Effect of Health Care Financing Administration regulation on radiology fellowship training.

RATIONALE AND OBJECTIVES: The purpose of this study was to assess the effect of Health Care Financing Administration (HCFA) regulations on radiology fellowship training. MATERIALS AND METHODS: Surveys were sent to 157 fellowship program directors in body imaging and vascular/ interventional radiology. Questions addressed program accreditation status, faculty supervision of fellows, and any change in faculty supervision of fellows in response to HCFA's revised plan for Medicare Part B reimbursement. RESULTS: Eighty of 157 (51%) surveys were returned. Thirty (37%) respondents indicated supervision of fellows had changed after institution of the new HCFA rules in July 1996. Vascular/interventional program directors (n = 25, 49%) were more likely to have changed their practice than body imaging program directors (n = 5, 17%). Nearly all respondents (29 of 30, 97%) indicating a change stated supervision had increased. Twenty-seven (33%) respondents also indicated faculty supervision was beyond that necessary for patient care and house staff education; most of these respondents (21 of 27, 78%) stated the new HCFA regulations were responsible. Many program directors also expressed concern the HCFA regulations might prevent fellows from obtaining sufficient experience to effectively learn independent clinical decision-making. CONCLUSION: HCFA regulations intended to address attending physician billing practices at teaching institutions may have had the unintended effect of substantively altering the training of radiology fellows.

Transcatheter treatment of life-threatening lower gastrointestinal bleeding due to advanced pelvic malignancy.

We present two patients with life-threatening, massive, lower gastrointestinal (GI) bleeding and locally advanced cervical carcinoma. Selective pelvic arteriography demonstrated that the site of bleeding originated from a pseudoaneurysm of the right internal iliac artery with fistulous communication to the sigmoid colon in one patient and from the left internal iliac artery into the rectum in the second patient. Transcatheter embolotherapy was then performed using balloon occlusion in one patient and coil embolization in the second patient. The iliac arteries should also be evaluated in patients with pelvic cancer who present with lower GI bleeding.

Sonographic features of mammary oil cysts.

Mammographic lesions that are pathognomonic for oil cysts require no further evaluation. Oil cysts, however, may first be discovered by ultrasonography. Between 1988 and 1995, we performed sonography of 26 oil cysts in 15 patients. Sonography was used to evaluate a palpable finding when an oil cyst was not initially perceived on the mammogram (47%) or as an initial evaluation of a palpable lump (33%); in addition, oil cysts were identified incidentally in 20% of cases. Retrospective review showed that the sonographic appearance of oil cysts is highly variable; only 8% mimic simple apocrine cysts. Twelve percent mimic an intracystic mass. Most have smooth walls (88%), are hypoechoic (65%), and have neither enhancement or shadowing (50%). The sonographic appearance of oil cysts can be suggestive of a pathologic lesion such as an intracystic carcinoma. Unnecessary biopsy can be avoided using directed mammography.

Acutely injured knee: effect of MR imaging on diagnostic and therapeutic decisions.

PURPOSE: To assess the effect of knee magnetic resonance (MR) imaging on the diagnosis and management of acute knee injury. MATERIALS AND METHODS: Two orthopedic knee surgeons prospectively completed pre- and post-MR imaging questionnaires on 84 of 91 consecutive patients with acute knee injury. The pre- and post-MR imaging clinical diagnoses, certainty regarding these diagnoses, other diagnostic tests, and subjective impression of the usefulness of MR imaging were determined. RESULTS: Seven hundred thirty-one of 840 pre- and post-MR imaging diagnoses agreed. Agreement was lowest for medial meniscal injuries (54 of 84). Significantly fewer meniscal injuries were suspected after MR imaging (P < .05). In 60 patients, the orthopedist changed at least one of the 10 potential diagnoses after MR imaging. Clinical diagnostic certainty increased by a mean of 14% for all diagnoses. The increase in diagnostic certainty was greatest for medial meniscal injuries (30%), followed by lateral meniscal injuries (21%). The proposed management changed in 41 patients, resulting in significantly fewer arthroscopic procedures (P < .01). The post-MR imaging management plans included 37% (27 of 73) fewer arthroscopic procedures. CONCLUSION: MR imaging affects the diagnosis and management of acute knee injury by decreasing the number of arthroscopic procedures, improving clinician diagnostic certainty, and assisting in management decisions.

Fluoroscopically guided injections into the foot and ankle: localization of the source of pain as a guide to treatment--prospective study.

PURPOSE: To determine the value of injections of local anesthetic and steroids in the foot and ankle in localizing the source of pain and their effect on clinical confidence and decision making. MATERIALS AND METHODS: In 47 patients, fluoroscopically guided injections of local anesthetic and steroid into the foot and ankle were performed in 106 intra- and extraarticular sites. Questionnaires were completed by the referring surgeon before and after injections to evaluate the level of confidence with regard to the source of pain for each site injected and the proposed treatment plan. RESULTS: Forty-three (91%) patients reported pain relief after injections. The level of confidence that the site injected was the source of pain increased in 68 (64%) sites, decreased in 19 (18%) sites, and remained unaltered in 19 (18%) sites (P < .01). The treatment plan was changed from nonsurgical initially to surgical in three (8%) of 36 patients and was changed from surgical to nonsurgical in three (27%) of 11 patients after injections. Of the remaining eight patients, treatment was altered in three (37%) as a result of pain relief after the injections. CONCLUSION: Fluoroscopically guided injections of local anesthetic and steroid in the foot and ankle can improve clinical confidence with regard to the site of pain and may be valuable in clinical decision making and patient treatment.

Plain film evaluation of degenerative disk disease at the lumbosacral junction.

OBJECTIVE: Diagnosing degenerative disk disease (DDD) at the lumbosacral junction (LSJ) on plain films is often difficult, compared with other disk levels. The purpose of this study was to determine whether criteria for diagnosis of DDD at the LSJ can be established for plain films. DESIGN AND PATIENTS: We retrospectively reviewed 100 lumbar MRI scans of patients who also had lumbar plain films. Using MRI as the reference standard, the LSJ was classified as normal (n=35) or exhibiting mild (n=45) or severe (n=20) DDD by two radiologists using accepted criteria. Measurements were performed on the plain films by two other radiologists and the average measurements were tabulated according to the three categories of DDD defined by MRI. Plain film measurements included the anterior and posterior disk heights (ADH, PDH), Farfan's ratio, determined by adding ADH to PDH and dividing that number by the measured anteroposterior (AP) length of the inferior end plate of L5 [(ADH+PDH)/AP length of L5], and lumbosacral angle (LSA). Subsequently, five additional radiologists interpreted the radiographs by visual inspection only, for DDD at the LSJ, both before and, several weeks later, after being provided with the quantitative data for normal versus DDD. RESULTS AND CONCLUSION: There was a statistically significant difference between normal disk and increasing severity of DDD on radiographs using the parameters of PDH and Farfan's ratio. There was no statistically significant difference regarding ADH or LSA. Diagnostic accuracy by visual inspection was not significantly altered using the quantitative data for interpretation of DDD (68% correct before, 69.5% correct after). Analysis of results indicates that PDH is the most reliable and easily used criterion for detection of DDD at the LSJ. A PDH < or =5.4 mm on plain lateral film indicates DDD; PDH > or =7.7 mm indicates the absence of DDD on plain film.

Evaluation of VoiceType Dictation for Windows for the radiologist.

The accuracy of the radiology vocabulary domain of the IBM VoiceType Dictation for Windows speech recognition system for use in a clinical setting was evaluated. Six men and one woman dictated a case report under several conditions. The impact of vocabulary domain, microphone position, personal enrollment, and background noise were assessed. The dictations were exported to Microsoft Word 6.0, printed, and graded for accuracy. The data were expressed as a percentage correct. The enrollment and training processes took an average of 5 hours to complete. The accuracy of VoiceType Dictation was significantly reduced by speech volume and background noise level so that it could not be used to dictate clinical information accurately in a hospital setting. Although IBM's VoiceType Dictation with the radiology vocabulary domain has improved speech recognition, it is not a reliable dictation system for accurate and efficient clinical dictation in a hospital setting.