” Presentations by speakers from devel-oped areas made clear that every profes-sional society already offers a variety of activities to help radiologists from less developed countries. Those include send-ing visiting professors to the countries, sponsoring fellowships for radiologists in training to study abroad and providing edu-cational materials online. The impact of these efforts is unclear, however said International Advisory Committee member Gabriel P. Krestin, M.D., Ph.D., of the Netherlands. “The needs of developing countries 10 to 15 years ago are the same as their needs

today,” said Dr. Krestin, who on Monday received RSNA Honorary Membership. “I’m convinced that many young people profited a lot [from outreach efforts], but did we change anything in those countries or those regions? I don’t know if coordi-nation would be helpful, because it might just add bureaucracy, but we should have unified metrics so we can measure what we’re providing.” William Mayo-Smith, M.D., of Brown University, urged attendees to consider not only radiology societies, but also other medical specialty societies, hospitals and other institutions, non-government organi-zations and even individuals when trying to determine how best to organize outreach. “We must realize that we are a piece in the puzzle of medical care,” he said.

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radiation exposure

answer[Question on page 11a.]

APosition the patient as far from the x-ray tube, and as close to the image receptor as possible. collimate to the area of interest. use magnification mode only when needed, as the dose is higher.

Q&A courtesy of AAPM.

Digital Tomosynthesis Improves Lung Nodule DetectionDigital tomosynthesis (DT) is significantly more sensitive than conventional radiography at detecting lung nodules and its advantages are evident among general radiologists as well as thoracic radiologists, according to a study presented Tuesday. DT is a relaTively new technology that uses X-rays to create slice-based views from inside the body. Previous studies have shown that it is more sensitive than radiog-raphy at detecting lung nodules, but those studies have largely relied on radiologists with expertise in thoracic imaging, said James T. Dobbins III, Ph.D., associate pro-fessor of radiology at Duke University. For the new study, Dr. Dobbins and col-leagues had both tho-racic and general radi-ologists assess DT and radiography referenced to CT for the detection of lung nodules. The study group included 158 subjects at three institutions in the U.S. and one in Sweden who were imaged by chest CT, two-view con-ventional radiography (CXR), dual-energy radiography (DE), and DT on a flat-panel imaging device. Three experienced thoracic radiolo-gists confirmed the presence and location of nodules by CT and determined the appropriate management approach using Fleischner Society guidelines, rules created to improve follow-up and management of small lung nodules detected by CT. In addition, five general radiologists marked the nodules and then determined the appro-

priate course of action using CXR alone, CXR plus DE, DT alone, and DT plus DE. In all, 516 nodules were identified by CT. Overall detection sensitivity for all nodules was 3.8 percent for CXR, com-pared with 13.5 percent for DT. “The threefold improvement in sensitivity with tomosynthesis is consistent with previ-ous studies,” Dr. Dobbins noted. “What’s

unique about our study is that we’re including the role of dual-energy imaging and also look-ing at a broader range of expertise among radi-ologists.” DT also outper-formed CXR for deter-mining the best course of action using Fleis-chner Society criteria.

The addition of DE improved nodule detec-tion when paired with CXR but not when paired with DT. “Our results clearly demonstrate that tomosynthesis is far superior to conven-tional radiography for looking at lung nod-ules,” Dr. Dobbins said. “DT shows signifi-cantly improved clinical performance over CXR for pulmonary nodule detection and case management when evaluating nodules greater than three millimeters in diameter.” The clinical role for DT is still evolv-ing, Dr. Dobbins said, as researchers try to

determine the best implementation strategy. One promising option for DT is as a problem-solving tool for suspicious findings on radiog-raphy. Dr. Dobbins said this attribute would be particularly useful in healthcare environments where patients remain in the clinic until imag-ing results are complete. DT also has a potential role as an alterna-tive to CT for tracking changes in nodules over time, although further studies will be required to validate that approach. “While DT has mar-ginally higher radiation doses than two-view chest radiographs, it exposes the patient to con-siderably less radiation than the current genera-tion of CT techniques,” Dr. Dobbins said. A third, speculative application would involve using DT as a lower dose, lower cost lung cancer screening paradigm, he suggested. “We’ll need to demonstrate outcomes compa-rable with CT before that can happen,” he said. James T. Dobbins III, Ph.D.

Our results clearly demon-strate that tomosynthesis is far superior to conven-tional radiography for looking at lung nodules

James t. dobbins iii, Ph.d.

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stereotactic body radiotherapy effectively manages Pain in metastasesUsing stereotactic body radiotherapy (SBRT) to treat soft tissue metastases is effective for pain management and local control, and is well tolerated by patients, according to research presented Tuesday.

According to presenter Reed Cope, a fourth-

year medical student at the Oregon Health and Science University, skeletal muscle/soft tis-sue metastases are rare, representing 0.5 to 4 percent of all metasta-ses. “These metastases are often very painful, so palliation of pain is an important com-ponent of their care,” Cope said. “They also carry a very poor prognosis, with the latest series to date reporting a mean overall survival of 5.7 months.” SBRT may be a way of achieving symptom relief and effective local control, but Cope said that a literature search found very little about how to treat soft tissue metastases—not even information about institutional experiences with treating these metastases. In this retrospective study, performed in conjunction with the Mayo Clinic in Rochester, Minn., Cope looked at nine patients (ranging in age from 40 to 77) with 12 cases of skeletal muscle/soft tissue metastases of varying tissue types that were treated at Mayo with SBRT between 2008 and 2012. Researchers calculated median overall and progression-free survival from

the data of SBRT administration and reviewed and classified acute toxicity and late toxicity. The response to treatment was based predominantly on radiologic imaging. Of the 12 skeletal muscle/soft tissue metastases treated, the most common tissue type was melanoma (33 percent), and the most common site

treated was the psoas muscle (33 per-cent). More than half (58 percent) of the patients presented with pain at the time of SBRT treatment. “Of those seven patients who had the most painful lesions, five had substantial improvement—essentially complete reso-lution of pain,” Cope said. “That’s very encouraging.” Most patients undergoing SBRT expe-rienced grade 1 or 2 acute toxicity, said Cope, “basically fatigue and pain flare.” But there was no grade 3 or grade 4 tox-icity associated with SBRT. “When we looked at toxicities, SBRT was tolerated very well, which is also encouraging,” he said. According to Cope, local coverage with SBRT was “excellent,” ranging from 88.5 to 100 percent depending on the site,

and there were no local recurrences in follow-up imaging. Five of the sites had a complete response, six of the sites a par-tial response, and one site didn’t receive follow-up imaging. “Despite the excellent local control, all of the patients went on to develop distant metastases,” Cope said, with a median progression-free survival of 87 days and a median overall survival of 9.7 months from the time of SBRT administration. “Using SBRT is a rational approach,” Cope continued. “It is a good option that should be considered, especially for pain-ful metastases. These seem to respond very

well and SBRT is well tolerated. If it’s being used as an attempt to control the dis-ease, then you need to think long and hard about the patient’s overall prognosis.” Cope concluded that more research is needed to compare SBRT with other therapies such as standard external beam therapy for soft tissue metastases. “A randomized control trial would be ideal, but it would be something that would be [difficult] considering how rare these metastases are,” he said, adding that such a trial would probably have to be multi-centered.Reed Cope

Attendees stopping by the Academy of Radiology Research (ARR) booth this week are doing their part to help preserve the future of National Insti-tutes of Health (NIH) research, which suffered government sequestration cuts in 2013. Visitors are invited to use a laptop, iPad or their own mobile device to email members of Congress in support of NIH imaging research from the ARR booth located in the Grand Concourse, Level Three (near Starbucks). Attendees can also contact Congress via the Academy’s grassroots advocacy website, action.imagingcoalition.org.

Visit ARR Booth to Preserve NIH Research

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Nuance RSNA 2013 Bulletin Ad -Blue Colorway PRINT.pdf 1 10/28/13 5:25 PM