www.MidEssexRay.com

Payment structures influence dental radiography utilisation?

2009-04-13T12:40:00.006+01:00

NHS dentists were traditionally paid for individual “items of treatment”: each X-ray they took resulted in a payment. In England, the number of X-rays taken in 2003/04 averaged 53.2 per 100 “courses of treatment”. Since 2006, however, NHS dentists in England have not received payments for individual X-rays, but only for completed courses of treatment. Preliminary results for 2007/08 show that the number of X-rays taken by dentists in England has decreased to 31.5 per 100 courses of treatment. In Scotland, by contrast, where the traditional method of payment for dentists continues, there has been no equivalent reduction.

Margaret McCarthy
Financial Times 11 April 2009
link
blogs.ft.com/mccartney

Screening for occult cancer in idiopathic DVT?

2009-04-03T22:27:00.001+01:00

From:

Should patients with venous thrombosis have cancer screening?

RK Patel

Thrombus, 2009 Apr. Volume 13, Number 1.

http://www.thrombus.co.uk/thrombus/View_article.asp?AID=1988

Other Refs:

Venous Thromboembolism and Occult Malignancy: Simultaneous Detection During Pulmonary CT Angiography with CT Venography
Bierry et al. Am. J. Roentgenol 2008; 191: 885-889
DOI:10.2214/AJR.07.3516
http://www.ajronline.org/cgi/content/abstract/191/3/885

Occult malignancy in patients with venous thromboembolism: risk indicators and a...
Oktar et al. Phlebology.2007; 22: 75-79
http://phleb.rsmjournals.com/cgi/content/abstract/22/2/75

Screening for occult cancer in patients with acute venous thromboembolism.
Monreal M, Trujillo-Santos J.
Curr Opin Pulm Med. 2007 Sep;13(5):368-71.

[Occult cancer and venous thromboembolism: which screening in patients with inaugural deep vein thrombosis?]
Pathol Biol (Paris). 2008 Jun;56(4):205-10.
Lévesque H.[Article in French]

Recently completed trial:

Screening for Occult Malignancy in Idiopathic Venous Thromboembolism (Univeristy of Padova)

http://clinicaltrials.gov/ct2/show/NCT00361647

Twitter

2009-03-14T22:24:00.006Z

MidEssexRay is now tweeting at http://twitter.com/midessexray .
My tweets are on the top of this blog.

Other radiology tweets include
http://twitter.com/scanman
http://twitter.com/radrounds

There are discussions about twitter in medicine here and here , and here is a link to a list of medical tweets.

More on Speech Recognition

2009-03-14T11:44:00.004Z

We've been using it for a while.
I like it but I'm the first to admit that there are problems, one of which is errors in transcription, aggravated by the fact that I'm not a very good proofreader.

Here's an interesting post from Dr Dalai discussing recent publications in the literature.
Speech Recognition Sucks and it Costs More

Picture of robot sculptures by Clayton Bailey from
http://www.c2i.ntu.edu.sg/AI+CI/Resources/AI_Artwork/RobotSculptures-Bailey97.html

www.academicproductivity.com

2009-02-26T07:23:00.003Z

I found this site while googling "online reference management software". It's a blog with lots of interesting articles, for those who are interested in such things.
Apart from periodic reviews on reference managers, other articles I liked were:
Stop Powerpointing and Start Outlining in which the author points out the disadvantages of using powerpoint to plan your talk, and suggests n alternative method,
and a discussion of a post from Luis Ahn discussing the difference between research and publishing papers.

http://www.academicproductivity.com/

So does it matter if your workforce is unhappy?

2009-01-23T12:28:00.005Z

Almost one half of radiologists actively interpreting mammograms do not enjoy that part of their job. Reported enjoyment was not related to performance

Radiologists' performance and their enjoyment of interpreting screening mammograms.

Geller BM, Bowles EJ, Sohng HY, Brenner RJ, Miglioretti DL, Carney PA, Elmore JG.

AJR Am J Roentgenol. 2009 Feb;192(2):361-9.
Link

Portable CT scanner

2009-01-09T12:50:00.004Z

I came across this product on the internet: The CereTom 8-slice portable CT scanner.

Radiographer ghholt has a picture of it on Flickr parked in a hospital corridor with the comment

When I started CT Scanning 28 years ago I never thought I would ever be pushing a portable again. Now all the CT Tech's out there have something to look forward to...

"Seeing real people"

2008-12-06T18:42:00.004Z

A study presented at the RSNA suggests that the performance of radiologists is improved when they have a picture of the patient whose examination is being reported.

Hmm...

Source:

The Placebo Journal blog

Wall Street Journal

BoneXpert: automated bone age determination

2008-11-07T23:22:00.006Z

BoneXpert is a software product that computes bone age automatically based using the Greulich-Pyle and the Tanner-Whitehouse systems. It is installed on a PC and can be set up as a "PACS listener" so that the radiographer can send the hand x-ray (as a DICOM file) from PACS to the BoneXpert PC, where the analysis is carried out automatically in 10 seconds. The images then appear on the BoneXpert PC with the patient details and the name of the referring physician.

I haven't tried it myself, but the program can be downloaded from the website. The first five analyses are free. Thereafter, licensing thereafter is on a fee-per-analysis basis, currently 5 Euro per image, with discounts for developing countries. BoneXpert "conforms to the European Community Directive for Medical Devices EC 1993/42, as indicated by the CE mark".

The website also has a list of publications which have been accepted in peer-reviwed journals which suggest that the product has been validated , based on the Greulich-Pyle atlas.

Sounds interesting, and possibly even cost-effective.

Socioeconomic Status Most Important Factor in NHL Survival

2008-11-01T11:42:00.004Z

I've been rich and I've been poor. Believe me, rich is better.

Mae West

Low socioeconomic status is significantly associated with a higher risk for mortality among elderly patients with non-Hodgkin's lymphoma (NHL) Low socioeconomic status is significantly associated with a higher risk for mortality among elderly patients with non-Hodgkin's lymphoma (NHL).

Article in Medscape

Ref:

Wang M, Burau KD, Fang S, Wang H, Du XL.

Ethnic variations in diagnosis, treatment, socioeconomic status, and survival in a large population-based cohort of elderly patients with non-Hodgkin lymphoma.

Cancer. 2008 Oct 20. [Epub ahead of print]

Also:

Bray C, Morrison DS, McKay P.

Socio-economic deprivation and survival of non-Hodgkin lymphoma in Scotland.

Leuk Lymphoma. 2008 May;49(5):917-23.

X-rays generated from sticky tape

2008-10-24T12:21:00.004+01:00

Researchers at UCLA have found that peeling sticky tape in a vacuum generated sufficient x-rays to obtain a radiograph of a finger.
ref: Camara, C. G., Escobar, J. V., Hird, J. R. & Putterman, S. J. Nature 455, 1089–1092 (2008).
Nature News Published online 22 October 2008 doi:10.1038/news.2008.1185
Read more...

(Thanks to BoingBoing)

Piero della Francesca and multiplanar recons

2008-10-24T10:41:00.003+01:00

From Piero della Francesca's, De prospectiva pingendi, Book 3, figure lxiv. Casa Editrice Le Lettere

The brain continues to be represented using projections first devised in Renaissance Italy to illustrate the head; and for the neuroscientist 600 years later, Piero's little known illustrations provide a remarkable legacy of graphic representation that endures to this day

GD Schott
Perspectives, The art of medicine: Piero della Francesca's projections and neuroimaging today
The Lancet 2008; 372:1378-1379
DOI:10.1016/S0140-6736(08)61576-7
http://www.thelancet.com/journals/lancet/article/PIIS0140673608615767/fulltext

Auctioning Radiology Services

2008-10-17T14:02:00.007+01:00

Jean-Léon Gérôme Slave Auction (c1884)

A new firm called Telerays has developed a novel Web-based auction approach to teleradiology services that calls for readings to be awarded to the lowest bidder. The company is currently recruiting radiologists to sign up to provide readings and is marketing its services to hospitals and imaging centers.

A couple of useful online utilities

2008-09-19T09:30:00.017+01:00

Gustav Klutsis. (Latvian, 1895-1944). Maquette for Radio-Announcer. 1922. Painted cardboard, paper, wood, thread, and metal brads, 45 3/4 x 14 1/2 x 14 1/2" (106.1 x 36.8 x 36.8 cm). Sidney and Harriet Janis Collection Fund. Museum of Modern Art, New York. http://www.moma.org/

I recently discovered a usfeul online utility (free of course) called slideshare (http://www.slideshare.net/), where you can post you powerpoints online. It feels a bit like YouTube, except that it has slideshows rather than videos.

I gave a talk this morning to our surgeons about "Personalising your Internet" by using Web 2.0 applications like iGoogle, Google Reader, Google Docs, CiteuLike, and so on, which I have posted on Slideshare. (Link)

Another site I have been playing with is Survey Pro (http://www.esurveyspro.com/), which allows you to set up online surveys. There are free and paid versions. It's easy to use, and worth looking at if you ever want to conduct an online survey.

Digital rectal examination in primary care not that accurate?

2008-09-09T11:07:00.011+01:00

Albrecht Durer Hand (21 May 1471)

http://astrodreamer.squarespace.com/blog/2008/6/19/miles-davis-irving-penn-durer-emerson.html

I found this a bit surprising:

1069 patients were referred to the University Hospital of North Staffordshire to the 14-day urgent colorectal cancer referral service. Of these, 108 patients were referred as having a 'palpable rectal tumour'. Only 32 of the 108 were found to have a rectal lesion on examination in the hospital. Ten tumours were missed by GPs' DREs.

The diagnostic value of digital rectal examination in primary care for palpable rectal tumour
C. W. Ang, R. Dawson, C. Hall and M. Farmer Colorectal Disease
Published Online: 14 Sep 2007
DOI 10.1111/j.1463-1318.2007.01381

http://www3.interscience.wiley.com/journal/120125657/abstract

New accessory for PACS workstation

2008-08-15T11:51:00.004+01:00

Just back after 4 weeks away on an Art History summer school at the Courtauld Institute. It's been quite busy at work, and I've not had much time for lunch on some days. I've just learnt of a device that it might be possible to have installed in our PACS workstations that may come in useful at times like this: a PC toaster.

When I looked today it was only 29 US dollars from this site.

Check out this reporting station

2008-07-15T01:48:00.001+01:00

This is the "Aura" from Poetic Technologies. Here's a review. What more could one ask for in a reporting station?

whichinterventionaldevice.com

2008-07-11T01:02:00.006+01:00

Vittorio Carpaccio
St George and the Dragon (1502) Scuola di San Giorgio degli Schiavoni, Venice from the Web Gallery of Art

'Which Interventional Device' is a community-based website, run by interventional radiologist Philip Haslam, providing information on interventional devices with reviews from actual users.

This is fantastic! I've been looking for something like this for ages, and it is likely to be incredibly useful, as it can be difficult getting information about these products from people not employed by the vendors.

In addition to information about interventional devices, there is a training section with instructional videos of interventional procedures, and a global interventional forum for discussing cases. They are expanding into imaging equipment as well, and the site has a review of the Zonare ultrasound system. Coming up next year, from the same team, is 'Which Medical Device'.

Different technical approaches to high-end CT

2008-07-11T00:11:00.006+01:00

Vladimir Tatlin Model of the Monument to the Third International (1920) from Essential Architecture

A few years ago, when I was trying to decide which 4-slice CT scanner to buy, the author of a famous CT textbook, whom I met at a conference, told me "They're all the same. Just choose the one who gives you the best deal".

Things are not so simple anymore. The various manufacturers have adopted quite different appoaches to high-end CT. Here's a nice article in Aunt Minnie, based on a talk by Matthias Prokop:

Fourth-generation MDCT scanners do cardiac differently

Localisation of contraceptive implants

2008-07-10T11:24:00.004+01:00

Briton Riviere, Androcles and the Lion (1908) Auckland Art Gallery

I've been asked on a couple of occasions to localise a contraceptive implant that the referring doctors wanted to remove and had difficulty locating. I found this a bit difficult until I looked on google and found that the manufacturers had full and detailed instructions online. Here's one: http://www.implanonlocalization.com/ , with a comprehensive 18-page pdf manual, plus a couple of videos thrown in for good measure. It's obviously a bit of a problem if they've gone to all this effort. Ultrasound is the imaging method of choice. If this fails, they recommend MRI. I've not had to resort to MRI.

CT for detecting post oesphagectomy leak

2008-07-07T07:00:00.003+01:00

Joseph Mallord William Turner Seascape with a Squall Coming Up © Tokyo Fuji Art Museum

The authors of this study found that

CT was better tolerated and more sensitive but less specific than fluoroscopy for detecting occult anastomotic leak.

Radiological detection of post-oesophagectomy anastomotic leak a comparison between multidetector CT and fluoroscopy
by: S Upponi, A Ganeshan, H Dcosta, M Betts, N Maynard, H Bungay, A Slater
British Journal of Radiology, Vol. 81, No. 967. (July 2008), pp. 545-548.
Link

Medworm RSS filter engine

2008-07-06T07:00:00.002+01:00

Looking for an RSS feed for a journal? Can't find it on their website? You could try googling it, or you could look in Medworm. I was looking for an RSS feed for Clinical Radiology and found it through Medworm. They didn't have one for the British Journal of Radiology, though, and I couldn't find it on the BIR site either, but located it via Google.

As an aside, I used to use iGoogle as a means of getting RSS feeds, but have since switched to Google reader. On iGoogle, a maximum of 9 items are displayed, which is not sufficient for all the articles in one issue of a journal. I also find Google reader easier to organise. I'm sure there are lots of other feed readers out there, but I seem to do most things through Google, and the reader works fine for me, so I haven't bothered to try any of the others.

The National Health Service is 60 years old today

2008-07-05T09:21:00.011+01:00

Illustration from the cover of todays BMJ

The British National Health Service started on 5 July 1948, 60 years ago today.
The online Guardian has an interesting page to mark this event, with lots of articles and features, and I recently posted a 1948 public information film explaning the new service, as well as a clip from Michael Moore's film Sicko, which you can see here.

Reducing unnecessary MRI and CT scans could cut wait times: study

2008-07-04T22:22:00.012+01:00

Pietro Longhi. The Pharmacist. Galleria dell'Accademia, Venice

Wait times for MRI and CT scans in Ontario - and probably elsewhere in Canada - could be reduced by cutting back on unnecessary scans ordered by doctors, a new study suggests.
"I think all of Canada is experiencing challenges with wait times. And I guess our message would be if you can cut down the inappropriate use, then you can actually improve access for the people who actually will benefit," lead author Dr. John You said.

The title of this post is taken from an article in the website of the Canadian Broadcasting Corporation (CBC). Radiologists might smile wearily, but I guess it's intended for the general public who may not be aware of what we all take for granted. In fact, there are some interesting findings about variations in imaging utilisation and the diagnostic yield of various common investigations. The authors of the study suggest that:

The province should develop a web-based ordering system that would capture, in real time, the reasons why imaging tests are ordered and test results. Such a system would make it easier to audit the appropriateness of ordering patterns.

Read more here.

The study is said to have been published in the June issue of the Canadian Association of Radiologists Journal but I couldn't find it in the table of contents. Perhaps they meant July.

Surf the web, send emails, view CT scans and more on your ultrasound scanner

2008-07-03T01:46:00.007+01:00

The Siemens Acuson P50 ultrasound scanner is powered by an Apple MacBook Pro , Apple MacBook laptop with 2 GB RAM, a 160 GB hard disk and a 2.0GHz Intel Dual-Core Pentium M processor. It's intended for cardiac and vascular applications.

Apparently they've placed an order at the Royal London.

It can be connected to the internet and function as a normal Mac laptop, and I guess you could install Osirix on it and use it as a DICOM workstation.

Safety of Buscopan (it's safe)

2008-06-28T20:21:00.006+01:00

Buscopan (hyoscine-N-butylbromide) is widely used as a spasmolytic for barium enemas, CT colonography, and abdominal MRI to improve the quality of the examination. It's a safe drug: safer than many people realise. Here is some sensible advice from the authors of a recent review article

All radiologists and radiographers either supervising examinations where this drug is used or those administering it directly to the patient need to be aware of the true contraindications. This should not include all patients with ischaemic heart disease or those with glaucoma. We would recommend that only patients with unstable cardiac disease have Buscopan withheld and that all patients are told to attend hospital immediately if, following the examination, they develop painful, blurred vision, in one or both eyes.

R. Dyde, A.H. Chapman, R. Gale, A. Mackintosh and D.J.M. Tolan
Precautions to be taken by radiologists and radiographers when prescribing hyoscine-N-butylbromide
Clinical Radiology 2008 July; 63 (7): 739-743.
doi:10.1016/j.crad.2008.02.008

Pubmed

Most radiologists feel that Buscopan is more effective than glucagon, and there are studies to support this view, such as this one by Rogalla et al (Radiology 2005;236:184-188).

I really can't figure out why it's not licensed in the United States. In the US it is approved for the treatment of flatulent colic in horses although not if the horses are going to be eaten by humans. (Link to product info)

The Radiology Assistant

2008-06-26T23:58:00.005+01:00

the Radiology Assistant is the educational web site of the Radiological Society of The Netherlands, focusing on common radiological issues in a problem oriented way for radiology residents and radiologists.

This is an excellent site and a superb source of reference, with lots of succinct articles written by experts in the field. Highly recommended. Check it out. It's been added as a link in the sidebar of this blog.

"A centrally funded health service, free at the point of delivery"

2008-06-22T12:17:00.010+01:00

This public information film from 1948, when the British National Health Service was founded, is a timely reminder of what it's all about.

...the hunt for a better funding model is never called off, with each new foray unfolding along similar lines. It begins with the NHS being judged as seriously underperforming. The real reason for this, whether admitted by the government of the day or not, is because not enough money is being spent on it. Early in the hunt comes sightings of the "bottomless pit" of insatiable healthcare demands, quickly followed by assertions that substantial increases in healthcare spending are "unsustainable." When asked for their advice, economists tell politicians that a tax based system provides governments and patients with the best deal. As a sideshow to the main event are the hucksters, peddling their own funding models, hoping that some of the billions spent on the NHS might end up in their pockets, or those of their backers.

Tony Delamothe, BMJ 2008;336:1410-1412 (21 June), doi:10.1136/bmj.a292
Free full text

Here is an excerpt from Michael Moore's Sicko (2007).

"Why does a CT scan cost so much in the USA?"

2008-06-21T17:16:00.006+01:00

There's a post in Vijay's blog from October 2007 discussing the cost of healthcare in the United States http://www.catscanman.net/blog/?p=267. It makes interesting reading, as do the comments that have been posted by various people describing their experiences.

Here is the video about the incident:

There has been a lot of grumbling in Britain about the "Stalinist" National Health Service (NHS), but there are worse ways to organise a country's healthcare. I work for the NHS, and I am only too aware of its deficiencies, but those who wish to dismantle it should consider the possible consequences of alternative systems. Privatisation of the previously state-owned British railways did not lead to improved service. There is no inherent reason why a privatised national healthcare system in the UK will fare any better. Railway journeys in the UK are extremely expensive compared to the rest of the UK. I'm always being told how cheap it is to go shopping in the US compared to the UK. What will happen if our healthcare is privatised?

Link: Keep our NHS public

Radiology party trick

2008-06-21T16:08:00.009+01:00

"What's wrong?"
"Someone stepped on me during the last dance."
"Want me to have a look at it?"
"OH MY GOD!!"

Read on.....

I've added the Samurai Radiologist's blog Not Totally Rad to my list. His posts cover all sorts of things other than radiology. There are imaging-related article as well, of course, including this one which reviews studies from the published literature, but may nevertheless be inaccessible from hospital PCs due to "adult content": Radiology comes through for sexual imaging.

My thanks to Vijay, : I found this indirectly via his blog.

Great online resources

2008-05-01T18:47:00.011+01:00

I became aware of an excellent free online interactive anatomy atlas :

http://www.e-anatomy.org/

through a recent article in Radiology:

Stuart R. Pomerantz Net Assets: Personal Technology for Productivity in Radiology
Radiology 2008 247: 307-310 (DOI: 10.1148/radiol.2472080187)
http://radiology.rsnajnls.org/cgi/content/full/247/2/307

The article also mentions various other search engines like Yottalook and Goldminer, which are already on the side bar of this blog.

One other tip from the article: if you are looking for CT or MRI protocols, you can, for intnce, put "MRI" and "protocol" as search terms in Yottalook. Because it's a radiology-specific search engine, you get better results than with google.

Device for optimising PACS viewing conditions

2008-04-24T13:23:00.004+01:00

PACS monitors are ideally viewed in darkish conditions. These are difficult to achieve in your typical ward or casualty department. This device is designed for use with laptops but can probably be modified for use with single PACS monitors.

Instructions on how to make one:
http://www.instructables.com/id/Laptop-Compubody-Sock/

"The decline in positioning skills" (according to a radiographer)

2008-02-23T15:26:00.010Z

A post from the blog of a radiographer who is now a PACS adminstrator:

....recently I have noticed that positioning skills have been declining or Technologists just don’t seem to care much anymore.

I have pondered as to why this seems to be happening and have come up with a few theories that I will list below in no particular order as I think they all have a part in the decline of the skills.....

In summary, the main reasons he gives are:

Modern radiographer training.
The effects of PACS.
Radiologists accepting poor quality images.
CT and MRI (discussed in the comments to the main article).

Read more here.
(From A Ferret's VIew of PACS and Life).

The picture above comes from this site which is worth a look.

Microsoft PACS, RIS, and more ...

2008-02-15T21:22:00.004Z

Microsoft have entered the healthcare market in a big way with a family of products called Amalga.

I found this out yesterday via a post on Dr Dalai's blog. It's not just RIS/PACS: Amalga is a "Unified Intelligence System" for healthcare organisations that includes a HIS (Hospital Information System) "built around an Electronic Medical Record (EMR) that includes complete patient and bed management, laboratory, Medication Management, Radiology Information System/Picture Archiving and Communication System (RIS/PACS), pathology, financial accounting, materials management, and human resource systems".

It does look rather interesting. Wait and see.

Ultrasound reports: attitudes of referring clinicians to style and content

2008-02-13T22:58:00.005Z

My colleague, ultrasonographer Leigh Baldock, presented the findings of a survey she carried out as part of her MSc dissertation. This is what our referrers want from us in our ultrasound reports:

Clinical details re-stated at the beginning of the report.
Comments on the technical quality of the examination, especially if the examination is suboptimal.
Mention all organs that have been examined.
Measurements of abnormal organs, giving a normal range and the measurement of the corresponding normal organ for those with a bilateral presentation.
Avoid the use of ultrasound terminology unless it is known that the clinician receiving the report has knowledge of such terminology.
Relate to the clinical question.
Include significant incidental findings.
Include differential diagnoses, but not too many.
Suggest further steps in the investigation of the patient.
Give advice on further patient management if the referring clinician is a GP or a medical clinician.
End with a conclusion.
Be clear and give a comprehensive description even if the findings are normal.

Also:

There was no substantial difference between the preferences of GPs, medical and surgical referrers, although surgeons do not appear to value recommendations for further management of patients.
All groups of clinicians are happy for radiologists/sonographers to arrange follow-up examinations, but examinations should not be cancelled without discussion with the referring clinician.

These findings are similar to those in previous published studies.

Leigh will be leaving us shortly to work in Colchester, and we'll miss her. Good luck, and thanks for everything, Leigh.

New version of Carl's Table

2008-02-12T22:58:00.001Z

We have three Carl's Tables, and like them very much. Now there's a new version, available in Spring 2008, with even more features, such as electric monitor adjustment, independent task lighting, and even an "air circulation system" with two adjustable air ports, like the air conditioning in a car. Very nice, but at US$12950 it's just slightly more than we can afford right now.

More details on the Anthro site, including comparison charts, and a video of Carl himself playing the banjo.

New high energy ultrasound technique improves visualisation of liver tumours

2008-02-09T13:58:00.002Z

A new ultrasound technique developed at Duke University known as Acoustic Radiation Force Impulse imaging (ARFI) improves visualisation of liver tumours by using the elasticity or stiffness of the tumour to improve contrast between it and the surrounding tissue.
(Credit: Image courtesy of Pratt School of Engineering, Duke University)

Siemens are working on a prototype.

There have been several articles about this in radiology websites, but I thought this one, from a non-medical scientific site, provided a nice summary:
http://www.sciencedaily.com/releases/2008/01/080107181336.htm

This is the article:
In vivo visualization of abdominal malignancies with acoustic radiation force elastography
B J Fahey et al 2008 Phys. Med. Biol. 53 279-293
doi:10.1088/0031-9155/53/1/020
Link

Global helium supplies running out

2008-02-09T12:39:00.001Z

One fifth of the world's helium supplies are used in for cooling the superconducting magnets used in MRI scanners. Now supplies of helium are running out.

As it says in this article, Goodbye Helium, Goodbye Brainscans.

Here's another article.

Musculoskeletal and Orthopaedic MRI blog

2008-01-28T01:58:00.000Z

Another radiology blog, this one dealing with musculoskeletal/orthopaedic MRI:
http://musculoskeletalmri.blogspot.com/.

I came across this on Sumer's blog.

PostureMinder: Automatic posture monitoring for workstations

2008-01-22T17:51:00.000Z

I came across this product in a PC magazine.

PostureMinder uses any standard, off-the-shelf webcam to continually check your posture while you work. If you slump or lean consistently for a minute or two at a time, the software detects this and provides an an on-screen reminder to help you avoid spending long periods in these damaging postures.

I've not seen or tried it but it's had a good review in PC Advisor.

A useful add-on for your PACS workstation? It's only £29.

http://www.postureminder.co.uk/

The website also has some good links to ergonomics sites.

Hand Hygiene

2008-01-14T17:36:00.000Z

Hand washing to prevent infection transmission is a hot topic in our hospital. Only last week we had a talk from our infection control nurse. Now I see it's the subject of an editorial in Radiology.

It's worth reading (link to article below).

The most interesting bit for me was on how to avoid skin irritation, which has been shown in studies to be a real and widespread problem.

It is important to avoid such side effects of frequent hand washing, in part because they can reduce compliance and also because fissures and lesions on damaged hands are more susceptible to colonization by microorganisms, thereby fostering transmission. Multiple steps can be taken to minimize skin irritation associated with hand hygiene.
First, a hand-friendly hygiene agent should be readily available. Alcohol-based hand rubs containing emollients are better tolerated by health care personnel than plain soap or antimicrobial soap alone.
Second, health care workers need to be reminded of the value of regular frequent use of hand-care products such as hand lotions or creams. In one study at the University of Wisconsin, Madison, Wis, scheduled use of an oil-containing lotion improved skin condition and led to a 50% increase in hand
washing frequency among health care personnel who initially suffered from long-standing hand irritation.
Routine hand washing with soap and water after using an alcohol-based rub can lead to dermatitis and should be avoided.

Hand Hygiene Lisa R. Delaney, and Richard B. Gunderman Radiology 2008;246:15-19

GE launches health IT educational programme

2008-01-09T06:34:00.000Z

According to an article in Health Imaging News,

GE Healthcare has created a vendor-independent educational program designed specifically for biomedical and technical professionals to enhance their knowledge of IT concepts for healthcare.

It was a bit difficult to get more details about the course itself, but here's the GE site: http://www.gehealthcare.com/hcit. It turns out that the courses are all held in the USA.

While searching, I came across an interesting Healthcare IT blog, run by Adam Chee in Singapore:
www.binaryhealthcare.com, to which I've added a link on this site.

Radiopaedia.org 2.0

2008-01-07T17:50:00.000Z

This looks really good. In the words of the creator of this site,

The aim of Radiopaedia.org is to develop an online text where information is up to date and relevant to the needs of radiology staff, both registrars and consultants. In addition, the wiki format will allow discussion of topics and resolution of areas of confusion. There are many worthwhile online resources already, however most are not collaborative and therefore lack the ability to respond to users needs.
Anyone can create an article. Anyone can edit an existing one. Contributions remain logged to your name, and can be included in your CV, along with a link to your User Page.
Due to the immediacy of editing, new information can be introduced immediately when it becomes available. Errors can be corrected immediately, with no need to wait for the next edition.

Among other things there's a useful section on "Staging etc". Check it out:

http://www.radiopaedia.org/

radRounds

2008-01-05T11:33:00.000Z

I received an invitation to join radRounds, a new radiology social networking site, a bit like Facebook, founded by Steven Chan, a radiologist in New York State. The main purpose is "sharing one's interests, expertise, and connections with others". It looks quite good, and I've signed up. At present there are only a handful of UK members, but the site is still in its infancy. Have a look.

www.radrounds.com

Lean Thinking ..plus the other side of life at Toyota

2007-12-26T17:34:00.000Z

Over the last couple of years there has been a lot of interest in using "Lean" techniques in healthcare to improve efficiency and quality in service delivery. "Lean" was invented by Toyota, and began life as the Toyota Production System.

Much of this, I believe, is relevant to the delivery of Radiology services, and the Bristish National Health Service is now interested in it too. The NHS institute has a section on its website on Lean Thinking, which has links to a lot of useful and interesting stuff.

However, an article in the Economist (19 Dec 2007) shows another aspect of working at Toyota. The company may be hyper-efficient, but employees in Japan put in enormous amounts of unpaid overtime. In 2002, A 30 year old Toyota quality control manager collapsed and died at work at 4 am. He had been doing 80 hours of unpaid overtime work per month in the 6 months prior to his death much of which was "voluntary" and unpaid. Last month, a court accepted his wife's claim that his death was due to overwork.

How to build a website like this one

2007-11-06T12:41:00.001Z

Fancy building your own site? It's easy, and it's free. If you know how to shop online, you already possess the IT skills you need.

Here are the slides from a presentation I gave recently at the Management in Radiology (MIR) Congress in Oxford:
http://www.imagingmanagement.org/downloads/mir2007/Th9.45webblog.pdf

A full list of presentations from this meeting can be found here.

CERT : Continuing Education for Radiologic Technologists

2007-11-06T08:16:00.000Z

The American Roentgen Ray Society will be starting a new series of monthly CPD articles for Radiologic Technologists (i.e. Radiographers) in January 2008, called CERT (Continuing Education for Radiologic Technologists).

Topics will include:

CT of Pancreatic Carcinoma: Two Original Research Studies
CT in Trauma Radiography: The Acetabulus, Tibia, and Scaphoid
CT: Radiation Dose Update
Women’s Imaging: Two Original Mammography Research Studies
Women’s Imaging: Viewing Monitors and Dose Reduction Research
Women’s Imaging: Computer-Assisted Detection, Current Research
CT Colonography: Current Research

More details here.

CERT lessons are approved ARRT Category A credit; I don't know whether or not they are recognised by the UK Society of Radiographers.

Free online teaching material

2007-09-16T01:31:00.000+01:00

Free online teaching material from the Uniformed Services University Department of Radiology and Radiological Sciences, kindly provided by Dr James G. Smirniotopoulos:

Check them out:

Brain Lesion Locator
Chest Film Review
MedPix Teaching File and Database
Case of Week - Category 1 CME -

Interruptions at work

2007-09-15T23:39:00.000+01:00

A common problem for all radiologists: being interrupted. It's time consuming and disruptive, and the distraction can lead to loss of concentration, and errors in reporting.

In a 2005 study, researchers at the University of California at Irvine found that information workers at an outsourcing company spent an average of 11 minutes on a project or task before they were interrupted. Once diverted, it took them 25 minutes to return to the original task. Sound familiar?
Article from CFO.com.

Nevertheless, being consulted is part of our job.

Some suggestions, from a letter in Radiology, :

Institute a radiology consultant of the day or specific times for consultation.
Close the door, at least until you have finished reviewing the complex examination on your monitor.
Finish what you are doing before engaging with the clinicians .

More suggestions are found in this post in Lifehack, How to Avoid Lengthy Interruptions a Work. The one I like best is

When someone arrives for a pop-bye, stand and greet her but don’t sit down. Standing tells your visitor that you have things to do so let’s get on with it.

Accessories for Owls

2007-09-10T02:29:00.000+01:00

According to Carl Gray, Radiologists and Pathologists tend to be "Owls" (Need three alarm clocks - Hate getting out of bed - Cannot function before 10 am, revived by lunch - Fully functional by mid-afternoon, productive in evenings - Stay up till 1 or 2 am routinely - Cannot sleep because of ideas - On holiday, sleep in even later).

I'm definitely an Owl.

I've recently learnt about some useful accessories for the Owl.

The Sonic Boom Alarm Clock is extremely loud and has a thing that goes under your pillow or mattress to vibrate you out of bed.

The Flying Alarm Clock flies around your room and you have to get up and catch it to switch it off.

I already have three alarm clocks, in addition to my wife's and my mobile phones, which makes five alarms in total, and there's no more space on the bedside table...

Radiation exposure and pregnancy

2007-09-07T00:33:00.000+01:00

According to a recent article in Radiographics,

Radiation doses from properly performed radiologic examinations in pregnant women are extremely unlikely to harm the embryo or fetus; thus, when such examinations are necessary for the patient's health care, they should not be withheld.

Cynthia H. McCollough, Beth A. Schueler, Thomas D. Atwell, Natalie N. Braun, Dawn M. Regner, Douglas L. Brown, and Andrew J. LeRoy
Radiation Exposure and Pregnancy: When Should We Be Concerned?
RadioGraphics 2007 27: 909-917 (DOI: 10.1148/rg.274065149)

New Guidelines: Urinary Tract Infection in Children

2007-08-22T11:17:00.000+01:00

The National Institute for Clinical Excellence (NICE) have issued new guidelines for UTI in children (Ref CG54).
There is a handy quick reference guide (Imaging is covered in pages 12 - 13).
Other relevant NICE documents, including the full guidance, can be found here.

A few months ago my paediatrician colleague Dr Job Cyriac gave a nice lecture on this topic. You can view his slides here.

A significant change in radiological practice has been the reduction in the number of micturating cystourethrograms, which is great for everyone.

CAD for detecting bone metastases on CT

2007-08-16T22:55:00.000+01:00

There was some discussion at work the other day about how detection of bone mets on CT could be quite tricky. The authors of this article, which describes a computer aided detection (CAD) system for detecting lytic lesions in the spine, put it rather diplomatically

"It has been postulated that bone metastases are missed at CT ... there is a perception that these [bone] windows are underused by radiologists and oncologists."

CAD has been developed for lung and breast lesions. This might be another useful application.

O'Connor SD, Yao J, Summers RM.
Lytic metastases in thoracolumbar spine: computer-aided detection at CT-preliminary study.
Radiology. 2007 Mar;242(3):811-6

Open source PACS solution for private clinics

2007-08-12T12:01:00.000+01:00

I installed Osirix , a free (Open Source) imaging workstation program, on a stand-alone iMac at our local private hospital almost two years ago (described here), and it has been used very successfully for reading CT and MRI exams loaded from CDs.

The iMac cost about £2000. (You can check current prices at www.apple.com) . A proprietary workstation would have cost 10 times that amount, at least. Also, each time there is a software update, the upgrade is free, and there has been fantastic free support from the online community of users and developers. Much better than from some commercial products I have used.

At Chesapeake Medical Imaging, they used Macs and Open Source software, including Osirix, to view and archive images from at least half a dozen CT and MRI scanners (Siemens, Toshiba, and Philips), in four clinics, doing 80 multi-scan patient studies every day, (about 3GB of data per day and a terabyte per year), and solved a quarter-million-dollar problem for about $12,000.
http://www.apple.com/science/profiles/cmi/

What's missing from the the Open-Source Osirix PACS solution is integration with the Radiology Information System (RIS), so it's not quite ready for big public hospitals, but it does seem like an excellent idea for smaller private facilities.

I suspect that one of the stumbling blocks may be that in many organisations, IT departments lack the ability, skills or inclination to do anything not covered by the Microsoft service manuals, while corporate management do not know any better and do not challenge the IT guys. It's a pity, because there are enormous potential benefits in cost savings and quality of care.

By the way, there's an online tutorial on how to use Osirix. I've not had to use it but you can check it out here.

ACR Guidance Document for Safe MR Practices

2007-08-12T11:09:00.000+01:00

A very long and comprehensive artcle was published recently in the AJR
ACR Guidance Document for Safe MR Practices: 2007
AJR 2007; 188:1447-1474

Meanwhile, here's a low-cost device that might be ueful for screening people visiting your MRI facility

FREE online software for designing your reporting room (or ward, or bedroom, or kitchen)

2007-08-11T15:29:00.000+01:00

Floorplanner is an internet-based program that allows you to draw floor plans and lay out your room. There's a free version which should be adequate for small projects, and it's very easy to use. The illustration above shows a plan of our reporting room which I've done from memory, and is not exactly to scale. (I'll publish a more accurate version later).
I found this via Dumb Little Man.

PACS Display Quality Assurance Check : FREE!

2007-08-04T15:40:00.000+01:00

Can you read the text in all three boxes?
If not, your monitor may not be suitable for interpreting x-rays.

The PACS Display Quality Assurance Check is a free tool designed to assist with a QA programme for PACS web display devices.
We're currently looking into implementing it.

CT of Lefort fractures

2007-08-04T15:01:00.000+01:00

Here's an article I've referred to from time to time when someone comes into the CT scanner with an unpleasant facial injury.

Rhea JT, Novelline RA.
How to simplify the CT diagnosis of Le Fort fractures.
AJR Am J Roentgenol. 2005 May;184(5):1700-5.
Free full text

Digital dictation part 2...

2007-08-04T14:55:00.000+01:00

Our old PACS, a low-cost affair based on web browsers, and with no RIS-PACS integration, has been replaced by an Agfa Impax PACS, and we now have one-way RIS-PACS integration, so that when an examination is opened on the RIS, the images automatically load up on PACS.

It still needs a bit of tweaking, but it has made a world of difference, and reporting is much easier. I have now stopped using casette tapes.

Some time ago I published a post expressing reservations about digital dictation systems, but, as one correspondent suggested, it was because our system was not properly set up. He was right and I was wrong. We do not have speech recognition at present, but I'm investigating this actively.

How dark should your PACS reporting room be?

2007-07-14T14:53:00.002+01:00

Not pitch black, but about 40-25 lux, comparable to a dim hotel room at night, according to one study. (Image above from RSNA News May 2007)

RSNA News May 2007 (p 13-14).

Other references:

Viewing conditions for diagnostic images in three major Dublin hospitals: a comparison with WHO and CEC recommendations E Mccarthy, PC Brennan Br J Radiol, Vol. 76, No. 902. (1 February 2003), pp. 94-97. Link

Ambient Lighting: Effect of Illumination on Soft-Copy Viewing of Radiographs of the Wrist Patrick C Brennan, Mark Mcentee, Michael Evanoff, Peter Phillips, William T O'Connor, David J Manning Am. J. Roentgenol., Vol. 188, No. 2. (1 February 2007), pp. W177-180. Link

Cleaning your monitors

2007-07-11T07:49:00.001+01:00

Grey scale monitors cost thousands of pounds each. Here's advice from Barco about how to clean them:

And by the way, please don't touch the screen with your finger when pointing to something interesting.

Free online software for calculating bone age

2007-04-30T23:56:00.000+01:00

I came across this on Sumer Sethi's famous Radiology blog.
http://sumerdoc.blogspot.com/2007/04/bone-age-estimation.html.

I'm not sure if it's easier than flipping through the Greulich and Pyle Atlas, and I've never used the Tanner Whitehouse method. Nor do I know if this method has been validated (I've tried to look in PubMed). But it looks like it might be interesting for people who like this sort of thing.
http://vl.academicdirect.ro/medical_informatics/bone_age/v1.0/

More bone age software, for Mac only, and integrated with Osirix:
http://homepage.mac.com/d2p/radiology/boneage.html

Medslist: Store a list of your medications online

2007-04-30T23:07:00.000+01:00

This is not really to do with radiology but I'm sure a lot of people would find it useful.

A third year medical student has developed a website where you can list your medications, store them online, and even print out a pdf.
http://www.medslist.org/

The author also has a rather attractive website:
http://www.grahamazon.com/

Workstation ergonomics and PACS reading room design

2007-04-03T08:21:00.000+01:00

One of the risks of PACS is work-related injuries as a result of using workstations for prolonged periods.

This article was posted on Lifehack. It's an online video tutorial on workstation ergonomics, with a self assessment checklist. Highly recommeded for anyone who spends time with computers (of whom radiologists are only a tiny minority)

Here are some articles about PACS reading room ergonomics and design:

Harisinghani MG, et al Importance and effects of altered workplace ergonomics in modern radiology suites. Radiographics. 2004 Mar-Apr;24(2):615-27.

Prabhu SP, et al. Ergonomics of digital imaging. Br J Radiol. 2005 Jul;78(931):582-6.

Here's more:
A powerpoint presentation of Dr Eliot Siegel's resentation at the UK Radiological Congress 2006, a presentation from GE, and a video by Dr Siegel: Digital eye for the analog guy.

This is not a post-contrast CT

2007-03-28T00:27:00.000+01:00

The patient had a haemoglobin of 23, which presumably accounts for the increased attenuation in the cerebral vessels.

Radiology Grand Rounds X

2007-03-24T23:18:00.000Z

I am hosting this month's Radiology Grand Rounds on behalf of Dr Sumer Sethi. An explanation of the general idea can be found in his site: http://radiologygrandrounds.blogspot.com/

Here's my contribution, two cases which I saw recently, an unsuspected myocardial infarct, and a patient with superior mesenteric artery syndrome.

Here are some other submissions, one from GC George, and another from Chris Depelteau.

"Radiology journal watch" is a new feature at filmjacket.com. 'You can now view titles for all, and abstracts for most, articles in the current issues or AJR, Radiology and Radiographics at a glance. You can also view the titles for all articles in the current issues of each journal separately by expanding the panels on the main page's lower right (you may need to scroll down a bit). The listings automatically update themselves frequently, so the content is always fresh.'
Check it out here.

Last, but not least, three submissions from the man himself, Sumer:

Gadolinium in renal failure (please also see my entry on this site, three posts down from this one, dated 9 February 2007),

Sumers's attempt to compile all radiology related blogs at one place- The radiology Blogosphere,

and a review of literature on acrominion shape.

The Radiology Grand Rounds archives can be found at www.radiologygrandrounds.blogspot.com.

I wonder how much these cost

2007-03-16T10:25:00.000Z

I saw these at the ECR, and as usual I could not get a straight answer about pricing, but they might be just the thing for someone wanting an extra MRI scanner in the casualty department.

Update: MEHT Policy for accidental overexposure

2007-03-01T11:16:00.000Z

PROCEDURE k - PROCEDURE TO ENSURE THAT THE PROBABILITY AND MAGNITUDE OF ACCIDENTAL OVER EXPOSURES ARE REDUCED
Revised Feb 2007

PURPOSE
To provide a mechanism for recording and investigation incidents where an individual undergoing a medical exposure receives a radiation dose greater than intended.
To identify persons responsible for making and acting on those reports and to identify the actions to be taken, including reporting to external agencies as considered appropriate.

Posted here.

Safety warning: Nephrogenic Systemic Fibrosis (NSF)and gadolinium

2007-02-09T13:32:00.000Z

Advice from the MHRA:

Nephrogenic Systemic Fibrosis (NSF) is a debilitating and sometimes fatal condition. It has been associated with some intravenous gadolinium-containing magnetic resonance imaging (MRI) contrast agents in patients with severe renal impairment. On the basis of the available evidence, the UK Commission on Human Medicines (CHM) together with the European Pharmacovigilance Working Party (PhVWP) of the Committee for Medicinal Products for Human Use (CHMP) recommended:

Do not use Omniscan (gadodiamide) in patients with severe renal impairment (ie, GFR [glomerular filtration rate] <30ml/min/1·73m2)>
Careful consideration should be given to the use of other gadolinium-containing MRI contrast agents in patients with severe renal impairment (ie, GFR <30ml/min/1·73m2).

MHRA Safety Warning

Online GFR calculator

More info
European Society of Urogenital Radiology
RSNA News Feb '07
The International Center for Nephrogenic Fibrosing Dermopathy Research (ICNFDR)

Recent articles in Radiology here and here.

New Radiology Educational Resource

2007-02-03T06:44:00.000Z

Thereportingroom.com is a new, free educational site developed by Simon Morley of UCH. The team includes Gerald de Lacey and Lol Berman.

The aim of this website is to allow you to test yourself at interpreting radiology cases using software similar to normal day to day practice. We have developed viewing software which runs on your web browser allowing you to scroll through stacks of CT and MRI images and view plain film images with windowing zoom and pan functionality - just like a PACS workstation.

It looks very good, but note that you need a reasonable computer with a broadband connection and adobe flash player. Some computers in some UK hospitals may not be up to the job.

I've added a permanent link to this site, which I via Sumer's excellent Radiology site (where, ahem, MidEssexRay has recently had an honourable mention).

Investigation of suspected malignant pleural effusion

2007-02-02T19:45:00.000Z

Good article in the latest BMJ:

Rahman NM, Davies RJ, Gleeson FV.
Investigating suspected malignant pleural effusion.
BMJ. 2007 Jan 27;334(7586):206-7.

These are the BTS guidelines referred to in the above article:

Maskell NA, Butland RJ; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society.
BTS guidelines for the investigation of a unilateral pleural effusion in adults.
Thorax. 2003 May;58 Suppl 2:ii8-17.

I note that the BMJ appears to have started a series on "Rational Imaging". Good idea.

Extravasation of contrast in CT

2007-01-30T07:18:00.000Z

It happens occassionally, despite all precautions. Here, the extravasation was about 10 cm proximal to the injection site in the antecubital fossa, which we had not come across before. An x-ray confirmed that it was contrast.

This is not an advert for Dell

2007-01-29T16:53:00.000Z

Since my previous post on using consumer-grade monitors for diagnosis there have been more reports on this subject, all suggesting that an appropriate consumer-grade colour monitor might perform just as well as medical-grade grey scale monitors costing 10 times more.

Read them here, here and here.

I've spoken to some vendors about this and mentioned it in the RCR PACS group forum, and the objections to these monitors have been to do with quality control and longevity.

We'll see what happens in future.

The monitor in question is the 24" Dell 2405 , which has now been superseded by the 2407. It has comparable brightness and contrast to medical grade monitors (not the case with other consumer-grade products), is currently on the "A-list". of PC Pro. Here's the review.

I've never even seen one of these Dells so this post is not a personal endorsement or recommendation.

Radiology Search Engines added

2007-01-28T15:57:00.000Z

Yottalook (beta) is a Radiology Search engine for images or references that is based on Google .
Goldminer is a radiological image search engine hosted by the American Roentgen Ray Society, and results are limited to "images from respected peer-reviewed images".

Here's more about them from Pacsweb.

Yottalook and Goldminer have been added to the 'Links' section of this site, on the right hand sidebar.

New addition: MRI lumbar spine nomenclature

2007-01-26T14:42:00.000Z

I have posted a summary of the American Society of Neuroradiology nomenclature for lumbar disc pathology, and an MR-based grading system for lumbar root compromise due to disk herniation (Pfirrmann 2004) in the "Protocols and Guidelines" section.

You can go to the page directly from here.

Cancer staging manual added to this site

2007-01-25T18:25:00.000Z

I've added a Cancer Staging Manual with a link to the RCR guidelines and, for a start, pages for lung, renal and prostate cancer, with details of TNM staging and other things I've found useful. These are things I've found difficult to remember, and I've posted them here to save myself the trouble of hunting around for books etc.
You can get to the manual from the 'Protocols and Guidelines' page, or by clicking here.

MRI safety questionnaire added to Protocols and Guidelines Section

2007-01-22T09:52:00.000Z

For the benefit of our patients, and the convenience of our esteemed customers, the MRI saftey questionnaire can now be downloaded from the "guidelines and protocols" section of this site.
To go straight to the page, click here .

Build your own PACS using free open-source software

2007-01-13T10:31:00.000Z

From Antoine Rosset, developer of Osirix.
This is based on Apple Mac components but the all software is open source, and can be downloaded from the internet.

Full step-by -step instructions here.

You can work out the cost of the hardware (in the UK) by visiting the Apple Store.

From today's CT list

2007-01-05T19:31:00.000Z

Small bowel obstruction due to left inguinal hernia

Sonosite portable ultrasound machines on eBay

2007-01-03T20:22:00.000Z

I look on eBay for medical equipment from time to time, out of idle curiosty. SonoSite portable ultrasound machines are frequently on sale, and there were more than ususal today: one SonoSite 180 plus, one SonoSite 180, one MicroMaxx, one Titan, one Sonoheart, as well as a linear SonoSite probe.

Our old SonoSite 180 could do with replacement, and that linear probe would come in handy. If I recall correctly, our SonoSite originally cost £18 000 with one probe only.

PIOPED II

2006-12-31T22:05:00.001Z

Recommendations formulated on the basis of the results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II trial have recently been published. Some of our current protocols are at variance with these.

For instance, we currently image patients with a moderate clinical probability of PE and a negative d-dimer. The PIOPED II investigators recommend that in such patients no further testing is necessary.

I won't go into all the other details, but it makes interesting reading, and we'll be reviewing our practice in consultation with the physicians.

Diagnostic Pathways in Acute Pulmonary Embolism: Recommendations of the PIOPED II Investigators.
Stein PD,Woodard PK,Weg JG,Wakefield TW,Tapson VF,Sostman HD,Sos TA,Quinn DA,Leeper KV Jr,Hull RD,Hales CA,Gottschalk A,Goodman LR,Fowler SE,Buckley JD.
Radiology. 2007 Jan;242(1):15-21.
http://intl-radiology.rsnajnls.org/cgi/content/full/242/1/15
MEHTRadiology citation
(A similar version of this editorial was published in the December 2006 issue of the American Journal of Medicine)

Also by the same authors:
Multidetector computed tomography for acute pulmonary embolism
N Engl J Med. 2006 Jun 1;354(22):2317-27.
CONCLUSIONS: In patients with suspected pulmonary embolism, multidetector CTA-CTV has a higher diagnostic sensitivity than does CTA alone, with similar specificity. The predictive value of either CTA or CTA-CTV is high with a concordant clinical assessment, but additional testing is necessary when the clinical probability is inconsistent with the imaging results.

Digital Dictation and Voice Recognition: Not ready for prime time?

2006-09-16T12:29:00.000+01:00

Our digital dictation system consists of a Philips Speech Mike linked in to our RIS (TC-RAD, McKesson). For plain film reporting, after using it for a year or two, I have switched back to using cassette tapes, and guess what? I estimate that my productivity is up 20%, and fatigue levels reduced by 50%. Other colleagues have reported similar experiences.

The problem with our digital dictation system is that it involves numerous mouse clicks and aiming a cursor several times during the dictation process, and this increases the total amount of work very substantially if the report is very brief (e.g. "Normal appearances"). Also, transcription of reports by secretaries from digital dictation involves more steps and is inherently less efficient than transcription from tape.

There are advantages to digital dictation, and it's OK for longer reports like CT and MRI reports. It allows secretaries to retrieve and locate dictated reports more easily. However, at least in our version, there are very serious inadequacies.

As for voice recognition (VR), I tried that too, for several months, and put enormous effort into training the system, which was created by bolting the Dragon dictation system (which seems to have nothing but outstanding reviews in PC magazines) onto our digital dictation system. I came to the conclusion that I would have been better served by doing a touch typing course.

Here's an online article that describes in great detail the experiences of many users with radiological voice recognition systems. I concur with the opinions expressed.
Voice, I mean Speech Recognition, Buggy Whips, and OODA Loops

If VR makes sense on an accountant's spreadsheet in terms of staffing levels and turnaround times, this may be because the spreadsheet has not recorded all of the variables. I am now extremely sceptical about the practicalities and costs of these systems in their current form.

From personal experience I am wary of verbal or published recommendations for VR systems and other software products, especially those designed for medical use, where standards and expectations are often extremely low. Someone who has spent vast sums of money on a poor quality product may be reluctant to admit (even to himself, let alone to the outside world) that it was all a big mistake.

Drinking barium to protect the fetus during CT pulmonary angiography

2006-09-13T21:07:00.000+01:00

This phantom study suggests that ingestion of barium will shield the fetus of a woman undergoing CT pulmonary angiography.
It's cheap, harmless and seems logical, so why not?

Yousefzadeh DK, Ward MB, Reft C.
Internal barium shielding to minimize fetal irradiation in spiral chest CT: a phantom simulation experiment.
Radiology. 2006 Jun;239(3):751-8.

Simpler CT reporting for clnical trials?

2006-04-22T22:08:00.000+01:00

"In the majority of patients with hepatic metastases of colorectal cancer, measuring the maximal diameter of the single largest lesion yielded the same treatment-response classification as measuring up to five target lesions. This result suggests that it may be possible to reduce the number of lesions measured in clinical trials."

CT of Colon Cancer Metastases to the Liver Using Modified RECIST Criteria: Determining the Ideal Number of Target Lesions to Measure
Zacharia, Saini, Halpern and Sumner. AJR April 2006; 186:1067-1070

Now wouldn't that make life so much easier?

http://www.ajronline.org/cgi/content/abstract/186/4/1067

Barium enemas on the cover of Radiology!

2006-04-19T23:43:00.000+01:00

Makes a change from virtual colonoscopy :-)

Unlike other authors, this group found that in their series, technical errors were more common than perceptual errors, and the majority of missed polyps were in the proximal colon.

Thompson, Foster, Paulson et al
Causes of Errors in Polyp Detection at Air-Contrast Barium Enema Examination
Radiology April 2006;239:139-148.

CiteULike: FREE Online reference manager

2006-03-30T05:51:00.000+01:00

I discovered this site through a link on our hospital intranet.
It's free, online and easy to use.
You can also set up a "group" for your department or colleagues so you can share references, as we have done.

http://www.citeulike.org/
http://www.citeulike.org/group/MEHTRadiology

Free software for CT and MRI cerebral perfusion and breast MRI

2006-01-20T23:24:00.001Z

I came across this website offering free software, developed in conjunction with the University of Dusseldorf, for analysng CT and MRI cerebral perfusion studies, (stroketool-CT and stroketool) and contrast enhanced breast MRI studies (mammatool).

We already have equivalents of stroketool and mammatool in our MRI unit so we would have no real use for this software, but someone might find it fun to play with.

On the other hand, stroketool-CT might be useful, since we don't have cerebral perfusion software installed on our CT workstation. However I can't think of a way round the ethical and legal issues, i.e. giving iv contrast to stroke patients just to play around with free software that, according to the website "may not be used for diagnosis or patient treatment".

http://www.digitalimagesolutions.de/

I found the software via http://www.idoimaging.com/.

Study shows PC monitors equivalent to PACS workstation for detecting wrist fractures

2005-11-26T21:39:00.000Z

A recent study reports equivalent performance for detection of wrist fractures between a 17" PC monitor with a web browser, and a 2 MP diagnostic quality Barco monitor with a PACS workstation.

The authors concluded that:
there is no difference in the accuracy of observer performance in the detection of wrist fractures on digital radiographs with a standard PC compared with that with a high-quality workstation. In our opinion, important factors in achievement of this result are the use of image magnification to employ the maximum spatial resolution of the original digital image and the use of an environment with low ambient light.

In the UK a 17" PC monitor of the type they describe costs about 300 GBP, compared to about 2000 GBP for the 2MP Barco. The PACS workstation probably costs another 10 000 GBP at least, whereas web browser displays run off standard PCs.

Of course for large volume reporting, high resolution monitors make sense, otherwise you'd have to zoom everything right up and pan around a lot, but in other situations, e.g. casualty departments, PC monitors are probably fine (provided the viewing area is dark, which is another story)

Personal Computer versus Workstation Display: Observer Performance in Detection of Wrist Fractures on Digital Radiographs
Anthony J. Doyle,, James Le Fevre, and Graeme D. Anderson
Radiology Dec 2005;237:872-877

Ultrasound poor (herniography good) at detecting clinically occult hernias

2005-11-12T17:40:00.000Z

In this study, ultrasound had a sensitivity of 29% and specificity of 90% compared with the herniography. Correlation with surgical findings showed ultrasound to have a sensitivity of 33% and a specificity of 100%.

I'm not surprised about the ultrasound results. I can't comment on the herniography part, since I've only ever done one (many years ago), but maybe I'll need to start practising.

Adeeb Alam, Colin Nice and Raman Uberoi
The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults
European Radiology 2005 (Dec) 15 (12): 2457 - 2461

Fantasy Health Minister: I'm on the high scorers list

2005-10-26T21:10:00.000+01:00

As described in a previous post, it's an online game where you get to be the Health Minister and select from a range of policy decisions.

I scored 8851 on my last attempt, which made me the seventh highest scorer. Note that I got the health of the nation to 96%, but some of the higher scorers did not do as well. This is because the score also depends on popularity, and you have to please everyone, including the private sector.

At present, I'm the only Authoritarian on the high scorers' list.
(I'm "dr_lee_xray"' in case you were wondering).
Most of the others are Idealists...Pah!!

Fantasy Health Minister

CT vs MR cholangiography for biliary calculi

2005-10-16T02:58:00.001+01:00

In our hospital we tend to use CT cholangiography (CTCh) more often than than MR cholangiopancreatography (MRCP) for the non-invasive detection of common bile duct stones because CT is more readily available, and we find CTCh a simpler and more robust test. Of course MRCP has no radiation and does not need any injections, but how do the two tests compare in terms of diagnostic accuracy?

A recent paper addresses this question. 40 patients had both CTCh and MRCP, with the following results:

For detection of choledochal stones the two tests were comparable:
CTCh: sens 87%, spec 96%
MRCP: sens 80%, spec 88%

For detection of gallstones MRCP was a bit better,
CTCh: sens 78%, spec 100%
MRCP: sens 94%, spec 88%
(The reduced sensitivity of CTCh was due to non-opacification of the gall bladder due a stone being stuck in the gall bladder neck)

CTCh demonstrated bile leakage in one patient, and air in the biliary tree in two patients, which were not detected on MRCP.
CTCh also has the advantage over MRCP in demonstrating anastomotic patency, since opacification in CTCh reflects flow, whereas MRCP only demonstrates the presence of fluid.

I've never been able to figure out why are there so few papers on CTCh compared to MRCP. According to the article, Biliscopin (the contrast agent used for CTCh) is not approved for use in the USA. I didn't realise this but perhaps that's part of the reason. (As an aside, it's odd how some substances are permitted in one country but not another, for no obvious reason. Buscopan, for instance, is not licensed for use in the USA either).

Okada M, Fukada J, Toya K, Ito R, Ohashi T, Yorozu A.
The value of drip infusion cholangiography using multidetector-row helical CT in patients with choledocholithiasis.
Eur Radiol. 2005 Oct;15(10):2140-5

Want to run the National Health Service?

2005-10-09T01:05:00.000+01:00

Here's an online game where you get to be the Health Minister and select from a range of policy decisions, which in turn have an effect on the health of the Nation, your budget, and your popularity.

On my last attempt I got the health of the nation up to 96% (you start at 43%), kept within budget, and increased my popularity. You also get an indication of your political complexion. Mine varies but so far it's usually 'authoritarian', occasionally 'idealist' or 'realist', but never 'liberal'.

Fantasy Health Minister

Hospital to install OsiriX: open source diagnostic workstation

2005-09-27T21:36:00.000+01:00

A small private hospital where I do a bit of work will be buying an iMac to run OsiriX, an open source diagnostic workstation developed at UCLA and the University of Geneva.

It's not as sophisticated or as fast as the expensive Vitrea workstations we use in the big NHS hospital, but those cost about £35000, compared to £2000 for the iMac, and would not be financially viable for a small hospital with a relatively low volume of work.

An iMac with 2G of RAM will be adequate for our requirements and the software is downloaded for free from the OsiriX website, so it's excellent value for money.

Incidentally, one commercial company did offer us an outrageously expensive workstation with no multiplanar or 3D capability, that could not even read the discs produced by a CT scanner from their own company.

Upgrades for OsiriX are frequent and free, the instruction manuals are on wiki, and excellent applications support is provided by the online community on a yahoo discussion group.

As an open source product, anyone with the skills and interest can contribute to its development, and many people do.

You can also plug your iPod straight into your Mac workstation and save files and pictures to it. (I'm not sure how radiology images on an iPod photo are of any real use, but I guess some people might think they look cute).
Or download music from iTunes more easily than from your home PC .... oooops!

For a lot more money, you can buy the most expensive available PowerMac, with lots and lots of RAM, and install a VolumePro board from TeraRecon, for which a special version of Osirix is available. This is meant to provide much better 3D performance but I haven't seen it myself. It's still cheaper than the commercial products though.

The public healthcare sector might like to keep an eye on this, especially now that many state hospitals are feeling the squeeze financially. OsiriX is NOT a replacement for commercial 3D workstations, but it does have a lot of functionality at a low price, and is in continuous development.

Disclaimer:
I am a PC user. I do not own a Mac. My mother has a Mac: I think it's fine, and I have nothing against Macs. I do not have an iPod either: I have a Zen Neeon, which does not work with Macs.

Links:
Osirix
Apple
TeraRecon
Definition of Open Source
Vitrea Diagnostic Workstation from Vital Images Inc.
Zen Neeon Cheaper and better than the iPod
Hospital bosses ordered to cut debts The Guardian 16 Sep 2005

2005-09-27T21:26:00.000+01:00

One third of the population mistakenly believes that an anaesthetist is not a doctor, according to a BBC Radio 4 programme I am listening to right now.

http://www.bbc.co.uk/radio4/science/casenotes.shtml

I bet that's not the case with radiologists :-)

Ultrasound instead of chest x-rays for nasogastric tube localisation

2005-09-24T01:47:00.000+01:00

I was giving a talk to our staff on "looking for medical information on the internet". There was a live demo on using PubMed, and the topic of nasogastric tubes was suggested by someone who clearly found the whole business of doing chest x-rays for localisation a bit tedious.

This is an article we found:

Sonography as an alternative to radiography for nasogastric feeding tube location.
Vigneau C, Baudel JL, Guidet B, Offenstadt G, Maury E
Intensive Care Med. 2005 Sep 20; [Epub ahead of print]
Bedside sonography performed by nonradiologists is a sensitive method for confirming the position of weighted-tip feeding nasogastric feeding tubes. It is more rapid than conventional radiography and can easily be taught to ICU physicians. Conventional radiography could be reserved for cases in which sonography is inconclusive.

Whoopee! Our ICU physicians have said they want to get their own ultrasound machine.

We'll see.

Making Gadolinium DTPA in your kitchen

2005-09-24T01:42:00.000+01:00

According to a lecturer (a chemist) at recent MRI course I attended, Gadolinium DTPA (the fabulously expensive contrast agent used in MRI scanning) is a very simple compound that any first year chemistry student could make at home.

In China, they are not too concerned with copyrights and patents, I was told, so the pharmaceutical companies have started factories there to protect themselves. Enough said.

My sister studied chemistry at university, but unfortunately that was some time ago and she is unable to assist our department in obtaining cheap supplies.

Learning from ER: embolectomy for stroke

2005-04-15T19:36:00.000+01:00

Last night on ER: Season 11 Episode 15: Alone in a Crowd
A young mother of three (Cynthia Nixon of Sex in the City) is brought in with symptoms of a potentially fatal stroke .....

Its too late for thrombolysis but the interventional radiologist carries out an embolectomy using a new technique ...

I'd not heard of this one before, so I turned to Google.
Here's the result of one Google search.

Thrombolysis nust be initiated within three hours of onset of an acute stroke, but embolectomy with the Merci retrieval system is effective up to 8 hours after onset of stroke symptoms.

A description of the technique can be found here.
For a video, click here.
The vendor's site is here.

References:

Mechanical thrombectomy of the internal carotid artery and middle cerebral arteries for acute stroke by using the retriever device.
Martinez H, Zoarski GH, Obuchowski AM, Stallmayer MJ, Papangelou A, Airan-Javia S
AJNR Am J Neuroradiol. 2004 Nov-Dec;25(10):1812-5
Abstract

MERCI 1: a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia.
Gobin YP, Starkman S, Duckwiler GR, Grobelny T, Kidwell CS, Jahan R, Pile-Spellman J, Segal A, Vinuela F, Saver JL.
Stroke. 2004 Dec;35(12):2848-54. Epub 2004 Oct 28
Abstract

And a case report published in 2000 claiming to be 'the first reported use of a snare to remove clot in the setting of thromboembolic stroke'
Transcatheter snare removal of acute middle cerebral artery thromboembolism: technical case report.
Chopko BW, Kerber C, Wong W, Georgy B.
Neurosurgery. 2000 Jun;46(6):1529-31
Abstract

Other things I've learnt from ER:

Different ways of holding and positioning a Sonosite portable ultrasound machine.

How to rule out a mandibular fracture and avoid doing an x-ray (get the patient to bite a tongue depressor, then twang it; if it doesn't hurt, there's no fracture).

I'll be submitting my ER viewing for CME credits.

Farewell to intravenous urography

2005-04-10T14:54:00.000+01:00

We've now stopped doing IVUs in my department!

In place of IVUs, we do noncontrast CT for investigation of urinary stones, and CT urography, where indicated, for haematuria. (Indications for ultrasound are, for now, unchanged).

CT urography is a better test, and more sensitive for detecting stones, urothelial lesions and tumours. The main drawback is radiation dose. However, for stone disease, the dose from a noncontrast CT can be brought to levels similar to that of an IVU using a low-dose technique. For patients with haematuria at high risk for cancer, many of them would have ended up with a CT anyway, and if not I think the extra dose is justified by improved diagnostic confidence and accuracy. As they say, if it was me or one of my relatives .....

The technique is relatively simple, and it is easier to get consistent results than with a conventional IVU. It takes less time, and a morning's work in the IVU room can be completed in the CT scanner in about an hour. One extra radiographer has now been allocated to the CT scanner (in place of the one who used to do IVUs), which has helped to resolve some of our staffing problems. The radiographers are delighted because they didn't like doing IVUs. The urologists are pleased as well.

Our CT urography protocol, on a Toshiba Aquilion 16, consists of a low dose noncontrast run to detect stones, followed by post-contrast imaging using a split blous technique which produces a combined nephrographic and excretory phase image. Imaging is done supine, and repeated in the prone position if ureteric opacification is inadequate.

Whole-body CT screening

2005-04-09T12:25:00.000+01:00

A whole-body CT screening centre has been in operation at a town near mine, part of a chain called Lifescan. Patients pay between £300 (for a lung scan) and £750 (whole body CT with virtual colonoscopy) for CT scans to screen for unsuspected disease. Anything that is found that might possibly be significant then needs to be followed up. Sometimes early, unsuspected cancer is found . But often, the abnormalities turn out to be insignificant and of no consequence.

This ends up being very expensive, and a team from the Massachusets General Hospital concluded that CT screening was not cost-effective.
Cost-Effectiveness of Whole-Body CT Screening
Beinfield, Wittenberg, Gazelle, Radiology 2005 Feb;234:415-422

If the patient pays directly, this is not too much of a problem (at least for the health care providers), but medical insurers do not cover CT screening, and in many countries, the state ends up bearing the cost.

Here is what others have said:

Prof Adrian Dixon of Cambridge University, Warden of the Faculty of Clinical Radiology (the Royal College of Radiologists)
Another topical issue is the question of walk-in screening centres offering to "save lives" by whole-body CT screening, sometimes for profit. In the UK, the National Screening Committee has suggested that the National Health Service should not offer such screening at present (Muir Gray, personal communication). Many sources suggest that a radiologist's private practice should mirror their NHS practice. The current radiological and radiographic workforce can barely cope with the existing workload, let alone such new ventures. It will be interesting to hear what other countries recommend. Several observers have noted that such walk-in centres are usually located in relation to educated health-conscious consumers who can afford such procedures! ....... Hard facts from primary research are urgently needed. But I cannot see too many grant giving bodies rushing to assess what is currently viewed as a somewhat opportunistic and entrepreneurial endeavour.
Whole-body CT health screening.
Dixon AK. Br J Radiol. 2004 May; 77(917):370-1

A group from the Mayo Clinic
CT screening for lung cancer offers the possibility of reducing mortality from lung cancer. Our preliminary results do not support this possibility and may raise concerns that false-positive results and overdiagnosis could actually result in more harm than good .....
Our data do not suggest a mortality benefit; whether CT for lung cancer meets the criteria for an effective screening test remains to be proved .....
Our preliminary mortality results should cause physicians to pause and reexamine their positions if they are performing routine CT screening outside of a clinical trial.
CT Screening for Lung Cancer:Five-year Prospective Experience
Swensen et al. Radiology 2005 April ;235:259-265.

A group from Stanford (with regard to the situation in the United States)
Direct-to-consumer marketing of self-referred imaging services, in both print advertisements and informational brochures, fails to provide prospective consumers with comprehensive balanced information vital to informed autonomous decision making. Professional guidelines and oversight for advertising and promotion of these services are needed.
Advertising, Patient Decision Making, and Self-referral for Computed Tomographic and Magnetic Resonance Imaging
Illes et al. Archives of Internal Medicine, December 13, 2004; 164(22): 2415 - 2419.

Could a computer report rheumatology clinic films, please?

2005-03-15T13:39:00.000Z

We radiologists just love reporting rheumatology clinic films, meticulously comparing one hand with another to see if there are new erosions..... yeah sure.

Now that radiographers are reporting skeletal films, perhaps they might like to expand their role to include the rheumatology clinics. And when they get bored, perhaps this product will be ready for use:

Computer aided diagnosis (CAD) in rheumatoid arthritis
P. Peloschek, G. Langs, F. Kainberger, H. Bischof, W.G. Kropatsch, H. Imhof ECR 2005