CTPA Predicts PE Mortality

According to a study published in the March 2004 issue of Radiology, a newly developed clot-volume ranking index may help predict the mortality of patients with pulmonary emboli (PE). Researchers quantified the clot size with CT pulmonary angiography (CTPA) and a standardized index, called the CTPE index, and successfully predicted patient outcome.

For the study, multi-detector row CT was performed in 59 hospitalized patients (22-89 years old). Two radiologists, who were blinded to patient outcome, identified PE retrospectively. A pulmonary arterial obstruction index was derived for each set of images on the basis of embolus size and location. Researchers used logistic regression to compare PE indexes with patient outcomesurvival or death. They found that patients with a clot burden of 60% or greater, as determined by the CTPE index, are at increased risk of death and may require aggressive treatment such as catheter-directed thrombolysis or thrombolytic therapy in intensive care.

Overall, the results showed that quantifying the PE index with CTPA is a notable predictor of patient outcome.

As CTPA continues to prove successful in tests and begins to replace conventional pulmonary angiography as a first-line examination for detecting PE, traditional hospital practice procedures of dealing with a patient suffering from PE will be impacted.

“The radiology community is in a paradigm shift in the diagnosis of PE,” said John A. Pezzullo, MD, study coauthor and assistant professor of radiology at Brown University in Providence, RI. “Traditionally, if PE was clinically suspected, the patient would have a nuclear medicine V/Q scan. For most patients, however, the existence of PE was indeterminate and a conventional pulmonary angiogram was necessary. With the development of multi-detector CT scanners, it has now become possible to visualize the pulmonary vasculature at the segmental and subsegmental levels, and directly visualize clot with the pulmonary arteries. CTPA studies are now reported as either positive or negative with a high degree of certainty. CTPA studies are currently and will continue to replace the more traditional methods of diagnosing PE.”

SCAR to Highlight Open-Source Solutions

Approximately 3,000 are expected to attend the 2004 Society for Computer Applications in Radiology meeting, which will be held May 20-23, 2004, in Vancouver, Canada. This year’s theme, Opening New Frontiers, represents the growing interest throughout the industry in using open-source softwarea new technical frontierand honors the anniversary of the Lewis and Clark expedition.

Leo F. Black, MD, CEO of the Mayo Clinic Jacksonville (ret), will deliver the keynote address on implementing paperless and filmless medical records systems for improved clinical care and cost savings. Adding to the scientific content of the meeting, this year’s event will feature the new Hot Topics session, where scientists will present their research for peer review.


According to the report “Financing the Future,” published by the Healthcare Financial Management Association and GE Healthcare Financial Services, Milwaukee, CFOs of 460 hospitals and health systems in the United States predict double-digit increases in capital spending.

Digital radiology systems, computerized physician order entry systems, and information technology systems were the top three capital projects hospitals expect to fund in the next 5 years. Population growthwithin states such as Idaho, Georgia, Florida, California, Tennessee, Alaska, Texas, Rhode Island, Arkansas, Arizona, Utah, and Delawareand expansion in outpatient and inpatient services are cited as reasons for the projected increase in capital spending.

Letter To Editor

Parallax Graph Misleads

I am writing regarding an article published in the December 2003 issue of Axis Imaging News, “A Parallax View of Diagnostic Imaging.” The article itself is interesting, as are many printed by your magazine. However, I am troubled by the graph (Figure 6) on page 60. This graph shows the change in radiologist reimbursement as a percentage of imaging expenditures over a 5-year period. The graph is misleading in that the relative heights of the columns are not in proportion to the listed numbers. If you measure the distance between 57% and 55% and add to it the difference between 57% and 56% (a difference of 3%), then compare it to the difference between the 55% and 52%  bars, you will find that the graphed difference is roughly twice what it should be if the bar heights were appropriately proportioned. What I find disturbing is that this is not possible to do if one is using a graphing program or spreadsheet; it has to be purposefully done. Manipulating the appearance of quantitative data to make a point should not be tolerated. If the data are unconvincing (as they appear when graphed appropriately), then perhaps they should be left out or the meaning left up to the reader; but not manipulated for dramatic effect.

Brian D. Coley, MD
Assistant Chief, Department of Radiology
Columbus Children’s Hospital
Clinical Associate Professor of Radiology and Pediatrics
The Ohio State University School of Medicine

Presented at ISET

International Symposium on Endovascular Therapy (ISET), in Miami, January 25-29.

Stent Prevents Reclogging. Michael J.B. Kutryk, MD, PhD, assistant professor of medicine at the University of Toronto, and staff cardiologist and clinical scientist at St Michael’s Hospital, discussed his research on the antibody-coated stent, which is used to open blocked blood vessels and then stimulates the body’s repair system to heal itself, thereby preventing reclogging and blood clots.

Kutryk says that the stent captures naturally occurring endothelial progenitor cells (EPCs) that are made in the bone marrow, circulate through the bloodstream, and help with the repair of damage to the blood vessel lining and in the generation of new vessels. The EPCs attach to the stent’s inside to form a smooth tissue layer, resulting in the promotion of healing and the prevention of restenosis and the formation of blood clots at the stented site. Kutryk’s animal research showed that after an hour more than 90% of the surface of the implanted antibody-coated stents were covered with EPCs. Implanted noncoated stents had less than 1.5% coverage by EPCs an hour after implant

Clot Filter. Also presented at the conference were results of a study by Bob Smouse, MD, clinical assistant professor of radiology and surgery at the University of Illinois, Peoria, that looked at the use of a small removable filter to prevent potential blood clots. Smouse conducted a study of 122 patients who were implanted with retrievable vena cava filters;  58 of those had the filters implanted as a prophylaxis after trauma, 45 for deep vein thrombosis, 16 for pulmonary embolism, 15 as a preventative measure before surgery, and 1 as a preventative measure during treatment to dissolve a blood clot. Filter removal was attempted in 51 patients, and was shown to be successful in 47 (92%). Filters were left in from 4 to 56 days, while those left in longer than 2 weeks were repositioned every 14 days.

In 71 patients (58%), the filter was left in permanently due to other severe medical conditions. One patient died due to original injuries, while several of the filters caught large blood clots from the leg, preventing them from traveling to the lungs.

To place the device, a physician typically makes a small incision in the groin, through which a catheter is placed. Encased in a sheath, the device is then advanced through the catheter to an abdominal vein. The sheath is then removed, while the device opens up and lodges in the vein. At the time of filter removal, the physician again inserts a catheter, snares a hook on the top of the filter, pulls it into the sheath, and removes it from the body. The device in the study recently received FDA clearance.

B. Van Houten

Presented at RNSA

The 89th scientific assembly and annual meeting of the Radiological Society of North America, November 30December 5, 2003

Can We Talk? The need for communication was the message of outgoing RSNA president Peggy Fritzsche, MD, during the presidential address at the 2003 meeting. In emphasizing the growing need for communications, Fritzsche quoted one of the masters, George Bernard Shaw: “The single biggest problem in communications is the illusion that it has taken place.” Fritzsche said she has seen the Internet and information technology replace daily rounds through radiology, and advised attendees to not be lured into thinking that technology is always the answer. “I’m convinced that technological advances must be tempered with equal advances in the ancient art of communication&we need to talk, meet, interact, have some more face time with each other. This will lead our profession forward to prosperity.” Fritzsche urged radiologists to improve communications with its four primary groups of communicants: colleagues and referrers, patients, medical students, and the general public.

Who Gets Paid What? Citing previously published statistics, Vijay Rao, MD, chair of radiology at Thomas Jefferson University Hospital, said growth in noninvasive diagnostic imaging (NDI) in relative value units (RVUs) performed by nonradiologists between 1993 and 1999 was 32.4%, while radiologist RVUs grew only 6.9%. In one of a series of papers mining Medicare Part B data (70000-90000 codes) from 1993 to 2001, Rao et al grouped 108 Medicare physician codes into nine provider groups and analyzed who got paid for NDI in 2001, and how much they received. In 2001, Medicare Part B  paid physicians $6,699,129,000 for noninvasive diagnostic imaging. Ten percent was paid to multispecialty groups, so the researchers based their calculations on the remaining $6 billion, and “a surprisingly large proportion of the payments go to other specialties,” Rao said. Radiologists received 55.4% of payments, while cardiologists received 25.2% of payments. Radiologists retained the greatest share of payments for studies performed in the hospital setting, with 74.2% of hospital inpatient payments and 86.6% of hospital outpatient payments. For office-based imaging, however, radiologists received only 41.3% of total payments; cardiologists took 32%; and the remainder went to other specialties. Specialties that took a significant share included primary care physicians, with 8.3%; surgeons with 7%; and internal medicine subspecialists other than cardiologists, 1%. In conclusion, Rao asked: “Is there an incentive for self-referral in the nonradiologist population?”

MRI Protocol for MS: Update. David Li, MD, University of British Columbia, presented an updated MRI protocol developed by the Consortium of Multiple Sclerosis Centers (CMSC), to be used for the diagnosis and follow-up of patients with multiple sclerosis. “Performing studies using a standardized protocol allows for improved comparison between studies and detection of new interval lesions,” noted Li. Recommendations proposed include: studies be performed at 1 tesla or higher; the use of 3-mm-thick (5mm, if not possible) non-gapped slices; reproducible positioning using the subcallosal line as a reference on an appropriate sagittal localizer; minimum of three sequences (sagittal FLAIR, axial T2 and FLAIR) and where necessary, to identify disease dissemination in time, post gadolinium enhanced T1. The protocol also includes indications for follow-up (routine MRI follow-up is not recommended except under specified circumstances), the use of a common reporting language with a suggested format. Also recommended is that studies be archived and permanently available and if possible, copies be given to patients on digital media. A complete description of the protocol and reporting template is available at the CMSC Web site: http://www.mscare.org/pdf/MRIProtocol2003.pdf .

Putting the House in Order. In her address to the annual gathering of the National Coalition for Quality in Diagnostic Imaging Services (NCQDIS), association counsel Diane Millman, JD, advised attendees that payors are taking a close look at imaging costs. “I think it is very important for us to realize that when people see utilization increase, there is an inclination to believe that the increase is at least partially unnecessary,” Millman advised. A health care attorney with Washington, DC-based Powers, Pyles, Sutter & Verville, Millman said one of her greatest concerns for imaging is competitive bidding. NCQDIS met with staff of the Congressional advisory group Medicare Payment Advisory Commission (MedPAC) last year, and “we did convince MedPAC not to make any recommendations to curb imaging,” she reported; however, she believes the issue of escalating imaging costs will have to be addressed “head on.” “We are going to have to look affirmatively at making sure our house is in order.” Questions to address, Millman said, include: what is increasing fastest and what the diagnoses are; who is ordering and who is performing; and whether payment should be tied to accreditation or quality.  Since that time, MedPac has held an open meeting on escalating diagnostic imaging costs to learn how the private sector is addressing the issue.

The organization has also retained the independent survey organization of Basilece & Associates to conduct a survey of the technical costs of performing imaging in the freestanding setting, in response to a call from the Centers for Medicare and Medicaid. NCQDIS President and HealthHelp CEO Cherrill Farnsworth urged participants to accurately and completely fill out the surveys that the organization mailed to the operators of freestanding imaging centers last month. For membership information, call (202) 872-6767.

Industry News

IBM announced a major $250 million initiative that will fund information-based medicine collaborations with Duke University Health System and Moffitt Cancer Center & Research Institute, as well as reorganize and expand the company’s suite of health care services to include a clinical transformation consulting practice and an information-based medicine business unit. Additional projects include the formation of the IBM Center for Healthcare Management and the creation of the IBM Research Healthcare and Life Sciences Institute…Frost & Sullivan, Palo Alto, Calif, awarded Philips Medical Systems, Bothell, Wash, the Medical Imaging Technology of the Year award for the Live 3D Echo ultrasound technology, and the Medical Imaging Company of the Year award. Recently, Philips Medical Systems expanded its collaboration with RaySearch, the radiation therapy software developer, to create systems for inverse treatment planning in intensity-modulated radiation therapy. According to the new agreement, Philips and RaySearch will focus on developing new systems that allow for the active management of a patient’s course of treatment&Siemens Medical Solutions, Malvern, Pa, has built a strategic partnership with Anceta LLC, Alexandria, Va, a subsidiary of the American Medical Group Association (AMGA). According to the partnership agreement, Siemens will supply information technology infrastructure and support services for the AMGA/Anceta Collaborative Data Warehouse, which stores comprehensive patient data for the hundreds of AMGA-member medical groups&Medrad Inc, Indianola, Pa, received the 2003 Malcolm Baldrige Quality Award, the nation’s top honor for companies that exhibit performance excellence and quality achievement. The award was presented  to Medrad’s CEO and President John Friel by President George Bush…HealthHelp, Houston, has earned health utilization management accreditation for 2004 by the American Accreditation Health Care Commission (URAC)&Lodox Systems North America LLC, South Lyon, Mich, a wholly owned subsidiary of Lodox Systems (Pty) Ltd, Benmore, South Africa, received the 2004 Frost & Sullivan Product Innovation Award for its Statscan system. The award recognizes Lodox Systems for its technology innovations that have enabled full-body digital radiography of critical care patients…The Food and Drug Administration (FDA) granted 510(k) clearance to Varian Medical Systems Inc, Palo Alto, Calif, for its On-Board Imager”, an accessory on Varian’s Clinac® and Trilogy” linear accelerators. Designed to improve the precision and effectiveness of cancer treatments, On-Board helps physicians target and track tumors accurately&Answering the demand from the global nuclear medicine community for isotopes used in targeted radiotherapy research for the development of new cancer therapies, MDS Nordion, Ottawa, announced the commercial availability of rhenium-186 (Re-186) and high specific activity lutetium-177 (Lu-177). Both Lu-177 and Re-186 emit gamma radiation that allows diagnostic imaging of tissue. Lu-177 is a low-energy beta emitter, which provides a tissue-penetration range that may prove efficacious in smaller tumors; Re-186 is currently used for palliation of pain from cancerous metas-tases in bones&The American Registry of Radiologic Technologists, St Paul, Minn, earned accreditation for its radiography and sonography certification programs by the National Commission for Certifying Agencies, the accredit-ing body of the National Organization for Competency Assurance&Swissray International, Elizabeth, NJ, has received the Frost & Sullivan 2004 Best Product Value award for its ddRModulaire&The Centers for Medicare & Medicaid Services (CMS) launched a new Web resource for mammography services at www.cms.hhsgov/suppliers/mammography/ . The Web page contains new information on mammography services, links to coding, the CMS online manual, and regulation information&Boston Scientific Corp received approval by the FDA to sell its drug-coated Taxus stent. Taxus is coated with drugs that prevent arteries from closing again. The company plans to launch Taxus in the United States immediately. Taxus will compete directly with Johnson & Johnson’s Cypher stent.

CT pulmonary angiography predicts PE mortality