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Welcome to my 36th (!) RSNA |
I always enjoy RSNA, it is good to catch up with old and new
friends, see what is new in our world of radiology, and last but not least
enjoy a piece of deep-dish pizza or a Wiener Schnitzel and Apfelstrudel at the
Christmas market.
Here are my observations:
1. RSNA this year was all about AI. Several major vendors were exhibiting AI driven workflows and new clinical applications for this new phenomenon. In addition, if you were able to make it to the basement of McCormick place, you would find a dedicated hall just for the AI vendors. However, the size of this so-called AI Showcase was in inverse proportion to the amount of traffic, maturity of the products, and number of real-world implementations.
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The AI "basement" |
There is no question in my mind that AI is still very new
and, except for some niche clinical applications, still has a long way to go
before large-scale deployment is going to happen. I asked several vendors how
many installs they had and the answer ranges from a couple to maybe a few
hundred, which compared with the number of hospitals worldwide is a drop in the
bucket. In addition, there was relatively little traffic in the dedicated AI hall,
much less than at the other two main exhibit floors, so AI did not appear to be
top of mind for most attendees.
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AI at its best: integrated with a PACS viewer |
There is no question that AI in the long term will become
ingrained in the daily workflow and add significant value and increase
specificity and sensitivity to the diagnosis by supporting the diagnostic
process, however, it might be a couple of years before we’ll see an impact,
especially in the day-to-day work of radiologists who work outside the major
academic centers, where most of the initial implementations are being tested
and deployed.
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This is how it should look: Path on left and Xray on right |
2. Digital pathology is taking off in the US. Several western
and northern European countries are at least 5 years ahead of the US as they
started implementing digital pathology 5+ years ago. FDA approvals held up
deployment in the US, but recent clearances are allowing its implementation.
There is also an issue with return on investment, which is negative, as you
cannot get rid of the slides containing the specimens. There are actually extra
costs as now you’ll need to get slide scanners, view stations and an image
display and management infrastructure. The good news is that the lag in implementation allows the
US to learn from early experiences and become leading edge instead of bleeding
edge.
Why is pathology important for radiology? The reason is that pathology
images and reports provide a valuable additional datapoint for the radiologist.
Initially, physicians would only look at shared pathology images during tumor
board discussions, but there are other applications such as for screening
immigrants who typically get an x-ray and possibly lab test to look for
infectious diseases.
Another major impact of the implementation of digital
pathology will be on image and archive management. It is very likely that these
images will be stored on the radiology PACS archive and almost certainly on the
enterprise archive or VNA, assuming that the facility has one. Most departments
are still trying to manage the onslaught of the additional data from 3-D breast
images (DBT) filling up the available data storage at least, if not more than twice as fast. Wait until you
get whole-slide scanned images from pathology, that are multiple gigabytes in
size.
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POCUS from GE, innovative 2-sided probe |
3. POC (Point of Care) ultrasound is continuing to make
inroads. Stanford recently put a POC-US in the hands of every resident and faculty physician, see link.
The top three players in this market is Philips with the Lumify, which seems to
have the most comprehensive set of features especially OB/GYN measurements and
templates, the GE unit, and the Butterfly. Butterfly is somewhat of an outlier as it
has a subscription model for its usage and uploads images in their cloud.
Pricing is between $6k and 2k for these units. A major challenge with these
devices is how to archive any of the images that the physician wants to keep as
they have to be properly identified with metadata to make sure they end up in
the correct patient folder.
4. In addition to POC-US, there is POC-DX, POC-CT and
POC-MR. The POC-DX, also known as the x-ray portables, have been around for a
long time, they are mainly used in the OR, ER and ICU’s to provide bedside
diagnostic x-ray.
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Cute portable for kids |
Fuji showed a flexible sensor detector which brought the weight of the
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Most innovative product IMHO: flex detector |
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Looks like a CT, moves like a portable |
POC-CT has grown up as well. These CT scanners have evolved
from a “CT on wheels” to truly portable units and can be moved around as easily
as portable x-ray units. These have built-in radiation screening as part of the
gantry and a lead flap in the front and back to screen any additional
radiation.
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POC MRI, my second most innovative product choice |
The POC-MR was a newbie at the show. It is still subject to
regulatory approval which can be expected later this year. Its application is
somewhat limited due to its low field strength (.064T), but the advantage of
the low magnetic field is that there are no issues with shielding, as a matter
of fact, they were scanning in real-time in the booth. The images are very
noisy but new advanced image processing and AI can improve the image quality up
to a point that they are usable for the application needed.
5. Photographs can assist in diagnosis. Photographs can
provide important contextual information and can be taken by providers as well
as patients using a camera or smartphone. There are clinical and technical
challenges to recording and managing these pictures. The clinical challenges
include privacy and how to deal with sensitive photos, including the definition
of what constitutes a sensitive photo. Technical challenges include security as
well as how to capture the appropriate metadata such as patient information and
body part.
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Good example showing photo and image |
There are two working groups established that are supported
jointly by HIMSS and SIIM to address these issues, the Photo Documentation
Workgroup dealing with the clinical and technical issues and the Data Standards
Evaluation Workgroup dealing with analyzing the existing standards for nomenclature
related to body part and anatomic region. White papers can be expected from
these workgroups in the near future.
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Still need huge glasses but effect is amazing |
6. Virtual Reality (VR) is moving to Augmented Reality (AR).
VR has been somewhat of a niche application, mostly used by surgeons to prepare
for surgery as it can show true 3-D models of the organs using CT or MR source
data. VR has always been a little bit disjunctive from the real patient as
there has been no real direct connection between the actual subject and the
images that are shown in a 3-D space. AR is changing that
as there is a direct connection between the patient and the image created by
the 3D. For example, a surgeon can look at the patient through his special AR
glasses and see the synthetic image super-imposed on the body part of interest.
Again, VR and AR are somewhat of a niche application but it is quite
fascinating and really cool to be able to have “x-ray vision” and look inside a
body and see its organs from different angles and perspectives, which should be
of great help to surgeons. A great example of how radiology supports other
specialties.
7. Monitor management for home reading is a challenge.
Imagine that you want to read from home, and for your worklist and reporting
you use a laptop computer. One would typically have two medical grade monitors,
but that could be three or four as well. The good news is that most
radiologists are starting to learn that using a medical grade monitor is a
requirement for reading anything CR/DR and certainly mammography.
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Monitor management black box |
This means that the monitors are calibrated to show each
individual pixel value into a greyscale value that an observer can distinguish
so as not to miss any subtle changes in pathology, and they are typically
managed remotely including the possibility of keeping those calibration curves
in case the quality of the monitor display was challenged in a potential
malpractice lawsuit (which is not uncommon).
However, when trying to connect those multiple monitors
using a standard windows PC, the hanging protocols, i.e. where the images are
displayed is challenging and it might vary upon rebooting the PC. Therefore,
one might use one of those small “black boxes,” which has a video board inside
and a controller that can remotely connect to the calibration management
software. It manages the display order so that it is consistent any time a
radiologist connects his or her laptop again.
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MRI with built-in recliner |
8. New open MRI’s are being introduced. There have been open
MRI’s for a long time, the advantage is accessibility to the patient which is
especially important when doing surgery. Other reasons for doing an exam in an
open MRI might be for patients who are claustrophobic. Lastly, if a patient has
a condition that only shows up when he or she is standing or sitting, i.e. if
there is a need to show the load-bearing there is now a unit that allows the
patient to keep on sitting. Another example of how some of the common devices
are being created for niche applications.
9. 3-D printing is maturing. The novelty of 3-D printing is
somewhat over compared with last year’s RSNA, but there was still quite a bit
of interest,
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Amazing detail |
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Looking for volunteers! |
10. In case you missed the friendly ladies at the RAD-Aid
booth, you can website
and sign up as a volunteer. I have been very fortunate to have first-hand
experience with the impact that you can make by teaching in developing
countries and supporting your peers in your area of expertise. Remember, you
don’t have to be a radiologist teaching interpretation or IR, but there is also
a major need for people teaching basic x-ray as well as CT, MR, US, and even
how to procure and maintain systems, how to manage a department, and how to
troubleshoot image quality and technical problems.
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Excellent Tech support built in |
The good news is that some of the vendors are incorporating
features in their products that kind of “guide” a technologist through a
procedure. A good example is the Carestream CR console that shows how to expose
an extremity and make sure to use collimation, something that is obvious to
anyone taking an x-ray in the developed world, but is often overlooked in these
emerging markets. I can promise you that volunteering can not only make a major
difference in the lives of the ones you touch and interact with, but you’ll
become a different person.
In conclusion, this was another great year, there were some
great talks, my favorite was “AI in
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Cabs and Ubers lining up for drop-off |
However, regarding the state of AI, I have never seen so many vendors without FDA clearance promoting solutions based on limited datasets from only a subset of the populations, for example how valid is an AI algorithm based on a clinical study in China to a population in a downtown US city where the majority is African-American?
I am curious to see the progress made by the same time next year, if I missed you this time, I hope to see you next year!