CME Radiology Grand Rounds

The National Oncologic PET Registry (NOPR) was created in response to the Center for Medicare Services Coverage with Evidence development criteria. NOPR evolved into an evaluation of two complimentary registries -- FDG-PET for uncommon solid tumors and NaF-PET for bone metastases. This lecture will review the NOPR findings and the subsequent CMS coverage decisions.

The ability to measure biochemical and molecular processes to guide breast cancer treatment represents a significant advance in individualized breast cancer treatment. These assays have traditionally been performed by analysis of cell culture or tissue samples.  More recently, functional and molecular imaging allows in vivo assay of biochemistry and molecular biology that is highly complementary to tissue-based assay.  Molecular imaging can help inform drug trial of targeted breast cancer treatment and clinical decision making by (1) measuring regional expression of the therapeutic target, (2) testing the ability of drugs to interact with their intended targets, and (3) by  measuring cancer response early in the course of treatment.  This talk will review basic principals of molecular imaging in breast cancer, with an emphasis on those methods that have been tested in patients. The talk will review the current state of molecular imaging in breast cancer patients, including methods in routine clinical use, those undergoing advanced clinical trials, and those in early-phase testing.  Current trials and future directions will be highlighted.

Substantial concern about inappropriate use of imaging has led to recent federal regulations mandating the use of Clinical Decision Support (CDS) to improve quality of care and reduce waste. Using a case example, I will review the impact of large-scale CDS-enabled performance improvement initiatives on adoption of evidence into practice and describe features of effective imaging CDS programs in the context of new federal regulations.

As the global population ages, we have increasingly recognized the prevalence and public health implications of Alzheimer’s disease, a progressive degenerative disease of the mind for which there is no cure. Since the time of Alois Alzheimer’s seminal discovery over 100 years ago, our understanding of the genetic, molecular and physiologic underpinnings of the disease has markedly improved. This improved understanding is likely to lead to new therapies aimed at slowing or stopping the disease’s unrelenting progression. There have been numerous failures thus far, and will likely be future roadblocks in the development of a true disease-modifying therapy. Imaging may hold the key to improving our understanding of the disease and ultimately finding a cure.

MR in clinical practice is presently almost entirely a qualitative endeavor. Images “weighted” by different contrast mechanisms are collected and interpreted by the radiologist, who attempts to piece together what various tissues must be like, based on relative differences in appearances on these images. Traditionally, the physical properties underlying these contrast mechanisms are not measured, because measuring these properties is often slow, inefficient, or inaccurate. Thus image interpretation is difficult, and very difficult to standardize. However, there is a strong radiological and also physical rationale for changing the status quo. There is a case for the argument that with the imaging technologies available today, it should be possible to break out of these barriers, and start building a quantitative underlay to MRI that could be clinically practical and enable quantitative tissue characterization. This talk will focus on measurements utilizing two technologies under development at Case Western Reserve University, through-time non-Cartesian GRAPPA and MR Fingerprinting.

The structures of the knee continually change to reflect the biomechanical needs of growing children. Development of the cartilaginous, ligamentous, and osseous structures through skeletal maturation is reflected in the MR imaging appearance. These anatomic changes result in injuries that are unique to various stages of development. Recognition of the normal MR imaging appearance of the pediatric knee throughout growth will help to differentiate the expected from the abnormal. 

Functional magnetic resonance imaging (fMRI) based on measurement of blood oxygenation level dependent (BOLD) signal changes has had an enormous impact on basic studies of the human brain. However, the interpretation of BOLD studies, particularly in clinical populations, is challenging due to the physiological complexity of the BOLD signal. Quantitative fMRI methods measuring cerebral blood flow and oxygen metabolism have the potential to provide a deeper window on brain function in health and disease. The potential of these methods will be discussed in the context of current ideas about the physiological connections between brain blood flow and metabolism, and how flow and metabolism may be driven differently by excitatory and inhibitory neural activity.

Virginia Mason Medical Center was one of the first healthcare organizations to adapt the Toyota Production System of management. The Lean Management methodology has been in effect since 2002 at the organization and within the Department of Radiology. This is the story of our journey of continuous improvement and some of the applications we’ve seen to Radiology. Adapting the core concepts of Lean management to daily practice and reviewing some of our operational results employing this methodology, will be reviewed.

Stanford Children’s Health efforts in applied clinical informatics resulted in national attention in 2010 with the publication of the first-ever correlation between implementation of computerized physician order entry (CPOE) and a decrease in hospital-wide mortality. This landmark was followed with a 2011 NEJM article describing the first documented use of aggregate EMR data to make a real-time patient care decision. In this talk, Dr. Christopher Longhurst will share the "story behind the story" of these accomplishments, and outline how the EMR and clinical analytics supports the IOM vision for a learning healthcare system. Dr. Longhurst will also share some real-world examples of the value realized by bringing big data to the bedside in both clinical research and commercial startups.

Clinical trials provide a critical base of evidence for evaluating marketed products, but evidence generation remains challenged with the current practice which has proven to be too slow, unreliable and expensive as conducted in the past.  Limitations in the organization of research and access to data can be overcome by integrating research with practice. This lecture will review new initiatives for evidence generation to support innovation, growth, and clinical decision making.