In this December issue.

Time to Make a Call? The Ethics of Mandatory Reporting

SAT0364 DATA TO BE COLLECTED FOR AN OPTIMAL MANAGEMENT OF AXIAL SPONDYLOARTHRITIS IN DAILY PRACTICE: PROPOSAL FROM AN EVIDENCE BASED AND CONSENSUAL APPROACHES

Background: Artificial intelligence (AI) has recently made unprecedented contributions in every walk of life, but it has not been able to work its way into diagnostic medicine and standard clinical practice yet. Although data scientists, researchers, and medical experts have been working in the direction of designing and developing computer aided diagnosis (CAD) tools to serve as assistants to doctors, their large-scale adoption and integration into the healthcare system still seems far-fetched. Diagnostic radiology is no exception. Imagining techniques like magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) scans have been widely and very effectively employed by radiologists and neurologists for the differential diagnoses of neurological disorders for decades, yet no AI-powered systems to analyze such scans have been incorporated into the standard operating procedures of healthcare systems. Why? It is absolutely understandable that in diagnostic medicine, precious human lives are on the line, and hence there is no room even for the tiniest of mistakes. Nevertheless, with the advent of explainable artificial intelligence (XAI), the old-school black boxes of deep learning (DL) systems have been unraveled. Would XAI be the turning point for medical experts to finally embrace AI in diagnostic radiology? This review is a humble endeavor to find the answers to these questions. Methods: In this review, we present the journey and contributions of AI in developing systems to recognize, preprocess, and analyze brain MRI scans for differential diagnoses of various neurological disorders, with special emphasis on CAD systems embedded with explainability. A comprehensive review of the literature from 2017 to 2024 was conducted using host databases. We also present medical domain experts' opinions and summarize the challenges up ahead that need to be addressed in order to fully exploit the tremendous potential of XAI in its application to medical diagnostics and serve humanity. Results: Forty-seven studies were summarized and tabulated with information about the XAI technology and datasets employed, along with performance accuracies. The strengths and weaknesses of the studies have also been discussed. In addition, the opinions of seven medical experts from around the world have been presented to guide engineers and data scientists in developing such CAD tools. Conclusions: Current CAD research was observed to be focused on the enhancement of the performance accuracies of the DL regimens, with less attention being paid to the authenticity and usefulness of explanations. A shortage of ground truth data for explainability was also observed. Visual explanation methods were found to dominate; however, they might not be enough, and more thorough and human professor-like explanations would be required to build the trust of healthcare professionals. Special attention to these factors along with the legal, ethical, safety, and security issues can bridge the current gap between XAI and routine clinical practice.

A number of benign and malignant diseases with different causes, clinical features, management, and outcome can manifest as painful penile induration. The most common such conditions are active Peyronie disease, inflammation, trauma, venous or corporal thrombosis, acute ischemic disorders, and primary or secondary tumors. In patients with painful penile induration, a preliminary differential diagnosis is based on the patient's history and results of laboratory studies, penile inspection, and palpation. Imaging is often required to confirm the clinical diagnosis, assess the extent of disease, and determine patient treatment. A basic clinical investigation comprising penile inspection and palpation should be performed by the radiologist before imaging; such an evaluation is a great help in selecting the best imaging modality and examination technique. Moreover, acquisition of preliminary clinical information eases interpretation of the imaging features and facilitates identification of clinically relevant information that may result in a change in patient treatment. In standard clinical practice, color Doppler ultrasonography is often the first imaging modality used to evaluate patients with painful penile induration. This technique clearly demonstrates normal penile anatomy and its corresponding changes in most of the clinically relevant situations. Magnetic resonance imaging is the optimal imaging modality for tumor staging. Other imaging modalities are required less frequently.

Objectives:To survey the diagnostic radiography workforce in the United Kingdom (UK) at an organisational level to ascertain the scope of advanced practice and compliance with Health Education England standards for multiprofessional advanced clinical practice (ACP).Methods:174 diagnostic imaging departments were invited to participate in a cross-sectional electronic survey focused upon advanced level practice and their educational and accreditation expectations (October–December 2019). Breast imaging, computed tomography, fluoroscopy, interventional radiology, lithotripsy, magnetic resonance imaging and projectional radiography were included.Results:A total of 97 responses were received, of which 79 were eligible for inclusion (45%). Respondents reported advanced-level practice roles across all imaging modalities, which included clinical reporting, procedural-based and combined roles. Radiograph and mammogram reporting were most prevalent (95 and 67% of Trusts), with fluoroscopy the most frequent procedure-only role (25%). Only 39% of trusts required adherence to the four pillars of ACP within job descriptions, and only 12% requiring a full Masters qualification.Conclusions:Diagnostic radiographer reporting and procedure-based roles in the NHS are varied and widespread. However, inconsistencies in fulfilment against the expected standards for advanced practice exist. Realignment of advanced-level roles to delineate enhanced and advanced clinical practice may ensure consistency between roles and professions. A requirement for accreditation as an advanced (clinical) practitioner with adherence to advanced practice requirements could therefore provide value to accreditation for both individual practitioners and Trusts.Advances in knowledge:Within the UK, diagnostic radiographer roles previously self-identified as advanced-level practice may be termed enhanced practice when not adhering to expected ACP standards.

Cancers of unknown primary site: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

THIS MONTH IN ANESTHESIOLOGY

Texture analysis (TA) has proved to be useful to distinguish different tissues and disease states using magnetic resonance imaging (MRI). TA has been successfully applied clinically to improve identification of abnormalities in the brain, liver, and bone and, more recently, has been used to enhance the specificity of breast MRI. This preclinical study used a custom-made phantom containing different grades of reticulated foam embedded in agarose gel to assess the capability of TA to distinguish between different texture objects, under different imaging conditions. The aim was to assess whether TA could be used reliably with clinical protocols that were not optimized for texture analysis and also to investigate the effect that changing imaging sequence parameters would have on the outcome of TA. Clinical fast gradient echo sequences and two different breast RF coils were used in order to reflect standard clinical practice. Three protocols were used: (1) a high spatial resolution protocol run on a 1.5 Tesla (T) MRI scanner, (2) a parameter matched sequence run on a 3.0 T magnet, and (3) a high temporal resolution protocol also run on a 3.0 T magnet.For each protocol, three sequence parameters (repetition time, bandwidth/echo time, and flip angle) were altered from the baseline values to assess the impact of changes in acquisition parameters on the outcome of TA. TA was performed using MAZDA software and clearly differentiated four foam phantoms when using the wavelet transform method (WAV), also moderately so with the co-occurrence matrix method (COM). The outcome was generally improved for imaging protocols acquired on the 3.0 T scanner, particularly for the high spatial resolution protocol where changes to the acquisition parameters influenced the TA, especially changes to the bandwidth/echo time. For the other protocols, TA outcome was less affected by changes to the imaging parameters. This phantom study shows that acquisition parameters and protocols that are typically used for clinical breast imaging can result in good TA. Our findings suggest that changes to sequence parameters may not greatly influence the outcome of texture analysis, but rather that spatial resolution may be the most important factor to consider.

SummaryVirtual bronchoscopy is evolving rapidly, and is becoming accepted into standard clinical practice. Virtual bronchoscopy is a term, which encompasses not only multi‐row detector X‐ray computerized tomography‐derived images, but also other computer graphics and computer vision‐derived value‐added digital imagery. Other imaging data sources used to create three‐dimensional image renderings of the bronchial tree include magnetic resonance imaging, positron emission tomography, the digital colour image taken at real bronchoscopy as part of macro‐optical imaging, and various emerging micro‐optical imaging modalities, such as catheter‐based confocal microscopy and optical coherence tomography. Software solutions now exist for providing simple renderings of the bronchial tree through which a fly‐through of the airway lumen along the centreline of the airway can be added (the fly‐through mimics the view that a real flexible bronchoscope affords the operator). The images so produced are visually accurate and with currently available software also analytically correct. More advanced virtual bronchoscopic applications, including image‐based pathfinding to mediastinal and peripheral lung structures, are also in development, and are finding their way into clinical studies. Exciting and synergistic data sets composed of image data from multiple image sources are also being constructed. One emerging issue is to enhance the understanding and reporting on these data sets, which are often complex, and which are full of useful as well as redundant information. The new discipline of eidomics will inform the non‐specialist end user, and act to predict important outcomes. These increasingly powerful tools will continue to advance the use of imaging in technology‐supported personalized medicine, to compliment the information from genomics.

Filtering the good from the bad: A focus on kidney development and disease to celebrate John Bertram's long‐standing career in anatomy and renal research

Embolic stroke of unknown source (ESUS) accounts for 1 in 6 ischemic strokes. Current guidelines do not recommend routine cardiac magnetic resonance (CMR) imaging in ESUS, and beyond the identification of cardioembolic sources, there are no data assessing new clinical findings from CMR in ESUS. This study aimed to assess the prevalence of new cardiac and noncardiac findings and to determine their impact on clinical care in patients with ESUS. In this prospective, multicenter, observational study, CMR imaging was performed within 3 months of ESUS. All scans were reported according to standard clinical practice. A new clinical finding was defined as one not previously identified through prior clinical evaluation. A clinically significant finding was defined as one resulting in further investigation, follow-up, or treatment. A change in patient care was defined as initiation of medical, interventional, surgical, or palliative care. From 102 patients recruited, 96 underwent CMR imaging. One or more new clinical findings were observed in 59 patients (61%). New findings were clinically significant in 48 (81%) of these patients. Of 40 patients with a new clinically significant cardiac finding, 21 (53%) experienced a change in care (medical therapy, n=15; interventional/surgical procedure, n=6). In 12 patients with a new clinically significant extracardiac finding, 6 (50%) experienced a change in care (medical therapy, n=4; palliative care, n=2). CMR imaging identifies new clinically significant cardiac and noncardiac findings in half of patients with recent ESUS. Advanced cardiovascular screening should be considered in patients with ESUS. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04555538.

Purpose of the ReviewMany novel cardiac magnetic resonance imaging (cMR) techniques have been developed for diagnosis, risk stratification, and monitoring of myocardial disease. The field is changing rapidly with advances in imaging technology. The purpose of this review is to give an update on next-generation cMR techniques with promising developments for clinical translation in the last two years, and to outline clinical applications.Recent FindingsThere has been increasing widespread clinical adoption of T1/T2 mapping into standard of care clinical practice. Development of auto segmentation has enabled clinical integration, with potential applications to minimize the use of contrast. Advances in diffusion tensor imaging, multiparametric mapping with cardiac MRI fingerprinting, automated quantitative perfusion mapping, metabolic imaging, elastography, and 4D flow are advancing the ability of cMR to provide further quantitative characterization to enable deep myocardial disease phenotyping. Together these advanced imaging features further augment the ability of cMR to contribute to novel disease characterization and may provide an important platform for personalized medicine.SummaryNext-generation cMR techniques provide unique quantitative imaging features that can enable the identification of imaging biomarkers that may further refine disease classification and risk prediction. However, widespread clinical application continues to be limited by ground truth validation, reproducibility of the techniques across vendor platforms, increased scan time, and lack of widespread availability of advanced cardiac MRI physicists and expert readers. However, these techniques show great promise in minimizing the need for invasive testing, may elucidate novel pathophysiology, and may provide the ability for more accurate diagnosis of myocardial disease.

Utilisation and Prognostic Value of Cardiac Magnetic Resonance Imaging in Myocarditis

Diagnostic performance of neuroimaging in suspected idiopathic intracranial hypertension

Long COVID guidelines need to reflect lived experience