Radiology report turnaround: expectations and solutions.

The ultimate work product of a radiology department is a finalized radiology report. Radiology stakeholders are now demanding faster report turnaround times (RTAT) and anything that delays delivery of the finalized report will undermine the value of a radiology department. Traditional reporting methods are inherently inefficient and the desire to deliver fast RTAT will always be challenged. It is only through the adoption of an integrated radiology information system (RIS)/picture archiving and communication system (PACS) and voice recognition (VR) system that RTAT can consistently meet stakeholder expectations. VR systems also offer the opportunity to create standardized, higher quality reports.

Government reform of the National Health Service: implications for radiologists and diagnostic services.

Demand for radiology services within the National Health Service (NHS) continues unabated and current NHS operations cannot keep up with demand. Therefore, to meet this demand, the government has decided to outsource a significant number of investigations to the independent sector and will actively promote patient referrals to the new government sponsored Treatment Centres as they become available. This presents opportunities to patients, but threatens existing public sector providers (including doctors) as competition for radiology services may result in both loss of patient referrals and revenue to these providers. This article is a personal opinion and will focus on the current challenges facing the provision of radiology services in the NHS. I will suggest the possible negative outcomes for providers (NHS hospitals and staff alike) and will offer strategies, tactics and tools that can be employed to counter the threat to their existing services.

Teleradiology: another revolution in radiology?

Teleradiology systems are rapidly being deployed by an increasing number of radiological services. Many articles have already been published on the technological developments of teleradiology but little attention has been given to its expected impact on the delivery of health care. This review article will therefore outline the historical and current technological developments of teleradiology and its potential future implementation into mainstream radiology.

Magnetic resonance imaging of the adrenal gland.

The authors review their experience with magnetic resonance imaging (MRI) of the adrenal gland and discuss the appearance of adrenal diseases where MRI is clinically useful. A basic description of some of the newer pulse sequences is provided. Fat-suppressed MRI is advantageous because of reduction of cardiac and respiratory motion induced artifacts, accentuation of small differences in tissue contrast, and elimination of chemical shift artifacts. These advantages far outweigh the disadvantages of inhomogeneity of fat suppression and the fewer slices obtained per acquisition. Chemical shift imaging is used to differentiate benign from malignant adrenal diseases based on a gradient echo phase cycling technique. Detailed descriptions of MRI findings in adrenal pheochromocytomas, hemorrhage, cysts, adenomas, myelolipomas, and metastases are provided. Most pheochromocytomas appear markedly hyperintense to the liver on T2-weighted images. However, this appearance is not specific as adrenal metastases and adrenal adenomas may occasionally produce a similar appearance. In addition, pheochromocytomas may occasionally be isointense or hypointense to the liver on T2-weighted images. Differentiation of adrenal metastases from adrenal adenomas with MRI is problematic using signal intensity ratios (33% overlap) or T2 calculations. The future of discriminating between adrenal metastases and adenomas may rest with chemical shift MRI, which uses in- and out-of-phase gradient echo pulse sequences for differentiation. This approach relies on the fact that adrenal adenomas contain fat, while adrenal metastases do not. The reported accuracy of chemical shift imaging in differentiating between adrenal adenomas and adrenal metastases ranges from 96 to 100%. An algorithmic approach to differentiating benign from malignant adrenal diseases is presented that relies on an initial noncontrast CT with CT attenuation values obtained from the adrenal mass. If CT attenuation values are less than zero, the mass is characterized as benign. If the mass remains indeterminate after CT, chemical shift MR is performed. If the mass remains indeterminate after MR, biopsy is required.

Imaging of acute right lower abdominal quadrant pain.

This article reviews the clinical diagnosis of appendicitis, indications and options for appendiceal imaging, compares appendiceal CT techniques, and describes the imaging findings with appendicitis and alternative conditions that can clinically mimic appendicitis.

Imaging and interventional radiology in laparoscopic injuries to the gallbladder and biliary system.

Laparoscopic cholecystectomy has been prevalent in the United States since the late 1980s. Because of its increased use and potential for complications that can often be treated with interventional means, radiologists have become involved in treating patients with postlaparoscopic injury. This review details the imaging and interventional procedures involved in the care of patients with gallbladder and biliary problems due to laparoscopic cholecystectomy.

The incidental nonhyperfunctioning adrenal mass: an imaging algorithm for characterization.

Nonhyperfunctioning adrenal lesions such as cysts, myelolipomas, adrenal haemorrhage, adenoma and metastases are described. Definitive imaging features that help characterize adrenal cysts, myelolipomas and adrenal haemorrhage are illustrated and the differentiation of benign from malignant adrenal lesions using an algorithmic approach based on lipid sensitive imaging is provided.

Dose reduction in gastrointestinal and genitourinary fluoroscopy: use of grid-controlled pulsed fluoroscopy.

OBJECTIVE: We evaluated the diagnostic accuracy of a grid-controlled fluoroscopy unit compared with a conventional continuous fluoroscopy unit for a variety of abdominal and pelvic fluoroscopic examinations. SUBJECTS AND METHODS: Seventy patients (29 men and 41 women; age range, 24-78 years) were enrolled in one of seven abdominal and pelvic fluoroscopic examinations, including upper gastrointestinal series (n = 20), barium enema (n = 10), voiding cystourethrogram (n = 10), percutaneous abdominal catheter tube injection (n = 10), hysterosalpingogram (n = 10), and percutaneous needle insertion and catheter placement (nephrostomy, percutaneous biliary drainage) (n = 10). Each patient underwent at least 10 sec of continuous fluoroscopy that was randomly and blindly compared with 10-sec periods of pulsed fluoroscopy at 15, 7.5, and 3.75 frames per second. A radiologist outside the examination room, unaware of the frame rate per second, evaluated the procedure in real time on a television monitor. The radiologist assessed image quality and diagnostic acceptability using a scoring system. Statistical analysis was performed using the paired Student's t test. RESULTS: For all procedures at all frame rates, we found no statistically significant superiority of one frame rate over another. For most procedures, the slower frame rates were considered equivalent to continuous fluoroscopy when the images were assessed for image quality and diagnostic confidence. CONCLUSION: Our findings suggest that most abdominal and pelvic fluoroscopic procedures can be performed at substantially lower frame rates than those used for continuous fluoroscopy; adopting this procedure may lead to substantial dose savings for the patient and the fluoroscopy operator.

Articular muscle of the knee: a muscle seldom recognized on MR imaging.

OBJECTIVE: We studied the MR imaging characteristics of the articular muscle of the knee, an important but seldom recognized structure of the distal thigh and knee. SUBJECTS AND METHODS: We used a 1.5-T system to prospectively evaluate the articular muscle of the knee in five healthy volunteers (10 knees); then we retrospectively studied the knee examinations of 24 patients (30 knees). One reader made duplicate readings to prospectively assess the sagittal proton density-weighted and axial T1-weighted images of the healthy volunteers. Three independent readers retrospectively evaluated the sagittal proton density-weighted images of the 24 patients. RESULTS: The articular muscle of the knee was identified in 100% of prospective studies (10/10) and in 83% of retrospective studies (25/30). For the prospective study group, measurements (mean +/- SEM) were as follows: number of bundles, 2.4 +/- 0.68 (range, 1-4); length of uppermost bundle, 47.2 +/- 4.06 mm; width of origin, 8.6 +/- 0.79 mm; angle of origin, 11.4 degree +/- 1.29 degree; and cross-sectional bundle width, 19.8 +/- 2.05 mm2. CONCLUSION: The articular muscle of the knee can usually be identified by MR imaging as an independent entity, separate from the great (vastus) muscle group.

Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients.

OBJECTIVE: Patients in the intensive care unit are at increased risk of developing acute calculous and acalculous cholecystitis. Diagnosis based on clinical and sonographic findings is difficult in the presence of severe intercurrent disease. We did a study to evaluate the efficacy of percutaneous cholecystostomy as a diagnostic and therapeutic maneuver in 82 patients in the intensive care unit who had persistent unexplained sepsis. SUBJECTS AND METHODS: Eighty-two patients with unexplained sepsis underwent percutaneous cholecystostomy after a complete clinical, laboratory, and radiologic search showed no source of sepsis outside the gallbladder. All patients were febrile, 65 had an increased WBC count, and 37 were receiving vasopressors. Sonographic abnormalities included a distended gallbladder (71 patients), sludge (63 patients), gallstones (26 patients), wall thickening (34 patients), pericholecystic fluid (25 patients), and Murphy's sign (19 patients). RESULTS: Sonographic findings were not helpful in predicting response to percutaneous cholecystostomy. A dramatic improvement in clinical condition was observed in 48 patients (59%) within 48 hr. Signs of improvement included defervescence (41 patients), discontinuance of vasopressors (26 patients), and reduction in WBC count (33 patients). No clinical response was observed in 34 patients (41%). No complications related to catheter insertion occurred. CONCLUSION: Because acute cholecystitis is difficult to diagnose in patients in the intensive care unit, percutaneous cholecystostomy serves as a diagnostic and therapeutic maneuver in patients with unexplained sepsis when the gallbladder is the suspected source of sepsis. A response rate to percutaneous cholecystostomy of 59% was seen in this study. The gallbladder was cleared as a potential source of sepsis in the remaining patients.

Pseudomembranous colitis: diagnostic sensitivity of the abdominal plain radiograph.

We performed a retrospective study to determine the incidence of plain radiographic abnormalities in patients with pseudomembranous colitis (PMC). One hundred and fifty-two plain radiographs of the abdomen (taken within 3 days of pseudomembranous colitis diagnosis) from 152 patients with pseudomembranous colitis were reviewed. Forty-eight of 152 (32%) plain radiographs were abnormal, demonstrating: colonic ileus in 48/152 (32%), small bowel ileus in 31/152 (20%), ascites in 10/152 (7%), and nodular haustral thickening in 28/152 (18%). The distribution in 48 patients with colonic ileus included: right colon, 41/48 (86%), transverse colon, 35/48 (72%), and left colon, 26/48 (55%). Distribution in 28 patients with nodular haustral thickening included: right colon, 5/28 (18%), transverse colon, 15/28 (54%), and left colon, 14/28 (50%). Radiographic changes were non-specific in 32% of patients with changes more specific to PMC in only 18%.

Tumour size measurement in an oncology clinical trial: comparison between off-site and on-site measurements.

AIM: To evaluate the degree of variability between lesion measurements obtained by a single observer compared with multiple observers, and in selected cases evaluate which of the two measurements more accurately represented the lesion size. MATERIALS AND METHODS: In this study we compared the performance of a single off-site observer to multiple on-site observers during measurement of 300 abdominal and thoracic lesions. Lesion measurements that were larger than 1cm(2), differed by more than 50%, but by less than 100%, were compared by a single adjudicator, who was blinded to the measurement source (n=46). RESULTS: Measurements of the 300 lesions differed by an average of 109% (SD 251%). Of 266 lesions larger than 1cm(2), results of the single observer compared with multiple observers differed by more than 10% for 249 lesions, more than 30% for 169 lesions, more than 50% for 126 lesions, and more than 100% for 66 lesions. Forty-six lesions were compared by the adjudicator. The adjudicator selected the measurement of the single observer for 37 lesions (80.4%), and the measurement determined by one of the multiple observers for nine lesions (19.6%; p=0.00002). CONCLUSION: Measurement of lesion size by a single observer compared with multiple observers reveals a high degree of variability. An adjudicator selected the measurement of the single observer more frequently than that of multiple observers, with statistical significance. These findings suggest that studies designed to quantify imaging features should limit the number of observers.

Loculated pneumothoraces in patients with acute respiratory disease treated with mechanical ventilation: preliminary observations after image-guided drainage.

PURPOSE: To report the clinical impact of image-guided percutaneous drainage of loculated pneumothoraces in patients with acute respiratory disease treated with mechanical ventilation. MATERIALS AND METHODS: Sixteen loculated pneumothoraces were seen in nine patients. Twelve of the 16 lesions were considered suitable for drainage because of their size and location. They were percutaneously drained by means of image-guided placement of catheters that ranged in size from 16 F to 24 F. Gas exchange was assessed clinically, and follow-up chest radiographs and computed tomographic scans were evaluated. RESULTS: Loculated pneumothoraces were reduced in all patients. Improvement in the ratio of arterial oxygen pressure to fraction of inspired oxygen was identified in eight patients. All patients showed an improved arterial oxygen pressure. CONCLUSION: Image-guided catheter placement may play a role in the acute management of loculated pneumothorax and adult respiratory distress syndrome. This type of therapy may reverse the deterioration of gas exchange and reduce the risk of further pulmonary compromise.

Asymptomatic hydropneumothorax after therapeutic thoracentesis for malignant pleural effusions.

OBJECTIVE: The purpose of this study was to document in a historical cohort the incidence and clinical observations of pneumothorax ex vacuo after therapeutic thoracentesis for malignant pleural effusions in patients with underlying parenchymal lung disease. MATERIALS AND METHODS: Forty pneumothoraces resulted from 512 therapeutic thoracentesis performed for malignant pleural effusions over a 3-year period. Twenty-nine patients with pneumothoraces underwent catheter placement in the pleural space for treatment. Of these, 12 pneumothoraces resolved and 17 remained unchanged. We reviewed the charts of these 17 patients to document the cause of malignant pleural effusion, presence of underlying malignant parenchymal disease, volume of fluid aspirated, and improvement in symptoms. Clinical outcome was then evaluated, including size of residual pneumothorax, duration of catheter drainage, and reaccumulation of effusion. RESULTS: No patients' lungs reexpanded despite insertion of large-bore (16- to 35-French) chest tubes. All had pneumothoraces that occupied at least 30% of the hemithorax; all were asymptomatic; all had underlying parenchymal disease and noncompliant lungs. Pleural effusion reaccumulated in all 17 after removal of the chest tube. CONCLUSION: A subgroup of patients with malignant lung parenchymal disease who undergo therapeutic thoracentesis will develop asymptomatic hydropneumothoraces due to poor lung compliance. These patients do not require further catheter drainage. Pleural effusion will reaccumulate in the residual space over a variable period of time.

Adrenal masses: characterization with delayed contrast-enhanced CT.

PURPOSE: To evaluate the use of attenuation measurements from early delayed computed tomographic (CT) scans to differentiate benign from malignant lesions of the adrenal glands. MATERIALS AND METHODS: Forty-four patients (19 men, 25 women; age range, 21-88 years; mean age, 63 years) with 46 adrenal masses underwent dynamic contrast material-enhanced CT and early delayed CT (range, 12-18 minutes; mean delay, 14 minutes) with similar scanning parameters. Each patient also underwent non-contrast-enhanced CT within 3 months of the contrast-enhanced examination. Attenuation of adrenal masses on each type of scan was measured, and receiver operating characteristic analysis was performed. RESULTS: An attenuation threshold of 24 HU was selected; thus, all lesions with attenuation values of 24 HU or less were considered benign. When this threshold was applied to the results, the sensitivity of characterization of adrenal masses on early delayed scans was 96%, and the specificity was 96%. CONCLUSION: Adrenal masses detected with contrast-enhanced CT can be characterized as benign or malignant on early delayed scans of the adrenal glands.

State-of-the-art adrenal imaging.

The adrenal gland is a common site of disease, and detection of adrenal masses has increased with the expanding use of cross-sectional imaging. Radiology is playing a critical role in not only the detection of adrenal abnormalities but in characterizing them as benign or malignant. The purpose of the article is to illustrate and describe the appropriate radiologic work-up for diseases affecting the adrenal gland. The work-up of a suspected hyperfunctioning adrenal mass (pheochromocytoma and aldosteronoma) should start with appropriate biochemical screening tests followed by thin-collimation computed tomography (CT). If results of CT are not diagnostic, magnetic resonance (MR) and nuclear medicine imaging examinations should be performed. CT has become the study of choice to differentiate a benign adenoma from a metastasis in the oncology patient. If the attenuation of the adrenal gland is over 10 HU at nonenhanced CT, contrast material-enhanced CT should be performed and washout calculated. Over 50% washout of contrast material on a 10-minute delayed CT scan is diagnostic of an adenoma. For adrenal lesions that are indeterminate at CT in the oncology patient, chemical shift MR imaging or adrenal biopsy should be performed. Certain features can be used by the radiologist to establish a definitive diagnosis for most adrenal masses (including carcinoma, infections, and hemorrhage) based on imaging findings alone.

Clostridium difficile colitis: correlation of CT findings with severity of clinical disease.

Clinical records and abdominal CT scans from 64 patients with documented Clostridium difficile disease were reviewed to determine if any correlation existed between CT findings of colitis and severity of clinical disease. Clostridium difficile disease was documented with stool toxin titre levels and CT scans were performed within 3 days of stool sample. Clinical disease severity was estimated by tabulating the degree of fever, WBC count, frequency and duration of diarrhoea. Thirty-nine of 64 patients showed CT evidence of colitis of which 28/39 showed evidence of focal colitis and 11/39 had pancolitis. CT findings suggesting colitis included colonic wall thickening (39 patients), nodular mucosal thickening (11 patients), the 'accordion pattern' (3 patients), pericolonic oedema (27 patients) and ascites (10 patients). Twenty-five of 64 patients showed no CT evidence of colitis. The clinical severity of disease did not statistically differ (P < 0.05) between patients with CT evidence of colitis and those without colitis. The only CT finding that correlated with clinical severity of disease was nodular mucosal thickening which was found with significantly (P < 0.05) more frequency in patients with a WBC count > 11,000 mm3. CT changes with Cl. difficile disease correlate poorly with the clinical severity. This and negative findings do not exclude the disease.

Characterization of adrenal masses (< 5 cm) by use of chemical shift MR imaging: observer performance versus quantitative measures.

OBJECTIVE: The purposes of this study were to evaluate the ability of chemical shift MR imaging to differentiate 1- to 5-cm adrenal adenomas from metastases and to compare subjective interpretation with several different quantitative measures. SUBJECTS AND METHODS: Forty-three patients with 46 proved adrenal lesions (28 adenomas and 18 metastases) had MR imaging with a gradient-echo breath-hold technique and echo time varied to obtain in-phase and out-of-phase images. Qualitative analysis of the MR images was done by three experienced observers, who reported their confidence in diagnosing the benignity versus the malignancy of the adrenal masses on the basis of signal loss on out-of-phase images. Quantitative analysis was performed by calculating the difference in signal intensity between in-phase and out-of-phase images by use of regions of interest (signal intensity index) and by use of adrenal-liver, adrenal-spleen, and adrenal-muscle signal intensity ratios. Results between quantitative and qualitative measures were compared by use of receiver operating characteristic (ROC) analysis. RESULTS: The mean signal intensity was significantly different between adenomas and metastases on out-of-phase images (64 versus 98) (p < .0005) but not in-phase images (130 versus 122) (p = .47). The adrenal-spleen ratio discriminated between adenomas and metastases better than did the adrenal-liver ratio, the adrenal-muscle ratio, or the signal intensity index. No significant difference in interpretation among the three observers was evident (areas under the ROC curves, 0.93, 0.95, and 0.96). The performance of the observers was comparable to the results obtained with the adrenal-spleen ratio measurement (area under the ROC curve, 0.97). CONCLUSION: Experienced observers were able to differentiate adrenal adenomas from metastases just as well as quantitative measures. The adrenal-spleen ratio is the best quantitative means of distinguishing benign from malignant adrenal masses. Chemical shift MR imaging is a good but imperfect discriminator of adrenal adenomas.