This is not a post-contrast CT

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

Radiology Grand Rounds X

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

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

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

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

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

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

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

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

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

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

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

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

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

Small bowel obstruction due to left inguinal hernia

Sonosite portable ultrasound machines on eBay

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

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?

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

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?

"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