Geoff Rubin

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• Hanneman, K., Playford, D., Dey, D., van Assen, M., Mastrodicasa, D., Cook, T. S., Gichoya, J. W., Williamson, E. E., Rubin, G. D., & , A. H. (2024). Value Creation Through Artificial Intelligence and Cardiovascular Imaging: A Scientific Statement From the American Heart Association. Circulation, 149(6), e296-e311.
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  Multiple applications for machine learning and artificial intelligence (AI) in cardiovascular imaging are being proposed and developed. However, the processes involved in implementing AI in cardiovascular imaging are highly diverse, varying by imaging modality, patient subtype, features to be extracted and analyzed, and clinical application. This article establishes a framework that defines value from an organizational perspective, followed by value chain analysis to identify the activities in which AI might produce the greatest incremental value creation. The various perspectives that should be considered are highlighted, including clinicians, imagers, hospitals, patients, and payers. Integrating the perspectives of all health care stakeholders is critical for creating value and ensuring the successful deployment of AI tools in a real-world setting. Different AI tools are summarized, along with the unique aspects of AI applications to various cardiac imaging modalities, including cardiac computed tomography, magnetic resonance imaging, and positron emission tomography. AI is applicable and has the potential to add value to cardiovascular imaging at every step along the patient journey, from selecting the more appropriate test to optimizing image acquisition and analysis, interpreting the results for classification and diagnosis, and predicting the risk for major adverse cardiac events.
• Cury, R. C., Abbara, S., Achenbach, S., Agatston, A., Berman, D. S., Budoff, M. J., Dill, K. E., Jacobs, J. E., Maroules, C. D., Rubin, G. D., Rybicki, F. J., Schoepf, U. J., Shaw, L. J., Stillman, A. E., White, C. S., Woodard, P. K., & Leipsic, J. A. (2022). CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. Journal of cardiovascular computed tomography, 10(4), 269-81.
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  The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.
• Cury, R. C., Blankstein, R., Leipsic, J., Abbara, S., Achenbach, S., Berman, D., Bittencourt, M., Budoff, M., Chinnaiyan, K., Choi, A. D., Ghoshhajra, B., Jacobs, J., Koweek, L., Lesser, J., Maroules, C., Rubin, G. D., Rybicki, F. J., Shaw, L. J., Williams, M. C., , Williamson, E., et al. (2022). CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System an expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America society of cardiovascular imaging (NASCI). Journal of cardiovascular computed tomography.
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  Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
• Cury, R. C., Leipsic, J., Abbara, S., Achenbach, S., Berman, D., Bittencourt, M., Budoff, M., Chinnaiyan, K., Choi, A. D., Ghoshhajra, B., Jacobs, J., Koweek, L., Lesser, J., Maroules, C., Rubin, G. D., Rybicki, F. J., Shaw, L. J., Williams, M. C., Williamson, E., , White, C. S., et al. (2022). CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). Radiology. Cardiothoracic imaging, 4(5), e220183.
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  Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care. Coronary Artery Disease, Coronary CTA, CAD-RADS, Reporting and Data System, Stenosis Severity, Report Standardization Terminology, Plaque Burden, Ischemia This article is published synchronously in , and . © 2022 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.
• Cury, R. C., Leipsic, J., Abbara, S., Achenbach, S., Berman, D., Bittencourt, M., Budoff, M., Chinnaiyan, K., Choi, A. D., Ghoshhajra, B., Jacobs, J., Koweek, L., Lesser, J., Maroules, C., Rubin, G. D., Rybicki, F. J., Shaw, L. J., Williams, M. C., Williamson, E., , White, C. S., et al. (2022). CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System.: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). Journal of the American College of Radiology : JACR, 19(11), 1185-1212.
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  Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
• Cury, R. C., Leipsic, J., Abbara, S., Achenbach, S., Berman, D., Bittencourt, M., Budoff, M., Chinnaiyan, K., Choi, A. D., Ghoshhajra, B., Jacobs, J., Koweek, L., Lesser, J., Maroules, C., Rubin, G. D., Rybicki, F. J., Shaw, L. J., Williams, M. C., Williamson, E., , White, C. S., et al. (2022). CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). JACC. Cardiovascular imaging, 15(11), 1974-2001.
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  Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
• D'Anniballe, V. M., Tushar, F. I., Faryna, K., Han, S., Mazurowski, M. A., Rubin, G. D., & Lo, J. Y. (2022). Multi-label annotation of text reports from computed tomography of the chest, abdomen, and pelvis using deep learning. BMC medical informatics and decision making, 22(1), 102.
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  There is progress to be made in building artificially intelligent systems to detect abnormalities that are not only accurate but can handle the true breadth of findings that radiologists encounter in body (chest, abdomen, and pelvis) computed tomography (CT). Currently, the major bottleneck for developing multi-disease classifiers is a lack of manually annotated data. The purpose of this work was to develop high throughput multi-label annotators for body CT reports that can be applied across a variety of abnormalities, organs, and disease states thereby mitigating the need for human annotation.
• Raman, R., Raman, B., Napel, S., & Rubin, G. D. (2022). Improved speed of bone removal in computed tomographic angiography using automated targeted morphological separation: method and evaluation in computed tomographic angiography of lower extremity occlusive disease. Journal of computer assisted tomography, 32(3), 485-91.
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  We developed an automated algorithm for bone removal in computed tomographic angiographic images that identifies and deletes connections between bone and vessels. Our automated algorithm is significantly faster than manual methods (2.45 minutes vs 73 minutes) and only generates about 2 small artifactual deletions per patient, mostly in the region of the ankle. Image quality was equivalent to manual methods. It shows promise as a tool for fast and accurate postprocessing of computed tomographic angiograms.
• Rubin, G. D., Cury, R. C., Leipsic, J., Abbara, S., Achenbach, S., Berman, D., Bittencourt, M., Budoff, M., Chinnaiyan, K., Choi, A. D., Ghoshhajra, B., Jacobs, J., Koweek, L., Lesser, J., Maroules, C., Rybicki, F. J., Shaw, L. J., Williams, M. C., Williamson, E., , White, C. S., et al. (2022). CAD-RADS™ 2.0 – 2022 Coronary Artery Disease – Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). Radiology: Cardiothoracic Imaging, 4(5). doi:10.1148/ryct.220183
• Rubin, G. D., Lo, J. Y., Mazurowski, M. A., Han, S., Faryna, K., Tushar, F. I., & D'Anniballe, V. M. (2022). Multi-label annotation of text reports from computed tomography of the chest, abdomen, and pelvis using deep learning. BMC Medical Informatics and Decision Making. doi:10.1186/s12911-022-01843-4
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  There is progress to be made in building artificially intelligent systems to detect abnormalities that are not only accurate but can handle the true breadth of findings that radiologists encounter in body (chest, abdomen, and pelvis) computed tomography (CT). Currently, the major bottleneck for developing multi-disease classifiers is a lack of manually annotated data. The purpose of this work was to develop high throughput multi-label annotators for body CT reports that can be applied across a variety of abnormalities, organs, and disease states thereby mitigating the need for human annotation.We used a dictionary approach to develop rule-based algorithms (RBA) for extraction of disease labels from radiology text reports. We targeted three organ systems (lungs/pleura, liver/gallbladder, kidneys/ureters) with four diseases per system based on their prevalence in our dataset. To expand the algorithms beyond pre-defined keywords, attention-guided recurrent neural networks (RNN) were trained using the RBA-extracted labels to classify reports as being positive for one or more diseases or normal for each organ system. Alternative effects on disease classification performance were evaluated using random initialization or pre-trained embedding as well as different sizes of training datasets. The RBA was tested on a subset of 2158 manually labeled reports and performance was reported as accuracy and F-score. The RNN was tested against a test set of 48,758 reports labeled by RBA and performance was reported as area under the receiver operating characteristic curve (AUC), with 95% CIs calculated using the DeLong method.Manual validation of the RBA confirmed 91-99% accuracy across the 15 different labels. Our models extracted disease labels from 261,229 radiology reports of 112,501 unique subjects. Pre-trained models outperformed random initialization across all diseases. As the training dataset size was reduced, performance was robust except for a few diseases with a relatively small number of cases. Pre-trained classification AUCs reached > 0.95 for all four disease outcomes and normality across all three organ systems.Our label-extracting pipeline was able to encompass a variety of cases and diseases in body CT reports by generalizing beyond strict rules with exceptional accuracy. The method described can be easily adapted to enable automated labeling of hospital-scale medical data sets for training image-based disease classifiers.
• Taylor, A. J., Cerqueira, M., Hodgson, J. M., Mark, D., Min, J., O'Gara, P., Rubin, G. D., , A. C., , S. o., , A. C., , A. H., , A. S., , A. S., , N. A., , S. f., & , S. f. (2022). ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Journal of cardiovascular computed tomography, 4(6), 407.e1-33.
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  The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance (CMR) appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria (1). The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease (CAD) was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography (CT) for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research.
• Tushar, F. I., D'Anniballe, V. M., Hou, R., Mazurowski, M. A., Fu, W., Samei, E., Rubin, G. D., & Lo, J. Y. (2022). Classification of Multiple Diseases on Body CT Scans Using Weakly Supervised Deep Learning. Radiology. Artificial intelligence, 4(1), e210026.
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  To design multidisease classifiers for body CT scans for three different organ systems using automatically extracted labels from radiology text reports.
• Won, J. H., Rubin, G. D., & Napel, S. (2022). Flattening the abdominal aortic tree for effective visualization. Conference proceedings : ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual Conference, 2006, 3345-8.
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  We developed a novel visualization method for providing an uncluttered view of the abdominal aorta and its branches. The method abstracts the complex geometry of vessels using a convex primitive, and uses a sweep line algorithm to find a suboptimal placement of the primitive. The method was evaluated using 10 CT angiography datasets and resulted in a clear visualization with all cluttering intersections removed. The method can be used to convey clinical findings, including lumen patency and lesion locations, in a single two-dimensional image.
• Zimmerman, M. E., Batlle, J. C., Biga, C., Blankstein, R., Ghoshhajra, B. B., Rabbat, M. G., Wesbey, G. E., & Rubin, G. D. (2022). The direct costs of coronary CT angiography relative to contrast-enhanced thoracic CT: Time-driven activity-based costing. Journal of cardiovascular computed tomography, 15(6), 477-483.
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  Coronary CT angiography (CCTA) and contrast-enhanced thoracic CT (CECT) are distinctly different diagnostic procedures that involve intravenous contrast-enhanced CT of the chest. The technical component of these procedures is reimbursed at the same rate by the Centers for Medicare and Medicaid Services (CMS). This study tests the hypothesis that the direct costs of performing these exams are significantly different.
• Draelos, R. L., Dov, D., Mazurowski, M. A., Lo, J. Y., Henao, R., Rubin, G. D., & Carin, L. (2021). Machine-learning-based multiple abnormality prediction with large-scale chest computed tomography volumes. Medical image analysis, 67, 101857.
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  Machine learning models for radiology benefit from large-scale data sets with high quality labels for abnormalities. We curated and analyzed a chest computed tomography (CT) data set of 36,316 volumes from 19,993 unique patients. This is the largest multiply-annotated volumetric medical imaging data set reported. To annotate this data set, we developed a rule-based method for automatically extracting abnormality labels from free-text radiology reports with an average F-score of 0.976 (min 0.941, max 1.0). We also developed a model for multi-organ, multi-disease classification of chest CT volumes that uses a deep convolutional neural network (CNN). This model reached a classification performance of AUROC >0.90 for 18 abnormalities, with an average AUROC of 0.773 for all 83 abnormalities, demonstrating the feasibility of learning from unfiltered whole volume CT data. We show that training on more labels improves performance significantly: for a subset of 9 labels - nodule, opacity, atelectasis, pleural effusion, consolidation, mass, pericardial effusion, cardiomegaly, and pneumothorax - the model's average AUROC increased by 10% when the number of training labels was increased from 9 to all 83. All code for volume preprocessing, automated label extraction, and the volume abnormality prediction model is publicly available. The 36,316 CT volumes and labels will also be made publicly available pending institutional approval.
• Johkoh, T., Lee, K. S., Nishino, M., Travis, W. D., Ryu, J. H., Lee, H. Y., Ryerson, C. J., Franquet, T., Bankier, A. A., Brown, K. K., Goo, J. M., Kauczor, H. U., Lynch, D. A., Nicholson, A. G., Richeldi, L., Schaefer-Prokop, C. M., Verschakelen, J., Raoof, S., Rubin, G. D., , Powell, C., et al. (2021). Chest CT Diagnosis and Clinical Management of Drug-Related Pneumonitis in Patients Receiving Molecular Targeting Agents and Immune Checkpoint Inhibitors: A Position Paper From the Fleischner Society. Chest, 159(3), 1107-1125.
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  Use of molecular targeting agents and immune checkpoint inhibitors (ICIs) has increased the frequency and broadened the spectrum of lung toxicity, particularly in patients with cancer. The diagnosis of drug-related pneumonitis (DRP) is usually achieved by excluding other potential known causes. Awareness of the incidence and risk factors for DRP is becoming increasingly important. The severity of symptoms associated with DRP may range from mild or none to life-threatening with rapid progression to death. Imaging features of DRP should be assessed in consideration of the distribution of lung parenchymal abnormalities (radiologic pattern approach). The CT patterns reflect acute (diffuse alveolar damage) interstitial pneumonia and transient (simple pulmonary eosinophilia) lung abnormality, subacute interstitial disease (organizing pneumonia and hypersensitivity pneumonitis), and chronic interstitial disease (nonspecific interstitial pneumonia). A single drug can be associated with multiple radiologic patterns. Treatment of a patient suspected of having DRP generally consists of drug discontinuation, immunosuppressive therapy, or both, along with supportive measures eventually including supplemental oxygen and intensive care. In this position paper, the authors provide diagnostic criteria and management recommendations for DRP that should be of interest to radiologists, clinicians, clinical trialists, and trial sponsors, among others.
• Johkoh, T., Lee, K. S., Nishino, M., Travis, W. D., Ryu, J. H., Lee, H. Y., Ryerson, C. J., Franquet, T., Bankier, A. A., Brown, K. K., Goo, J. M., Kauczor, H. U., Lynch, D. A., Nicholson, A. G., Richeldi, L., Schaefer-Prokop, C. M., Verschakelen, J., Raoof, S., Rubin, G. D., , Powell, C., et al. (2021). Chest CT Diagnosis and Clinical Management of Drug-related Pneumonitis in Patients Receiving Molecular Targeting Agents and Immune Checkpoint Inhibitors: A Position Paper from the Fleischner Society. Radiology, 298(3), 550-566.
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  Use of molecular targeting agents and immune checkpoint inhibitors (ICIs) has increased the frequency and broadened the spectrum of lung toxicity, particularly in patients with cancer. The diagnosis of drug-related pneumonitis (DRP) is usually achieved by excluding other potential known causes. Awareness of the incidence and risk factors for DRP is becoming increasingly important. The severity of symptoms associated with DRP may range from mild or none to life-threatening with rapid progression to death. Imaging features of DRP should be assessed in consideration of the distribution of lung parenchymal abnormalities (radiologic pattern approach). The CT patterns reflect acute (diffuse alveolar damage) interstitial pneumonia and transient (simple pulmonary eosinophilia) lung abnormality, subacute interstitial disease (organizing pneumonia and hypersensitivity pneumonitis), and chronic interstitial disease (nonspecific interstitial pneumonia). A single drug can be associated with multiple radiologic patterns. Treatment of a patient suspected of having DRP generally consists of drug discontinuation, immunosuppressive therapy, or both, along with supportive measures eventually including supplemental oxygen and intensive care. In this position paper, the authors provide diagnostic criteria and management recommendations for DRP that should be of interest to radiologists, clinicians, clinical trialists, and trial sponsors, among others. This article is a simultaneous joint publication in and . The articles are identical except for stylistic changes in keeping with each journal's style. Either version may be used in citing this article. Published under a CC BY 4.0 license.
• Kanne, J. P., Bai, H., Bernheim, A., Chung, M., Haramati, L. B., Kallmes, D. F., Little, B. P., Rubin, G. D., & Sverzellati, N. (2021). COVID-19 Imaging: What We Know Now and What Remains Unknown. Radiology, 299(3), E262-E279.
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  Infection with SARS-CoV-2 ranges from an asymptomatic condition to a severe and sometimes fatal disease, with mortality most frequently being the result of acute lung injury. The role of imaging has evolved during the pandemic, with CT initially being an alternative and possibly superior testing method compared with reverse transcriptase-polymerase chain reaction (RT-PCR) testing and evolving to having a more limited role based on specific indications. Several classification and reporting schemes were developed for chest imaging early during the pandemic for patients suspected of having COVID-19 to aid in triage when the availability of RT-PCR testing was limited and its level of performance was unclear. Interobserver agreement for categories with findings typical of COVID-19 and those suggesting an alternative diagnosis is high across multiple studies. Furthermore, some studies looking at the extent of lung involvement on chest radiographs and CT images showed correlations with critical illness and a need for mechanical ventilation. In addition to pulmonary manifestations, cardiovascular complications such as thromboembolism and myocarditis have been ascribed to COVID-19, sometimes contributing to neurologic and abdominal manifestations. Finally, artificial intelligence has shown promise for use in determining both the diagnosis and prognosis of COVID-19 pneumonia with respect to both radiography and CT.
• Remy-Jardin, M., Ryerson, C. J., Schiebler, M. L., Leung, A. N., Wild, J. M., Hoeper, M. M., Alderson, P. O., Goodman, L. R., Mayo, J., Haramati, L. B., Ohno, Y., Thistlethwaite, P., van Beek, E. J., Knight, S. L., Lynch, D. A., Rubin, G. D., & Humbert, M. (2021). Imaging of Pulmonary Hypertension in Adults: A Position Paper from the Fleischner Society. Radiology, 298(3), 531-549.
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  Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure greater than 20 mm Hg and classified into five different groups sharing similar pathophysiologic mechanisms, hemodynamic characteristics, and therapeutic management. Radiologists play a key role in the multidisciplinary assessment and management of PH. A working group was formed from within the Fleischner Society based on expertise in the imaging and/or management of patients with PH, as well as experience with methodologies of systematic reviews. The working group identified key questions focusing on the utility of CT, MRI, and nuclear medicine in the evaluation of PH: Is noninvasive imaging capable of identifying PH? What is the role of imaging in establishing the cause of PH? How does imaging determine the severity and complications of PH? How should imaging be used to assess chronic thromboembolic PH before treatment? Should imaging be performed after treatment of PH? This systematic review and position paper highlights the key role of imaging in the recognition, work-up, treatment planning, and follow-up of PH. This article is a simultaneous joint publication in and . The articles are identical except for stylistic changes in keeping with each journal's style. Either version may be used in citing this article. © 2021 RSNA and the European Respiratory Society.
• Remy-Jardin, M., Ryerson, C. J., Schiebler, M. L., Leung, A. N., Wild, J. M., Hoeper, M. M., Alderson, P. O., Goodman, L. R., Mayo, J., Haramati, L. B., Ohno, Y., Thistlethwaite, P., van Beek, E. J., Knight, S. L., Lynch, D. A., Rubin, G. D., & Humbert, M. (2021). Imaging of pulmonary hypertension in adults: a position paper from the Fleischner Society. The European respiratory journal, 57(1).
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  Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure greater than 20 mmHg and classified into five different groups sharing similar pathophysiologic mechanisms, haemodynamic characteristics, and therapeutic management. Radiologists play a key role in the multidisciplinary assessment and management of PH. A working group was formed from within the Fleischner Society based on expertise in the imaging and/or management of patients with PH, as well as experience with methodologies of systematic reviews. The working group identified key questions focusing on the utility of CT, MRI, and nuclear medicine in the evaluation of PH: Is noninvasive imaging capable of identifying PH? What is the role of imaging in establishing the cause of PH? How does imaging determine the severity and complications of PH? How should imaging be used to assess chronic thromboembolic PH before treatment? Should imaging be performed after treatment of PH? This systematic review and position paper highlights the key role of imaging in the recognition, work-up, treatment planning, and follow-up of PH.
• Rubin, G. D. (2021). CT Diagnosis of COVID-19: A View through the PICOTS Lens. Radiology, 301(1), E375-E377.
• Rubin, G. D. (2021). CT Diagnosis of COVID-19: A View through the PICOTS Lens. Radiology, 301(1), E375-E377. doi:10.1148/radiol.2021211454
• Samei, E., Richards, T., Segars, W. P., Daubert, M. A., Ivanov, A., Rubin, G. D., Douglas, P. S., & Hoffmann, U. (2021). Task-dependent estimability index to assess the quality of cardiac computed tomography angiography for quantifying coronary stenosis. Journal of medical imaging (Bellingham, Wash.), 8(1), 013501.
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  Quantifying stenosis in cardiac computed tomography angiography (CTA) images remains a difficult task, as image noise and cardiac motion can degrade image quality and distort underlying anatomic information. The purpose of this study was to develop a computational framework to objectively assess the precision of quantifying coronary stenosis in cardiac CTA. The framework used models of coronary vessels and plaques, asymmetric motion point spread functions, CT image blur (task-based modulation transfer functions) and noise (noise-power spectrums), and an automated maximum-likelihood estimator implemented as a matched template squared-difference operator. These factors were integrated into an estimability index ( ) as a task-based measure of image quality in cardiac CTA. The index was applied to assess how well it can to predict the quality of 132 clinical cases selected from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain trial. The cases were divided into two cohorts, high quality and low quality, based on clinical scores and the concordance of clinical evaluations of cases by experienced cardiac imagers. The framework was also used to ascertain protocol factors for CTA Biomarker initiative of the Quantitative Imaging Biomarker Alliance (QIBA). The index categorized the patient datasets with an area under the curve of 0.985, an accuracy of 0.977, and an optimal threshold of 25.58 corresponding to a stenosis estimation precision (standard deviation) of 3.91%. Data resampling and training-test validation methods demonstrated stable classifier thresholds and receiver operating curve performance. The framework was successfully applicable to the QIBA objective. A computational framework to objectively quantify stenosis estimation task performance was successfully implemented and was reflective of clinical results in the context of a prominent clinical trial with diverse sites, readers, scanners, acquisition protocols, and patients. It also demonstrated the potential for prospective optimization of imaging protocols toward targeted precision and measurement consistency in cardiac CT images.
• Li, B., Smith, T. B., Choudhury, K. R., Harrawood, B., Ebner, L., Roos, J. E., & Rubin, G. D. (2020). Influence of background lung characteristics on nodule detection with computed tomography. Journal of medical imaging (Bellingham, Wash.), 7(2), 022409.
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  We sought to characterize local lung complexity in chest computed tomography (CT) and to characterize its impact on the detectability of pulmonary nodules. Forty volumetric chest CT scans were created by embedding between three and five simulated 5-mm lung nodules into one of three volumetric chest CT datasets. Thirteen radiologists evaluated 157 nodules, resulting in 2041 detection opportunities. Analyzing the substrate CT data prior to nodule insertion, 14 image features were measured within a region around each nodule location. A generalized linear mixed-effects statistical model was fit to the data to verify the contribution of each metric on detectability. The model was tuned for simplicity, interpretability, and generalizability using stepwise regression applied to the primary features and their interactions. We found that variables corresponding to each of five categories (local structural distractors, local intensity, global context, local vascularity, and contiguity with structural distractors) were significant ( ) factors in a standardized model. Moreover, reader-specific models conveyed significant differences among readers with significant distraction (missed detections) influenced by local intensity- versus local-structural characteristics being mutually exclusive. Readers with significant local intensity distraction ( ) detected substantially fewer lung nodules than those who were significantly distracted by local structure ( ), 46.1% versus 65.3% mean nodules detected, respectively.
• Rubin, G. D., Ryerson, C. J., Haramati, L. B., Sverzellati, N., Kanne, J. P., Raoof, S., Schluger, N. W., Volpi, A., Yim, J. J., Martin, I. B., Anderson, D. J., Kong, C., Altes, T., Bush, A., Desai, S. R., Goldin, J., Goo, J. M., Humbert, M., Inoue, Y., , Kauczor, H. U., et al. (2020). The Role of Chest Imaging in Patient Management During the COVID-19 Pandemic: A Multinational Consensus Statement From the Fleischner Society. Chest, 158(1), 106-116.
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  With more than 900,000 confirmed cases worldwide and nearly 50,000 deaths during the first 3 months of 2020, the coronavirus disease 2019 (COVID-19) pandemic has emerged as an unprecedented health care crisis. The spread of COVID-19 has been heterogeneous, resulting in some regions having sporadic transmission and relatively few hospitalized patients with COVID-19 and others having community transmission that has led to overwhelming numbers of severe cases. For these regions, health care delivery has been disrupted and compromised by critical resource constraints in diagnostic testing, hospital beds, ventilators, and health care workers who have fallen ill to the virus exacerbated by shortages of personal protective equipment. Although mild cases mimic common upper respiratory viral infections, respiratory dysfunction becomes the principal source of morbidity and mortality as the disease advances. Thoracic imaging with chest radiography and CT are key tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 has not been considered within the multivariable context of the severity of respiratory disease, pretest probability, risk factors for disease progression, and critical resource constraints. To address this deficit, a multidisciplinary panel comprised principally of radiologists and pulmonologists from 10 countries with experience managing patients with COVID-19 across a spectrum of health care environments evaluated the utility of imaging within three scenarios representing varying risk factors, community conditions, and resource constraints. Fourteen key questions, corresponding to 11 decision points within the three scenarios and three additional clinical situations, were rated by the panel based on the anticipated value of the information that thoracic imaging would be expected to provide. The results were aggregated, resulting in five main and three additional recommendations intended to guide medical practitioners in the use of chest radiography and CT in the management of COVID-19.
• Rubin, G. D., Ryerson, C. J., Haramati, L. B., Sverzellati, N., Kanne, J. P., Raoof, S., Schluger, N. W., Volpi, A., Yim, J. J., Martin, I. B., Anderson, D. J., Kong, C., Altes, T., Bush, A., Desai, S. R., Goldin, O., Goo, J. M., Humbert, M., Inoue, Y., , Kauczor, H. U., et al. (2020). The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society. Radiology, 296(1), 172-180.
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  With more than 900 000 confirmed cases worldwide and nearly 50 000 deaths during the first 3 months of 2020, the coronavirus disease 2019 (COVID-19) pandemic has emerged as an unprecedented health care crisis. The spread of COVID-19 has been heterogeneous, resulting in some regions having sporadic transmission and relatively few hospitalized patients with COVID-19 and others having community transmission that has led to overwhelming numbers of severe cases. For these regions, health care delivery has been disrupted and compromised by critical resource constraints in diagnostic testing, hospital beds, ventilators, and health care workers who have fallen ill to the virus exacerbated by shortages of personal protective equipment. Although mild cases mimic common upper respiratory viral infections, respiratory dysfunction becomes the principal source of morbidity and mortality as the disease advances. Thoracic imaging with chest radiography and CT are key tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 has not been considered within the multivariable context of the severity of respiratory disease, pretest probability, risk factors for disease progression, and critical resource constraints. To address this deficit, a multidisciplinary panel comprised principally of radiologists and pulmonologists from 10 countries with experience managing patients with COVID-19 across a spectrum of health care environments evaluated the utility of imaging within three scenarios representing varying risk factors, community conditions, and resource constraints. Fourteen key questions, corresponding to 11 decision points within the three scenarios and three additional clinical situations, were rated by the panel based on the anticipated value of the information that thoracic imaging would be expected to provide. The results were aggregated, resulting in five main and three additional recommendations intended to guide medical practitioners in the use of chest radiography and CT in the management of COVID-19.
• Tailor, T. D., Tong, B. C., Gao, J., Henderson, L. M., Choudhury, K. R., & Rubin, G. D. (2020). Utilization of Lung Cancer Screening in the Medicare Fee-for-Service Population. Chest, 158(5), 2200-2210.
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  A number of organizations, including the US Preventive Services Task Force (USPSTF), recommend lung cancer screening (LCS) with low-dose CT (LDCT) imaging for high-risk current and former smokers. In 2015, Medicare issued a decision to cover LCS as a preventive health benefit; however, utilization by the Medicare population has not been thoroughly examined.
• White, C. S., & Rubin, G. D. (2020). The Puzzle of the Perifissural Nodule. Radiology. Cardiothoracic imaging, 2(4), e200409.
• Tailor, T. D., Choudhury, K. R., Tong, B. C., Christensen, J. D., Sosa, J. A., & Rubin, G. D. (2019). Geographic Access to CT for Lung Cancer Screening: A Census Tract-Level Analysis of Cigarette Smoking in the United States and Driving Distance to a CT Facility. Journal of the American College of Radiology : JACR, 16(1), 15-23.
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  Spatial access to health care resources is a requisite for utilization. Our purpose was to determine, at a census tract level, the geographic distribution of US smokers and their driving distance to an ACR-accredited CT facility.
• Tailor, T. D., Tong, B. C., Gao, J., Choudhury, K. R., & Rubin, G. D. (2019). A Geospatial Analysis of Factors Affecting Access to CT Facilities: Implications for Lung Cancer Screening. Journal of the American College of Radiology : JACR, 16(12), 1663-1668.
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  The association between access to CT facilities for lung cancer screening and population characteristics is understudied. We aimed to determine the relationship between census tract-level socioeconomic characteristics (SEC) and driving distance to an ACR-accredited CT facility.
• , W. C., Hirshfeld, J. W., Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., Eisenberg, M. J., Fogel, M. A., Gerber, T. C., Haines, D. E., Laskey, W. K., Limacher, M. C., Nichols, K. J., Pryma, D. A., Raff, G. L., Rubin, G. D., Smith, D., Stillman, A. E., , Thomas, S. A., et al. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways Developed in Collaboration With Mended Hearts. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 92(2), 203-221.
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  The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.
• , W. C., Hirshfeld, J. W., Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., Eisenberg, M. J., Fogel, M. A., Gerber, T. C., Haines, D. E., Laskey, W. K., Limacher, M. C., Nichols, K. J., Pryma, D. A., Raff, G. L., Rubin, G. D., Smith, D., Stillman, A. E., , Thomas, S. A., et al. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 2: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 92(2), 222-246.
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  The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure to clinical personnel. While the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. ACC leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. "Optimal Use of Ionizing Radiation in Cardiovascular Imaging - Best Practices for Safety and Effectiveness" is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. "Part I: Radiation Physics and Radiation Biology" addresses radiation physics, dosimetry and detrimental biologic effects. "Part II: Radiologic Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection" covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy). For each modality, it includes the determinants of radiation exposure and techniques to minimize exposure to both patients and to medical personnel.
• , W. C., Hirshfeld, J. W., Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., Eisenberg, M. J., Fogel, M. A., Gerber, T. C., Haines, D. E., Laskey, W. K., Limacher, M. C., Nichols, K. J., Pryma, D. A., Raff, G. L., Rubin, G. D., Smith, D., Stillman, A. E., , Thomas, S. A., et al. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 92(2), E35-E97.
• Hirshfeld, J. W., Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., Eisenberg, M. J., Fogel, M. A., Gerber, T. C., Haines, D. E., Laskey, W. K., Limacher, M. C., Hirshfeld, J. W., Nichols, K. J., Ferrari, V. A., Pryma, D. A., Bengel, F. M., Raff, G. L., Bergersen, L., , Rubin, G. D., et al. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology, 71(24), 2811-2828.
• Hirshfeld, J. W., Ferrari, V. A., Bengel, F. M., Bergersen, L., Chambers, C. E., Einstein, A. J., Eisenberg, M. J., Fogel, M. A., Gerber, T. C., Haines, D. E., Laskey, W. K., Limacher, M. C., Nichols, K. J., Pryma, D. A., Raff, G. L., Rubin, G. D., Smith, D., Stillman, A. E., Thomas, S. A., , Tsai, T. T., et al. (2018). 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology, 71(24), e283-e351.
• Richards, T., Sturgeon, G. M., Ramirez-Giraldo, J. C., Rubin, G. D., Koweek, L. H., Segars, W. P., & Samei, E. (2018). Quantification of uncertainty in the assessment of coronary plaque in CCTA through a dynamic cardiac phantom and 3D-printed plaque model. Journal of medical imaging (Bellingham, Wash.), 5(1), 013501.
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  The purpose of this study was to develop a dynamic physical cardiac phantom with a realistic coronary plaque to investigate stenosis measurement accuracy under clinically relevant heart-rates. The coronary plaque model (5 mm diameter, 50% stenosis, and 32 mm long) was designed and 3D-printed with tissue equivalent materials (calcified plaque with iodine-enhanced lumen). Realistic cardiac motion was modeled by converting computational cardiac motion vectors into compression and rotation profiles executed by a commercial base cardiac phantom. The phantom was imaged on a dual-source CT system applying a retrospective gated coronary CT angiography (CCTA) protocol using synthesized motion-synchronized electrocardiogram (ECG) waveforms. Multiplanar reformatted images were reconstructed along vessel centerlines. Enhanced lumens were segmented by five independent operators. On average, stenosis measurement accuracy was 0.9% positively biased for the motion-free condition. Average measurement accuracy monotonically decreased from 0.9% positive bias for the motion-free condition to 18.5% negative bias at 90 beats per minute. Contrast-to-noise ratio, lumen circularity, and segmentation conformity also decreased monotonically with increasing heart-rate. These results demonstrate successful implementation of a base cardiac phantom with a 3D-printed coronary plaque model, relevant motion profile, and coordinated ECG waveform. They further show the utility of the model to ascertain metrics of CCTA accuracy and image quality under realistic plaque, motion, and acquisition conditions.
• Rubin, G. D., & Abramson, R. G. (2018). Creating Value through Incremental Innovation: Managing Culture, Structure, and Process. Radiology, 288(2), 330-340.
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  While the looming threat of large-scale disruptive innovation consumes disproportionate attention, incremental innovation remains an important tool for preserving and growing radiology practices within a dynamic marketplace. Incremental innovation, defined as the process of making improvements or additions to an organization while maintaining the organization's core product or service model, is accessible to practices of all sizes and must not be overlooked if practices are to maintain their competitive advantage. This article explores cultural, structural, and process enablers for incremental innovation. Successful innovation cultures foster the ability to import and exploit external knowledge (adaptive capacity), encourage creative thought from all levels of the organization, display sensitivity toward the competency-destroying potential of certain changes, cultivate a positive perceptual bias toward organizational threats, and build tolerance for risk and uncertainty when prototyping new ideas. Structural elements promoting incremental innovation include dedicated resources for innovation planning, flexible and organic team structures, strong centralized governance models, robust communication systems, and organizational incentives encouraging exploration of new concepts. Processes important to innovation include periodic environmental scanning, strategic and scenario planning, use of an objectively gated system for testing and filtering new ideas, and use of an approach to implementation that emphasizes empowerment of project managers, removal of barriers, and proactive communication around change.
• Smith, T. B., Rubin, G. D., Solomon, J., Harrawood, B., Choudhury, K. R., & Samei, E. (2018). Local complexity metrics to quantify the effect of anatomical noise on detectability of lung nodules in chest CT imaging. Journal of medical imaging (Bellingham, Wash.), 5(4), 045502.
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  The purpose of this study is to (1) develop metrics to characterize the regional anatomical complexity of the lungs, and (2) relate these metrics with lung nodule detection in chest CT. A free-scrolling reader-study with virtually inserted nodules (13 radiologists × 157 total nodules = 2041 responses) is used to characterize human detection performance. Metrics of complexity based on the local density and orientation of distracting vasculature are developed for two-dimensional (2-D) and three-dimensional (3-D) considerations of the image volume. Assessed characteristics included the distribution of 2-D/3-D vessel structures of differing orientation (dubbed "2-D/3-D and dot-like/line-like distractor indices"), contiguity of inserted nodules with local vasculature, mean local gray-level surrounding each nodule, the proportion of lung voxels to total voxels in each section, and 3-D distance of each nodule from the trachea bifurcation. A generalized linear mixed-effects statistical model is used to determine the influence of each these metrics on nodule detectability. In order of decreasing effect size: 3-D line-like distractor index, 2-D line-like distractor index, 2-D dot-like distractor index, local mean gray-level, contiguity with 2-D dots, lung area, and contiguity with 3-D lines all significantly affect detectability ( ). These data demonstrate that local lung complexity degrades detection of lung nodules.
• Wood, A. M., Grotegut, C. A., Ronald, J., Pabon-Ramos, W., Pedro, C., Knechtle, S. J., Wysokinska, E., Rubin, G. D., Brady, C. W., & Gilner, J. B. (2018). Identification and Management of Abdominal Wall Varices in Pregnancy. Obstetrics and gynecology, 132(4), 882-887.
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  Portal hypertension in pregnancy is associated with elevated risk of variceal hemorrhage. Ectopic varices, those located outside the esophagus or stomach, are rare but have a high risk of associated maternal morbidity or mortality.
• Bankier, A. A., MacMahon, H., Goo, J. M., Rubin, G. D., Schaefer-Prokop, C. M., & Naidich, D. P. (2017). Recommendations for Measuring Pulmonary Nodules at CT: A Statement from the Fleischner Society. Radiology, 285(2), 584-600.
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  These recommendations for measuring pulmonary nodules at computed tomography (CT) are a statement from the Fleischner Society and, as such, incorporate the opinions of a multidisciplinary international group of thoracic radiologists, pulmonologists, surgeons, pathologists, and other specialists. The recommendations address nodule size measurements at CT, which is a topic of importance, given that all available guidelines for nodule management are essentially based on nodule size or changes thereof. The recommendations are organized according to practical questions that commonly arise when nodules are measured in routine clinical practice and are, together with their answers, summarized in a table. The recommendations include technical requirements for accurate nodule measurement, directions on how to accurately measure the size of nodules at the workstation, and directions on how to report nodule size and changes in size. The recommendations are designed to provide practical advice based on the available evidence from the literature; however, areas of uncertainty are also discussed, and topics needing future research are highlighted. RSNA, 2017 Online supplemental material is available for this article.
• Boll, D. T., Rubin, G. D., Heye, T., & Pierce, L. J. (2017). Affinity Chart Analysis: A Method for Structured Collection, Aggregation, and Response to Customer Needs in Radiology. AJR. American journal of roentgenology, 208(4), W134-W145.
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  The objective of this study is to analyze implementation of the voice-of-the-customer method to assess the current state of image postprocessing and reporting delivered by a radiology department and to plan improvements on the basis of referring physicians' preferences.
• Ebner, L., Tall, M., Choudhury, K. R., Ly, D. L., Roos, J. E., Napel, S., & Rubin, G. D. (2017). Variations in the functional visual field for detection of lung nodules on chest computed tomography: Impact of nodule size, distance, and local lung complexity. Medical physics, 44(7), 3483-3490.
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  To explore the characteristics that impact lung nodule detection by peripheral vision when searching for lung nodules on chest CT-scans.
• MacMahon, H., Naidich, D. P., Goo, J. M., Lee, K. S., Leung, A. N., Mayo, J. R., Mehta, A. C., Ohno, Y., Powell, C. A., Prokop, M., Rubin, G. D., Schaefer-Prokop, C. M., Travis, W. D., Van Schil, P. E., & Bankier, A. A. (2017). Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology, 284(1), 228-243.
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  The Fleischner Society Guidelines for management of solid nodules were published in 2005, and separate guidelines for subsolid nodules were issued in 2013. Since then, new information has become available; therefore, the guidelines have been revised to reflect current thinking on nodule management. The revised guidelines incorporate several substantive changes that reflect current thinking on the management of small nodules. The minimum threshold size for routine follow-up has been increased, and recommended follow-up intervals are now given as a range rather than as a precise time period to give radiologists, clinicians, and patients greater discretion to accommodate individual risk factors and preferences. The guidelines for solid and subsolid nodules have been combined in one simplified table, and specific recommendations have been included for multiple nodules. These guidelines represent the consensus of the Fleischner Society, and as such, they incorporate the opinions of a multidisciplinary international group of thoracic radiologists, pulmonologists, surgeons, pathologists, and other specialists. Changes from the previous guidelines issued by the Fleischner Society are based on new data and accumulated experience. RSNA, 2017 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on March 13, 2017.
• Rubin, G. D. (2017). Costing in Radiology and Health Care: Rationale, Relativity, Rudiments, and Realities. Radiology, 282(2), 333-347.
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  Costs direct decisions that influence the effectiveness of radiology in the care of patients on a daily basis. Yet many radiologists struggle to harness the power of cost measurement and cost management as a critical path toward establishing their value in patient care. When radiologists cannot articulate their value, they risk losing control over how imaging is delivered and supported. In the United States, recent payment trends directing value-based payments for bundles of care advance the imperative for radiology providers to articulate their value. This begins with the development of an understanding of the providers' own costs, as well as the complex interrelationships and imaging-associated costs of other participants across the imaging value chain. Controlling the costs of imaging necessitates understanding them at a procedural level and quantifying the costs of delivering specific imaging services. Effective product-level costing is dependent on a bottom-up approach, which is supported through recent innovations in time-dependent activity-based costing. Once the costs are understood, they can be managed. Within the high fixed cost and high overhead cost environment of health care provider organizations, stakeholders must understand the implications of misaligned top-down cost management approaches that can both paradoxically shift effort from low-cost workers to much costlier professionals and allocate overhead costs counterproductively. Radiology's engagement across a broad spectrum of care provides an excellent opportunity for radiology providers to take a leading role within the health care organizations to enhance value and margin through principled and effective cost management. Following a discussion of the rationale for measuring costs, this review contextualizes costs from the perspectives of a variety of stakeholders (relativity), discusses core concepts in how costs are classified (rudiments), presents common and improved methods for measuring costs in health care, and discusses how cost management strategies can either improve or hinder high-value health care (realities). RSNA, 2017 Online supplemental material is available for this article.
• Rubin, G. D., & Krupinski, E. A. (2017). Tracking Eye Movements during CT Interpretation: Inferences of Reader Performance and Clinical Competency Require Clinically Realistic Procedures for Unconstrained Search. Radiology, 283(3), 920.
• Rubin, G. D., & Patel, B. N. (2017). Financial Forecasting and Stochastic Modeling: Predicting the Impact of Business Decisions. Radiology, 283(2), 342-358.
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  In health care organizations, effective investment of precious resources is critical to assure that the organization delivers high-quality and sustainable patient care within a supportive environment for patients, their families, and the health care providers. This holds true for organizations independent of size, from small practices to large health systems. For radiologists whose role is to oversee the delivery of imaging services and the interpretation, communication, and curation of imaging-informed information, business decisions influence where and how they practice, the tools available for image acquisition and interpretation, and ultimately their professional satisfaction. With so much at stake, physicians must understand and embrace the methods necessary to develop and interpret robust financial analyses so they effectively participate in and better understand decision making. This review discusses the financial drivers upon which health care organizations base investment decisions and the central role that stochastic financial modeling should play in support of strategically aligned capital investments. Given a health care industry that has been slow to embrace advanced financial analytics, a fundamental message of this review is that the skills and analytical tools are readily attainable and well worth the effort to implement in the interest of informed decision making. RSNA, 2017 Online supplemental material is available for this article.
• Rubin, G. D., Krishnaraj, A., Mahesh, M., Rajendran, R. R., & Fishman, E. K. (2017). Enhancing Public Access to Relevant and Valued Medical Information: Fresh Directions for RadiologyInfo.org. Journal of the American College of Radiology : JACR, 14(5), 697-702.e4.
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  RadiologyInfo.org is a public information portal designed to support patient care and broaden public awareness of the essential role radiology plays in overall patient health care. Over the past 14 years, RadiologyInfo.org has evolved considerably to provide access to more than 220 mixed-media descriptions of tests, treatments, and diseases through a spectrum of mobile and desktop platforms, social media, and downloadable documents in both English and Spanish. In 2014, the RSNA-ACR Public Information Website Committee, which stewards RadiologyInfo.org, developed 3- to 5-year strategic and implementation plans for the website. The process was informed by RadiologyInfo.org user surveys, formal stakeholder interviews, focus groups, and usability testing. Metrics were established as key performance indicators to assess progress toward the stated goals of (1) optimizing content to enhance patient-centeredness, (2) enhancing reach and engagement, and (3) maintaining sustainability. Major changes resulting from this process include a complete redesign of the website, the replacement of text-rich PowerPoint presentations with conversational videos, and the development of an affiliate network. Over the past year, visits to RadiologyInfo.org have increased by 60.27% to 1,424,523 in August 2016 from 235 countries and territories. Twenty-two organizations have affiliated with RadiologyInfo.org with new organizations being added on a monthly basis. RadiologyInfo provides a tangible demonstration of how radiologists can engage directly with the global public to educate them on the value of radiology in their health care and to allay concerns and dispel misconceptions. Regular self-assessment and responsive planning will ensure its continued growth and relevance.
• Rubin, G. D., McNeil, B. J., Palkó, A., Thrall, J. H., Krestin, G. P., Muellner, A., & Kressel, H. Y. (2017). External Factors That Influence the Practice of Radiology: Proceedings of the International Society for Strategic Studies in Radiology Meeting. Radiology, 283(3), 845-853.
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  In both the United States and Europe, efforts to reduce soaring health care costs have led to intense scrutiny of both standard and innovative uses of imaging. Given that the United States spends a larger share of its gross domestic product on health care than any other nation and also has the most varied health care financing and delivery systems in the world, it has become an especially fertile environment for developing and testing approaches to controlling health care costs and value. This report focuses on recent reforms that have had a dampening effect on imaging use in the United States and provides a glimpse of obstacles that imaging practices may soon face or are already facing in other countries. On the basis of material presented at the 2015 meeting of the International Society for Strategic Studies in Radiology, this report outlines the effects of reforms aimed at (a) controlling imaging use, (b) controlling payer expense through changes in benefit design, and (c) controlling both costs and quality through "value-based" payment schemes. Reasons are considered for radiology practices on both sides of the Atlantic about why the emphasis needs to shift from providing a large volume of imaging services to increasing the value of imaging as manifested in clinical outcomes, patient satisfaction, and overall system savings. Options for facilitating the shift from volume to value are discussed, from the use of advanced management strategies that improve workflow to the creation of programs for patient engagement, the development of new clinical decision-making support tools, and the validation of clinically relevant imaging biomarkers. Radiologists in collaboration with industry must enhance their efforts to expand the performance of comparative effectiveness research to establish the value of these initiatives, while being mindful of the importance of minimizing conflicts of interest. RSNA, 2017.
• Cury, R. C., Abbara, S., Achenbach, S., Agatston, A., Berman, D. S., Budoff, M. J., Dill, K. E., Jacobs, J. E., Maroules, C. D., Rubin, G. D., Rybicki, F. J., Schoepf, U. J., Shaw, L. J., Stillman, A. E., White, C. S., Woodard, P. K., & Leipsic, J. A. (2016). CAD-RADS™: Coronary Artery Disease - Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. Journal of the American College of Radiology : JACR, 13(12 Pt A), 1458-1466.e9.
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  The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.
• Cury, R. C., Abbara, S., Achenbach, S., Agatston, A., Berman, D. S., Budoff, M. J., Dill, K. E., Jacobs, J. E., Maroules, C. D., Rubin, G. D., Rybicki, F. J., Schoepf, U. J., Shaw, L. J., Stillman, A. E., White, C. S., Woodard, P. K., & Leipsic, J. A. (2016). Coronary Artery Disease - Reporting and Data System (CAD-RADS): An Expert Consensus Document of SCCT, ACR and NASCI: Endorsed by the ACC. JACC. Cardiovascular imaging, 9(9), 1099-1113.
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  The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.
• Meinel, F. G., Haack, M., Weidenhagen, R., Hellbach, K., Rottenkolber, M., Armbruster, M., Jerkku, T., Thierfelder, K. M., Plum, J. L., Koeppel, T. A., Rubin, G. D., & Sommer, W. H. (2016). Effect of endoleaks on changes in aortoiliac volume after endovascular repair for abdominal aortic aneurysm. Clinical hemorheology and microcirculation, 64(2), 135-147.
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  To evaluate changes in aortoiliac volume after endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) in patients with and without endoleaks.
• Patel, B. N., & Rubin, G. D. (2016). Deal or No Deal? Negotiation 101. Journal of the American College of Radiology : JACR, 13(6), 756-8.
• Rubin, G. D. (2016). An Organizational Perspective and a Team Approach: Keys to Successful Business Planning. Journal of the American College of Radiology : JACR, 13(2), 228-9.
• Boiselle, P. M., Bardo, D. M., Rubin, G. D., & Tack, D. (2015). Expert Opinion: Is there Still a Role for Filtered-back Projection Reconstruction in Cardiothoracic CT?. Journal of thoracic imaging, 30(4), 219.
• Rubin, G. D. (2015). Lung nodule and cancer detection in computed tomography screening. Journal of thoracic imaging, 30(2), 130-8.
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  Fundamental to the diagnosis of lung cancer in computed tomography (CT) scans is the detection and interpretation of lung nodules. As the capabilities of CT scanners have advanced, higher levels of spatial resolution reveal tinier lung abnormalities. Not all detected lung nodules should be reported; however, radiologists strive to detect all nodules that might have relevance to cancer diagnosis. Although medium to large lung nodules are detected consistently, interreader agreement and reader sensitivity for lung nodule detection diminish substantially as the nodule size falls below 8 to 10 mm. The difficulty in establishing an absolute reference standard presents a challenge to the reliability of studies performed to evaluate lung nodule detection. In the interest of improving detection performance, investigators are using eye tracking to analyze the effectiveness with which radiologists search CT scans relative to their ability to recognize nodules within their search path in order to determine whether strategies might exist to improve performance across readers. Beyond the viewing of transverse CT reconstructions, image processing techniques such as thin-slab maximum-intensity projections are used to substantially improve reader performance. Finally, the development of computer-aided detection has continued to evolve with the expectation that one day it will serve routinely as a tireless partner to the radiologist to enhance detection performance without significant prolongation of the interpretive process. This review provides an introduction to the current understanding of these varied issues as we enter the era of widespread lung cancer screening.
• Rubin, G. D., Roos, J. E., Tall, M., Harrawood, B., Bag, S., Ly, D. L., Seaman, D. M., Hurwitz, L. M., Napel, S., & Roy Choudhury, K. (2015). Characterizing search, recognition, and decision in the detection of lung nodules on CT scans: elucidation with eye tracking. Radiology, 274(1), 276-86.
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  To determine the effectiveness of radiologists' search, recognition, and acceptance of lung nodules on computed tomographic (CT) images by using eye tracking.
• Mark, D. B., Anderson, J. L., Brinker, J. A., Brophy, J. A., Casey, D. E., Cross, R. R., Edmundowicz, D., Hachamovitch, R., Hlatky, M. A., Jacobs, J. E., Jaskie, S., Kett, K. G., Malhotra, V., Masoudi, F. A., McConnell, M. V., Rubin, G. D., Shaw, L. J., Sherman, M. E., Stanko, S., & Ward, R. P. (2014). ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee. Journal of the American College of Cardiology, 63(7), 698-721.
• Rubin, G. D. (2014). Computed tomography: revolutionizing the practice of medicine for 40 years. Radiology, 273(2 Suppl), S45-74.
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  Computed tomography (CT) has had a profound effect on the practice of medicine. Both the spectrum of clinical applications and the role that CT has played in enhancing the depth of our understanding of disease have been profound. Although almost 90 000 articles on CT have been published in peer-reviewed journals over the past 40 years, fewer than 5% of these have been published in Radiology. Nevertheless, these almost 4000 articles have provided a basis for many important medical advances. By enabling a deepened understanding of anatomy, physiology, and pathology, CT has facilitated key advances in the detection and management of disease. This article celebrates this breadth of scientific discovery and development by examining the impact that CT has had on the diagnosis, characterization, and management of a sampling of major health challenges, including stroke, vascular diseases, cancer, trauma, acute abdominal pain, and diffuse lung diseases, as related to key technical advances in CT and manifested in Radiology.
• Rubin, G. D., Leipsic, J., Joseph Schoepf, U., Fleischmann, D., & Napel, S. (2014). CT angiography after 20 years: a transformation in cardiovascular disease characterization continues to advance. Radiology, 271(3), 633-52.
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  Through a marriage of spiral computed tomography (CT) and graphical volumetric image processing, CT angiography was born 20 years ago. Fueled by a series of technical innovations in CT and image processing, over the next 5-15 years, CT angiography toppled conventional angiography, the undisputed diagnostic reference standard for vascular disease for the prior 70 years, as the preferred modality for the diagnosis and characterization of most cardiovascular abnormalities. This review recounts the evolution of CT angiography from its development and early challenges to a maturing modality that has provided unique insights into cardiovascular disease characterization and management. Selected clinical challenges, which include acute aortic syndromes, peripheral vascular disease, aortic stent-graft and transcatheter aortic valve assessment, and coronary artery disease, are presented as contrasting examples of how CT angiography is changing our approach to cardiovascular disease diagnosis and management. Finally, the recently introduced capabilities for multispectral imaging, tissue perfusion imaging, and radiation dose reduction through iterative reconstruction are explored with consideration toward the continued refinement and advancement of CT angiography.
• Toth, D. F., Töpker, M., Mayerhöfer, M. E., Rubin, G. D., Furtner, J., Asenbaum, U., Karanikas, G., Weber, M., Czerny, C., Herold, C. J., & Ringl, H. (2014). Rapid detection of bone metastasis at thoracoabdominal CT: accuracy and efficiency of a new visualization algorithm. Radiology, 270(3), 825-33.
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  To retrospectively assess the use of a combination of cancellous bone reconstructions (CBR) and multiplanar reconstructions (MPRs) for the detection of bone metastases at thoracoabdominal computed tomography (CT) compared with the use of MPRs alone.
• Ueda, T., Takaoka, H., Petrovitch, I., & Rubin, G. D. (2014). Detection of broken sutures and metal-ring fractures in AneuRx stent-grafts by using three-dimensional CT angiography after endovascular abdominal aortic aneurysm repair: association with late endoleak development and device migration. Radiology, 272(1), 275-83.
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  To determine the prevalence of demonstrable stent-graft degradation by using three-dimensional computed tomographic (CT) angiography to assess endoleak and stent-graft migration after endovascular aortic aneurysm repair (EVAR).
• Lee, G. K., Fox, P. M., Riboh, J., Hsu, C., Saber, S., Rubin, G. D., & Chang, J. (2013). Computed tomography angiography in microsurgery: indications, clinical utility, and pitfalls. Eplasty, 13, e42.
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  Computed tomographic angiography (CTA) can be used to obtain 3-dimensional vascular images and soft-tissue definition. The goal of this study was to evaluate the reliability, usefulness, and pitfalls of CTA in preoperative planning of microvascular reconstructive surgery.
• Rubin, G. D. (2013). Emerging and evolving roles for CT in screening for coronary heart disease. Journal of the American College of Radiology : JACR, 10(12), 943-8.
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  Coronary heart disease (CHD) is highly prevalent and is the primary cause of death for both men and women, worldwide. Because the disease develops over many years, there are opportunities to intervene and alter the course of CHD, assuming that there are reliable means for determining which individuals with coronary atherosclerosis will develop symptomatic CHD. CT provides 2 distinct means for coronary artery disease assessment--coronary artery calcium (CAC) measurement using noncontrast CT and coronary CT angiography (cCTA). The recent refinement of electrocardiographic triggering and gating with CT has enabled these techniques to be performed with greater reliability and substantially lower radiation exposure. This has led to widening availability of these diagnostic techniques and rapid expansion of our understanding of their potential clinical use. Within the context of CHD, 2 applications are particularly compelling--risk stratification of asymptomatic individuals with the intent of targeting therapy to prevent CHD and as gatekeeper to cardiac catheterization to minimize unnecessary invasive diagnostic coronary procedures. This review highlights key insights from recent investigations of CHD development and CT application toward the management of individuals at risk of developing or suspected of having CHD.
• Won, J. H., Jeon, Y., Rosenberg, J. K., Yoon, S., Rubin, G. D., & Napel, S. (2013). Uncluttered Single-Image Visualization of Vascular Structures Using GPU and Integer Programming. IEEE transactions on visualization and computer graphics, 19(1), 81-93.
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  Direct projection of 3D branching structures, such as networks of cables, blood vessels, or neurons onto a 2D image creates the illusion of intersecting structural parts and creates challenges for understanding and communication. We present a method for visualizing such structures, and demonstrate its utility in visualizing the abdominal aorta and its branches, whose tomographic images might be obtained by computed tomography or magnetic resonance angiography, in a single 2D stylistic image, without overlaps among branches. The visualization method, termed uncluttered single-image visualization (USIV), involves optimization of geometry. This paper proposes a novel optimization technique that utilizes an interesting connection of the optimization problem regarding USIV to the protein structure prediction problem. Adopting the integer linear programming-based formulation for the protein structure prediction problem, we tested the proposed technique using 30 visualizations produced from five patient scans with representative anatomical variants in the abdominal aortic vessel tree. The novel technique can exploit commodity-level parallelism, enabling use of general-purpose graphics processing unit (GPGPU) technology that yields a significant speedup. Comparison of the results with the other optimization technique previously reported elsewhere suggests that, in most aspects, the quality of the visualization is comparable to that of the previous one, with a significant gain in the computation time of the algorithm.
• Christe, A., Lin, M. C., Yen, A. C., Hallett, R. L., Roychoudhury, K., Schmitzberger, F., Fleischmann, D., Leung, A. N., Rubin, G. D., Rubin, G. D., Vock, P., & Roos, J. E. (2012). CT patterns of fungal pulmonary infections of the lung: comparison of standard-dose and simulated low-dose CT. European journal of radiology, 81(10), 2860-6.
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  To assess the effect of radiation dose reduction on the appearance and visual quantification of specific CT patterns of fungal infection in immuno-compromised patients.
• Pierce, L., Raman, K., Rosenberg, J., & Rubin, G. D. (2012). Quality Improvement in 3D Imaging. AJR. American journal of roentgenology, 198(1), 150-5.
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  The purpose of this study was to assess the effect of a quality control program on reducing errors in the generation of 3D images.
• Sommer, W. H., Becker, C. R., Haack, M., Rubin, G. D., Weidenhagen, R., Schwarz, F., Nikolaou, K., Reiser, M. F., Johnson, T. R., & Clevert, D. A. (2012). Time-resolved CT angiography for the detection and classification of endoleaks. Radiology, 263(3), 917-26.
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  To assess the feasibility and diagnostic performance of time-resolved computed tomographic (CT) angiography in the detection and classification of endoleaks after endovascular aortic aneurysm repair (EVAR) in high-risk patients.
• Takaoka, H., Ishibashi, I., Uehara, M., Rubin, G. D., Komuro, I., & Funabashi, N. (2012). Comparison of image characteristics of plaques in culprit coronary arteries by 64 slice CT and intravascular ultrasound in acute coronary syndromes. International journal of cardiology, 160(2), 119-26.
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  To evaluate plaque image characteristics in coronary artery culprit-lesions in subjects with acute coronary syndromes (ACS), we retrospectively compared coronary arterial images by 64-slice CT before conventional-coronary-angiogram with those by intravascular ultrasound (IVUS).
• Tall, M., Choudhury, K. R., Napel, S., Roos, J. E., & Rubin, G. D. (2012). Accuracy of a remote eye tracker for radiologic observer studies: effects of calibration and recording environment. Academic radiology, 19(2), 196-202.
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  To determine the accuracy and reproducibility of a remote eye-tracking system for studies of observer gaze while displaying volumetric chest computed tomography (CT) images.
• Marin, D., Nelson, R. C., Rubin, G. D., & Schindera, S. T. (2011). Body CT: technical advances for improving safety. AJR. American journal of roentgenology, 197(1), 33-41.
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  In this review, we attempt to address many of the issues that are related to ensuring patient benefit in body CT, balancing the use of ionizing radiation and iodinated contrast media. We attempt to not only summarize the literature but also make recommendations relevant to CT protocols, including the technical parameters of both the scanner and the associated contrast media.
• Nakatamari, H., Ueda, T., Ishioka, F., Raman, B., Kurihara, K., Rubin, G. D., Ito, H., & Sze, D. Y. (2011). Discriminant analysis of native thoracic aortic curvature: risk prediction for endoleak formation after thoracic endovascular aortic repair. Journal of vascular and interventional radiology : JVIR, 22(7), 974-979.e2.
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  To determine the association of native thoracic aortic curvature measured from computed tomographic (CT) angiography categorized by discriminant analysis with the development of endoleaks after thoracic endovascular aortic repair (EVAR).
• Pu, J., Paik, D. S., Meng, X., Roos, J. E., & Rubin, G. D. (2011). Shape "break-and-repair" strategy and its application to automated medical image segmentation. IEEE transactions on visualization and computer graphics, 17(1), 115-24.
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  In three-dimensional medical imaging, segmentation of specific anatomy structure is often a preprocessing step for computer-aided detection/diagnosis (CAD) purposes, and its performance has a significant impact on diagnosis of diseases as well as objective quantitative assessment of therapeutic efficacy. However, the existence of various diseases, image noise or artifacts, and individual anatomical variety generally impose a challenge for accurate segmentation of specific structures. To address these problems, a shape analysis strategy termed "break-and-repair" is presented in this study to facilitate automated medical image segmentation. Similar to surface approximation using a limited number of control points, the basic idea is to remove problematic regions and then estimate a smooth and complete surface shape by representing the remaining regions with high fidelity as an implicit function. The innovation of this shape analysis strategy is the capability of solving challenging medical image segmentation problems in a unified framework, regardless of the variability of anatomical structures in question. In our implementation, principal curvature analysis is used to identify and remove the problematic regions and radial basis function (RBF) based implicit surface fitting is used to achieve a closed (or complete) surface boundary. The feasibility and performance of this strategy are demonstrated by applying it to automated segmentation of two completely different anatomical structures depicted on CT examinations, namely human lungs and pulmonary nodules. Our quantitative experiments on a large number of clinical CT examinations collected from different sources demonstrate the accuracy, robustness, and generality of the shape "break-and-repair" strategy in medical image segmentation.
• Raman, B., Raman, R., Rubin, G. D., & Napel, S. (2011). Automated tracing of the adventitial contour of aortoiliac and peripheral arterial walls in CT angiography (CTA) to allow calculation of non-calcified plaque burden. Journal of digital imaging, 24(6), 1078-86.
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  Aortoiliac and lower extremity arterial atherosclerotic plaque burden is a risk factor for the development of visceral and peripheral ischemic and aneurismal vascular disease. While prior research allows automated quantification of calcified plaque in these body regions using CT angiograms, no automated method exists to quantify soft plaque. We developed an automatic algorithm that defines the outer wall contour and wall thickness of vessels to quantify non-calcified plaque in CT angiograms of the chest, abdomen, pelvis, and lower extremities. The algorithm encodes the search space as a constrained graph and calculates the outer wall contour by deriving a minimum cost path through the graph, following the visible outer wall contour while minimizing path tortuosity. Our algorithm was statistically equivalent to a reference standard made by two reviewers. Absolute error was 1.9 ± 2.3% compared to the inter-observer variability of 3.9 ± 3.6%. Wall thickness in vessels with atherosclerosis was 3.4 ± 1.6 mm compared to 1.2 ± 0.4 mm in normal vessels. The algorithm shows promise as a tool for quantification of non-calcified plaque in CT angiography. When combined with previous research, our method has the potential to quantify both non-calcified and calcified plaque in all clinically significant systemic arteries, from the thoracic aorta to the arteries of the calf, over a wide range of diameters. This algorithm has the potential to enable risk stratification of patients and facilitate investigations into the relationships between asymptomatic atherosclerosis and a variety of behavioral, physiologic, pathologic, and genotypic conditions.
• Ueda, T., Takaoka, H., Raman, B., Rosenberg, J., & Rubin, G. D. (2011). Impact of quantitatively determined native thoracic aortic tortuosity on endoleak development after thoracic endovascular aortic repair. AJR. American journal of roentgenology, 197(6), W1140-6.
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  The objective of our study was to assess whether there is an association between native thoracic aortic curvature and the development of endoleaks after thoracic endovascular aortic repair.
• , A. C., Mark, D. B., Berman, D. S., Budoff, M. J., Carr, J. J., Gerber, T. C., Hecht, H. S., Hlatky, M. A., Hodgson, J. M., Lauer, M. S., Miller, J. M., Morin, R. L., Mukherjee, D., Poon, M., Rubin, G. D., & Schwartz, R. S. (2010). ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation, 121(22), 2509-43.
• , A. C., Mark, D. B., Berman, D. S., Budoff, M. J., Carr, J. J., Gerber, T. C., Hecht, H. S., Hlatky, M. A., Hodgson, J. M., Lauer, M. S., Miller, J. M., Morin, R. L., Mukherjee, D., Poon, M., Rubin, G. D., & Schwartz, R. S. (2010). ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Journal of the American College of Cardiology, 55(23), 2663-99.
• Choudhury, K. R., Paik, D. S., Yi, C. A., Napel, S., Roos, J., & Rubin, G. D. (2010). Assessing operating characteristics of CAD algorithms in the absence of a gold standard. Medical physics, 37(4), 1788-95.
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  The authors examine potential bias when using a reference reader panel as "gold standard" for estimating operating characteristics of CAD algorithms for detecting lesions. As an alternative, the authors propose latent class analysis (LCA), which does not require an external gold standard to evaluate diagnostic accuracy.
• Hellinger, J. C., Epelman, M., & Rubin, G. D. (2010). Upper extremity computed tomographic angiography: state of the art technique and applications in 2010. Radiologic clinics of North America, 48(2), 397-421, ix.
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  From technical and interpretative perspectives, upper extremity computed tomographic angiography (CTA) is one of the more challenging vascular CTA applications. Synchronizing the relatively large scan coverage with a single bolus of contrast medium requires precise selection of acquisition and contrast delivery parameters. To avoid multiple acquisitions and minimize radiation exposure and contrast medium volume, it is important to have fundamental knowledge on how to select these parameters. Equally important is knowing how to adeptly apply advanced workstation visualization techniques and tool functions for the upper extremity vascular tree. In this review, upper extremity arterial and venous anatomy is discussed, followed by a detailed overview on state-of-the-art upper extremity CTA technical considerations and strategies. The review concludes with discussion and illustration of upper extremity CTA clinical applications.
• Lee, C. I., Tsai, E. B., Sigal, B. M., Plevritis, S. K., Garber, A. M., & Rubin, G. D. (2010). Incidental extracardiac findings at coronary CT: clinical and economic impact. AJR. American journal of roentgenology, 194(6), 1531-8.
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  The purpose of this study was to evaluate the prevalence of incidental extracardiac findings on coronary CT, to determine the associated downstream resource utilization, and to estimate additional costs per patient related to the associated diagnostic workup.
• Mark, D. B., Berman, D. S., Budoff, M. J., Carr, J. J., Gerber, T. C., Hecht, H. S., Hlatky, M. A., Hodgson, J. M., Lauer, M. S., Miller, J. M., Morin, R. L., Mukherjee, D., Poon, M., Rubin, G. D., Schwartz, R. S., & , A. C. (2010). ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 76(2), E1-42.
• Raman, B., Raman, R., Napel, S., & Rubin, G. D. (2010). Automated quantification of aortoaortic and aortoiliac angulation for computed tomographic angiography of abdominal aortic aneurysms before endovascular repair: preliminary study. Journal of vascular and interventional radiology : JVIR, 21(11), 1746-50.
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  The degree of angulation of abdominal aortic aneurysms (AAAs) has emerged as an important factor in assessing eligibility for endovascular aneurysm repair (EVAR). The authors developed an automatic algorithm that reduces variability of measurement of aortoiliac angulation. For highly structured manual methods, intraobserver variability was 8.2 degrees ± 5.0 (31% ± 20) and interobserver variability was 5.6 degrees ± 2.5 (20% ± 9.1) compared with 0.6 degrees ± 0.8 (2.2% ± 3.6) (intraobserver) and 0.4 degrees ± 0.4 (1.4% ± 1.9) (interobserver) for the automatic algorithm (P < .01). In phantoms, the automatically measured angles were equivalent to reference values (P < .05). This algorithm was also faster than manual methods and has the potential to enhance the clinical utility and reliability of computed tomographic angiography for preoperative assessment for EVAR.
• Roos, J. E., Paik, D., Olsen, D., Liu, E. G., Chow, L. C., Leung, A. N., Mindelzun, R., Choudhury, K. R., Naidich, D. P., Napel, S., & Rubin, G. D. (2010). Computer-aided detection (CAD) of lung nodules in CT scans: radiologist performance and reading time with incremental CAD assistance. European radiology, 20(3), 549-57.
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  The diagnostic performance of radiologists using incremental CAD assistance for lung nodule detection on CT and their temporal variation in performance during CAD evaluation was assessed.
• Taylor, A. J., Cerqueira, M., Hodgson, J. M., Mark, D., Min, J., O'Gara, P., Rubin, G. D., , A. C., , S. o., , A. C., , A. H., , A. S., , A. S., , N. A., , S. f., & , S. f. (2010). ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Circulation, 122(21), e525-55.
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  The American College of Cardiology Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research.
• Taylor, A. J., Cerqueira, M., Hodgson, J. M., Mark, D., Min, J., O'Gara, P., Rubin, G. D., , A. C., , S. o., , A. C., , A. H., , A. S., , A. S., , N. A., , S. f., , S. f., Kramer, C. M., Berman, D., Brown, A., , Chaudhry, F. A., et al. (2010). ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Journal of the American College of Cardiology, 56(22), 1864-94.
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  The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance (CMR) appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria (1). The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease (CAD) was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography (CT) for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research.
• Terashima, M., Nguyen, P. K., Rubin, G. D., Meyer, C. H., Shimakawa, A., Nishimura, D. G., Ehara, S., Iribarren, C., Courtney, B. K., Go, A. S., Hlatky, M. A., Fortmann, S. P., & McConnell, M. V. (2010). Right coronary wall CMR in the older asymptomatic advance cohort: positive remodeling and associations with type 2 diabetes and coronary calcium. Journal of cardiovascular magnetic resonance : official journal of the Society for Cardiovascular Magnetic Resonance, 12, 75.
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  Coronary wall cardiovascular magnetic resonance (CMR) is a promising noninvasive approach to assess subclinical atherosclerosis, but data are limited in subjects over 60 years old, who are at increased risk. The purpose of the study was to evaluate coronary wall CMR in an asymptomatic older cohort.
• Ueda, T., Fleischmann, D., Dake, M. D., Rubin, G. D., & Sze, D. Y. (2010). Incomplete endograft apposition to the aortic arch: bird-beak configuration increases risk of endoleak formation after thoracic endovascular aortic repair. Radiology, 255(2), 645-52.
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  To determine the clinical importance of the bird-beak configuration after thoracic endovascular aortic repair (TEVAR).
• Alexander, S. A., & Rubin, G. D. (2009). Imaging the thoracic aorta: anatomy, technical considerations, and trauma. Seminars in roentgenology, 44(1), 8-15.
• Chang, J., & Rubin, G. D. (2009). Solitary intercostal arterial trunk: a previously unreported anatomical variant. Circulation. Cardiovascular imaging, 2(6), e49-50.
• Lee, K. K., Fortmann, S. P., Fair, J. M., Iribarren, C., Rubin, G. D., Varady, A., Go, A. S., Quertermous, T., & Hlatky, M. A. (2009). Insulin resistance independently predicts the progression of coronary artery calcification. American heart journal, 157(5), 939-45.
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  Change in coronary artery calcification is a surrogate marker of subclinical coronary artery disease (CAD). In the only large prospective study, CAD risk factors predicted progression of coronary artery calcium (CAC).
• Won, J. H., Rosenberg, J., Rubin, G. D., & Napel, S. (2009). Uncluttered single-image visualization of the abdominal aortic vessel tree: method and evaluation. Medical physics, 36(11), 5245-60.
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  The authors develop a method to visualize the abdominal aorta and its branches, obtained by CT or MR angiography, in a single 2D stylistic image without overlap among branches.
• Zhao, S. H., Logan, L., Schraedley, P., & Rubin, G. D. (2009). Assessment of the anterior spinal artery and the artery of Adamkiewicz using multi-detector CT angiography. Chinese medical journal, 122(2), 145-9.
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  Damage to the spinal cord after the treatment of the descending thoracic and thoracoabdominal aortic aneurysms is an uncommon but devastating complication. The artery of Adamkiewicz (AKA) is the principal arterial supply of the anterior spinal artery (ASA) in the lower thoracic and lumbar level. The purpose of this study was to evaluate the visualization of the anterior spinal artery and the artery of Adamkiewicz, the affecting factors for the detection rate using multi-detector row CT (MDCT).
• Assimes, T. L., Knowles, J. W., Basu, A., Iribarren, C., Southwick, A., Tang, H., Absher, D., Li, J., Fair, J. M., Rubin, G. D., Sidney, S., Fortmann, S. P., Go, A. S., Hlatky, M. A., Myers, R. M., Risch, N., & Quertermous, T. (2008). Susceptibility locus for clinical and subclinical coronary artery disease at chromosome 9p21 in the multi-ethnic ADVANCE study. Human molecular genetics, 17(15), 2320-8.
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  A susceptibility locus for coronary artery disease (CAD) at chromosome 9p21 has recently been reported, which may influence the age of onset of CAD. We sought to replicate these findings among white subjects and to examine whether these results are consistent with other racial/ethnic groups by genotyping three single nucleotide polymorphisms (SNPs) in the risk interval in the Atherosclerotic Disease, Vascular Function, and Genetic Epidemiology (ADVANCE) study. One or more of these SNPs was associated with clinical CAD in whites, U.S. Hispanics and U.S. East Asians. None of the SNPs were associated with CAD in African Americans although the power to detect an odds ratio (OR) in this group equivalent to that seen in whites was only 24-30%. ORs were higher in Hispanics and East Asians and lower in African Americans, but in all groups the 95% confidence intervals overlapped with ORs observed in whites. High-risk alleles were also associated with increased coronary artery calcification in controls and the magnitude of these associations by racial/ethnic group closely mirrored the magnitude observed for clinical CAD. Unexpectedly, we noted significant genotype frequency differences between male and female cases (P = 0.003-0.05). Consequently, men tended towards a recessive and women tended towards a dominant mode of inheritance. Finally, an effect of genotype on the age of onset of CAD was detected but only in men carrying two versus one or no copy of the high-risk allele and presenting with CAD at age >50 years. Further investigations in other populations are needed to confirm or refute our findings.
• Burt, J. R., Iribarren, C., Fair, J. M., Norton, L. C., Mahbouba, M., Rubin, G. D., Hlatky, M. A., Go, A. S., Fortmann, S. P., & , A. D. (2008). Incidental findings on cardiac multidetector row computed tomography among healthy older adults: prevalence and clinical correlates. Archives of internal medicine, 168(7), 756-61.
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  With the widespread use of cardiac multidetector row computed tomography (MDCT), the issue of incidental findings is receiving increasing attention. Our objectives were to evaluate the prevalence of incidental findings discovered during cardiac MDCT scanning and to identify clinical variables associated with incidental findings.
• Douglas, P. S., Cerqueria, M., Rubin, G. D., & Chin, A. S. (2008). Extracardiac findings: what is a cardiologist to do?. JACC. Cardiovascular imaging, 1(5), 682-7.
• Hsu, C. S., Hellinger, J. C., Rubin, G. D., & Chang, J. (2008). CT angiography in pediatric extremity trauma: preoperative evaluation prior to reconstructive surgery. Hand (New York, N.Y.), 3(2), 139-45.
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  Computed tomographic angiography (CTA) is a noninvasive modality for evaluating the vascular system and planning treatment strategies. The goal of this study was to validate the clinical utility of CTA in assessment of suspected pediatric extremity traumatic vascular injury, prior to emergent and delayed reconstructive surgery. A retrospective review was performed of all operative patients under 18 years of age who underwent multidetector-row CTA for evaluation of suspected extremity vascular injury. Parameters investigated included age, type of injury, referral source, temporal relationship between the injury and the CTA, CTA findings, operations performed, intraoperative findings, and clinical outcome. Between January 2002 and September 2005, 10 pediatric patients (6 males/4 females; mean age 8 years old, range 3-17) sustained either blunt (N = 8) or penetrating (N = 2) trauma and underwent CTA of the upper (N = 5) or lower extremities (N = 5). A total of 30% (3/10) of patients were referred from the emergency department acutely, 50% (5/10) were referred from the inpatient wards subacutely, and 20% (2/10) were referred from the outpatient clinics electively. Half (N = 5) underwent CTA to evaluate need for vascular repair, whereas half (N = 5) underwent CTA to evaluate local vasculature for flap reconstruction. Overall, 40% (4/10) of CTA findings were normal, whereas 60% (6/10) revealed traumatic vascular injuries. Pertinent nonvascular findings included soft tissue defects (60%, 6/10), fractures (40%, 4/10), and contracture deformities (20%, 2/10). In all cases, procedures were completed without complications, and intraoperative findings confirmed those from CTA. At a mean follow-up of 28 months, all injuries have healed without complications. CTA is a reliable noninvasive modality to evaluate pediatric patients with suspected traumatic extremity vascular injury and to plan treatment strategies for both vascular repair and extremity reconstruction.
• Iribarren, C., Hlatky, M. A., Chandra, M., Fair, J. M., Rubin, G. D., Go, A. S., Burt, J. R., & Fortmann, S. P. (2008). Incidental pulmonary nodules on cardiac computed tomography: prognosis and use. The American journal of medicine, 121(11), 989-96.
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  Small asymptomatic lung nodules are found frequently in the course of cardiac computed tomography (CT) scanning. However, the utility of assessing and reporting incidental findings in healthy, asymptomatic subjects is unknown.
• Josephs, S. C., Rowley, H. A., Rubin, G. D., & , A. H. (2008). Atherosclerotic Peripheral Vascular Disease Symposium II: vascular magnetic resonance and computed tomographic imaging. Circulation, 118(25), 2837-44.
• Kaneoya, K., Ueda, T., Suito, H., Nanazawa, Y., Tamaru, J., Isobe, K., Naya, Y., Tobe, T., Motoori, K., Yamamoto, S., Rubin, G. D., Minami, M., & Ito, H. (2008). Functional computed tomography imaging of tumor-induced angiogenesis: preliminary results of new tracer kinetic modeling using a computer discretization approach. Radiation medicine, 26(4), 213-21.
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  The aim of this study was to establish functional computed tomography (CT) imaging as a method for assessing tumor-induced angiogenesis.
• Peng, P. D., Spain, D. A., Tataria, M., Hellinger, J. C., Rubin, G. D., & Brundage, S. I. (2008). CT angiography effectively evaluates extremity vascular trauma. The American surgeon, 74(2), 103-7.
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  Traditionally, conventional arteriography is the diagnostic modality of choice to evaluate for arterial injury. Recent technological advances have resulted in multidetector, fine resolution computed tomographic angiography (CTA). This study examines CTA for evaluation of extremity vascular trauma compared with conventional arteriography. Our hypothesis is that CTA provides accurate and timely diagnosis of peripheral vascular injuries and challenges the gold standard of arteriogram. Traumatic extremity injuries over a 5-year period were identified using a Level I trauma center registry and radiology database. Information collected included patient demographics, mechanism, imaging modality, vascular injuries, management, and follow-up. Two thousand two hundred and fifty-one patients were identified with extremity trauma. Twenty-four patients were taken directly to the operating room for evaluation and management of vascular injuries. Fifty-two underwent vascular imaging. Fourteen patients had conventional arteriograms with 13 abnormal studies: 7 were managed operatively, 2 embolized, and 4 observed. Thirty-eight patients underwent CTA with 17 abnormal scans: 9 were managed operatively, 3 embolized, and 5 observed. There were no false negatives or missed injuries. CTA provides accurate peripheral vascular imaging while additionally offering advantages of noninvasiveness and immediate availability. Secondary to these advantages, CTA has supplanted arteriography for initial radiographic evaluation of peripheral vascular injuries at our Level I trauma center. This study supports CTA as an effective alternative to conventional arteriography in assessing extremity vascular trauma.
• Pu, J., Roos, J., Yi, C. A., Napel, S., Rubin, G. D., & Paik, D. S. (2008). Adaptive border marching algorithm: automatic lung segmentation on chest CT images. Computerized medical imaging and graphics : the official journal of the Computerized Medical Imaging Society, 32(6), 452-62.
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  Segmentation of the lungs in chest-computed tomography (CT) is often performed as a preprocessing step in lung imaging. This task is complicated especially in presence of disease. This paper presents a lung segmentation algorithm called adaptive border marching (ABM). Its novelty lies in the fact that it smoothes the lung border in a geometric way and can be used to reliably include juxtapleural nodules while minimizing oversegmentation of adjacent regions such as the abdomen and mediastinum. Our experiments using 20 datasets demonstrate that this computational geometry algorithm can re-include all juxtapleural nodules and achieve an average oversegmentation ratio of 0.43% and an average under-segmentation ratio of 1.63% relative to an expert determined reference standard. The segmentation time of a typical case is under 1min on a typical PC. As compared to other available methods, ABM is more robust, more efficient and more straightforward to implement, and once the chest CT images are input, there is no further interaction needed from users. The clinical impact of this method is in potentially avoiding false negative CAD findings due to juxtapleural nodules and improving volumetry and doubling time accuracy.
• Raman, R., Raman, B., Napel, S., & Rubin, G. D. (2008). Semiautomated quantification of the mass and distribution of vascular calcification with multidetector CT: method and evaluation. Radiology, 247(1), 241-50.
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  Institutional review board approval was obtained for this HIPAA-compliant study. Informed consent was obtained for prospective evaluation in 21 asymptomatic volunteers (10 women, 11 men; mean age, 60 years) but waived for retrospective (10 patients with and five patients without disease) evaluation. Prospective validation was in phantoms. Quantification of mass and calcium distribution was performed with fast semiautomated method, without calibration. For actual versus measured mass in phantoms, R(2) was 0.98; absolute and percentage errors were 1.2 mg and 9.1%, respectively. In asymptomatic volunteers, mean interscan variability for calcium mass quantification in extracoronary arteries was 24.9 mg; mean was 991 units for Agatston scoring. In coronary arteries, mean variability was 5.5 mg; mean Agatston variability was 27.7 units. At retrospective computed tomography, mean total calcified mass was 321.3 mg. Accurate quantification of mass and distribution of calcification in simulated arteries with this method can be applied in vivo, with low interscan variability.
• Stillman, A. E., Rubin, G. D., Teague, S. D., White, R. D., Woodard, P. K., & Larson, P. A. (2008). Structured reporting: coronary CT angiography: a white paper from the American College of Radiology and the North American Society for Cardiovascular Imaging. Journal of the American College of Radiology : JACR, 5(7), 796-800.
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  With the growing use of electronic medical records, the trend of diagnostic imaging reporting is toward a more structured format. Advantages include improved quality and consistency of the reporting and ease of data mining. The essential elements of a structured report are provided and illustrated for coronary artery computed tomographic angiograms.
• Terashima, M., Nguyen, P. K., Rubin, G. D., Iribarren, C., Courtney, B. K., Go, A. S., Fortmann, S. P., & McConnell, M. V. (2008). Impaired coronary vasodilation by magnetic resonance angiography is associated with advanced coronary artery calcification. JACC. Cardiovascular imaging, 1(2), 167-73.
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  This study evaluated the hypothesis that impaired nitroglycerin (NTG)-induced coronary vasodilation is associated with advanced coronary atherosclerosis in asymptomatic older patients.
• Ueda, T., Fleischmann, D., Rubin, G. D., Dake, M. D., & Sze, D. Y. (2008). Imaging of the thoracic aorta before and after stent-graft repair of aneurysms and dissections. Seminars in thoracic and cardiovascular surgery, 20(4), 348-357.
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  Thoracic endovascular aortic repair (TEVAR) has become widely accepted as an important option for treatment of thoracic aortic diseases. Cross-sectional radiologic imaging plays a crucial role for evaluating a patient's candidacy for planning of the intervention and for assessment of postprocedural results and complications of TEVAR. Recent advances in imaging technologies, in part inspired by advances in stent-graft technology, have drastically changed the character and role of pre- and postprocedural imaging. Three-dimensional (3D) datasets acquired quickly by multidetector computed tomography (MDCT), angiography, or magnetic resonance angiography (MRA) allow multiplanar reformations and 3D viewing, as well as quantitative assessment of vessel lumens, walls, and surroundings. Catheter angiography, in contrast, is performed intraoperatively almost exclusively, and is no longer the gold standard for diagnostic or planning purposes. This article reviews state-of-the-art pre- and postprocedural imaging for TEVAR, especially focusing on the role of MDCT angiography.
• Poon, M., Rubin, G. D., Achenbach, S., Attebery, T. W., Berman, D. S., Brady, T. J., Jacobs, J. E., Hecht, H. S., Lima, J. A., & Weigold, W. G. (2007). Consensus update on the appropriate usage of cardiac computed tomographic angiography. The Journal of invasive cardiology, 19(11), 484-90.
• Rubin, G. D., & Silverman, S. G. (1995). HELICAL (SPIRAL) CT OF THE RETROPERITONEUM. Radiologic Clinics of North America. doi:10.1016/s0033-8389(22)00630-3
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  Helical CT promises to improve imaging of the retroperitoneum through the elimination of respiratory misregistration and the minimization of partial volume averaging. The speed of acquisition enables the entire abdomen and pelvis to be imaged in less than 2 minutes with standard collimator widths. This is a distinct advantage in critically ill patients, particularly in the case of trauma. Selective intravenously administered contrast enhancement is made possible with helical CT. Rapid scanning allows imaging in an arterial, renal cortical, renal medullary, or delayed collecting system phase. This property of helical CT enables CT angiography to emerge as a powerful minimally invasive alternative to conventional arteriography for imaging the abdominal aorta and its branches. After 4 years of investigating the use of volumetric CT, the clinical settings described herein remain the only clear indications for using helical CT in the kidney and retroperitoneum. These studies took advantage of the single most important feature of helical CT—the elimination of respiratory misregistration. Two broad diagnostic advantages result: (1) the ability to search and characterize a region thoroughly, such as in the evaluation of a small renal mass, or to search for the needle-tip during an interventional procedure; and (2) the ability to create multiplanar and 3-D images that are of sufficient quality to be useful in clinical practice, such as in imaging the vasculature (CT angiogram), and in surgical planning.

Presentations

• Rubin, G. D. (2022). Aortic Endografts: Issues for the Imager. Diagnostic Imaging Update. Jackson Hole, Wyoming: CME Science.