APPC--a new standardised coding system for trans-organisational PACS retrieval.

OBJECTIVES: As part of a general strategy to integrate the health care enterprise, Austria plans to connect the Picture Archiving and Communication Systems (PACS) of all radiological institutions into a nationwide network. To facilitate the search for relevant correlative imaging data in the PACS of different organisations, a coding system was compiled for all radiological procedures and necessary anatomical details. RESULTS: This code, called the Austrian PACS Procedure Code (APPC), was granted the status of a standard under HL7. Examples are provided of effective coding and filtering when searching for relevant imaging material using the APPC, as well as the planned process for future adjustments of the APPC. DISCUSSION: The implementation and how the APPC will fit into the future electronic environment, which will include an electronic health act for all citizens in Austria, are discussed. A comparison to other nationwide electronic health record projects and coding systems is given. Limitations and possible use in physical storage media are contemplated.

MRI of the knee: how do field strength and radiologist's experience influence diagnostic accuracy and interobserver correlation in assessing chondral and meniscal lesions and the integrity of the anterior cruciate ligament?

Accuracy of MRI reports is taken for granted. In this paper the inter-observer reliability in the interpretation of meniscal lesions, degree of chondropathy, and integrity of the ACL was analyzed while taking the radiologist's experience and field strength into account. Fifty-two MRI studies of knees were interpreted by 11 radiologists independently. Twenty-two were acquired on 1.0-T, 20 on 1.5-T, and 10 on 3.0-T systems. Four of the radiologists had more than 5 years and seven had 3 to 5 years of experience in interpreting MRI studies. The findings were compared with the intra-operative findings. Inter-observer variance, specificity, and sensitivity were evaluated for each field strength. Inter-observer correlation ranged between 0.370 for cartilage lesions and 0.597 for meniscal tears. Correlation values did not increase with experience or field strength. The number of false reports was dependent on the observer, but not on field strength. The rate of false interpretations was significantly higher for most criteria in the less experienced group. In conclusion, inter-observer correlation was low, although the diagnostic criteria were defined. The use of the classification scheme should be standardized by uniform training. Radiologist experience seems to be more important than field strength.

Tumor growth of suspected meningiomas in clinically healthy 80-year-olds: a follow up five years later.

BACKGROUND: The incidence of clinically silent meningiomas in 75-year-old individuals was determined five years ago in the Vienna Transdanube Ageing Study (VITA). At the time a watch-and-wait approach was recommended in cases of incidentally discovered meningiomas. METHODS: 420 out of the initial cohort of 532 test persons underwent control investigations after 2.5 and 5 years. Six of the nine known tumors were measured again and the patients underwent clinical, neurological and psychological tests. Changes in tumor size were determined and all new tumors seen on MRI investigation were carefully reviewed. RESULTS: Tumor growth was minimal in all six cases that were followed over the entire period. Two of the original meningioma patients had died and one patient had undergone tumor resection. CONCLUSIONS: The watch-and-wait approach recommended after the VITA study was confirmed by the present investigation. Tumor growth was slow in all cases; no clinical symptoms have been registered thus far. The intervals between control investigations may even be prolonged depending on the location of the tumor. In this age group the operation appears to pose a greater risk than the presence of an asymptomatic tumor.

VITA study: white matter hyperintensities of vascular and degenerative origin in the elderly.

The etiology of white matter hyperintensities (WMH) seen on T2-weighted cranial magnetic resonance images is a matter of debate. We investigated deep and periventricular WMH in the brains of a community-based cohort of 532 subjects aged 75-76 years. The objective of this study was to determine whether WMH at age of 75 years were associated rather with vascular factors than with degenerative factors. Arterial hypertension treated with antihypertensive drugs favored WMH, and WMH were found more frequently in subjects with focal vascular lesions. Additionally, we found significant associations between both, deep white matter and periventricular hyperintensities, and focal atrophy of medial temporal lobe structures. The odds ratio for deep WMH in subjects with more severe medial temporal atrophy was 4.4 (95%-CI: 1.9-9.8) that for periventricular hyperintensities was 3.9 (95%-CI: 1.7-8.8). These findings might indicate that not only vascular factors alone but also degenerative factors favor the occurrence of WMH after the age of 75 years.

Improving the safety of laparoscopic cholecystectomy: the routine use of preoperative magnetic resonance cholangiography.

BACKGROUND: The aim of this study was to determine the value of routinely performed preoperative magnetic resonance cholangiography (MRC) in detecting common bile duct (CBD) stones in patients stated to undergo elective laparoscopic cholecystectomy. In addition, we used MRC to investigate possible variants of the cystic duct. METHODS: Magnetic resonance cholangiography was performed preoperatively in 773 patients (311 male and 462 female; median age 55 years, range 16-91) who had no clinical signs of cholestasis prior to undergoing elective laparoscopic cholecystectomy. In cases where the MRC was positive for CBD stones, endoscopic retrograde cholangiopancreatiography (ERCP) was then performed. A total of 532 patients were available for continuous postoperatively follow-up (median 54 months, range 36-85). In 462 patients (247 female, and 215 male), MR images were also reviewed for variants of the cystic duct. RESULTS: In 705 patients (91%), MRC was negative for CBD stones. In 64 patients (9%) MRC was positive. Of these patients, 47 (6%) had CBD stones on ERCP. In 12 patients (2%), MRC was false positive. In five cases (0.6%), ERCP had an inconclusive result postoperative follow-up (532 patients, or 69%) revealed evidence of CBD stones in three patients (10.4%) despite a preoperative negative MRC result. Anatomical variants in the course of the cystic duct and its confluence with the common bile duct were found in 27 of 462 patients (6%). CONCLUSIONS: Magnetic resonance cholangiography proved to be a reliable screening technique in the preoperative evaluation of patients with silent CBD stones. Imaging of the course of the cystic duct is possible in a high percentage of cases. Therefore, MRC can be recommended as a screening technique before laparoscopic cholecystectomy.

[Lumbar meningeal enhancement after surgery in the posterior cranial fossa: a normal finding in children?]. / Lumbales meningeales Enhancement in der KM-MRT.

PURPOSE: Spinal meningeal Gd-DTPA enhancement after cranial surgery is a known observation of a not well understood underlying mechanism. This paper demonstrates that this MRI finding is a normal meningeal reaction to subarachnoid hemorrhage, which should not be mistaken for metastatic spread. MATERIAL AND METHODS: Three pediatric patients were examined by MRI for metastatic spread of malignant infratentorial tumors along the spinal canal two to nine days after the removal of the primary cerebral lesion. The findings were compared with a control group that underwent cranial surgery (cyst resection or fenestration of the posterior cranial fossa) without major bleeding into the subarachnoid space. Unenhanced and enhanced sequences were obtained to prove that the high signal within the CSF is caused by an abnormal Gd-DTPA uptake and not by methemoglobin. RESULTS: Meningeal enhancement was observed in all patients with intraoperative bleeding resembling subarachnoid masses on enhanced T 1 -weighted images. This was not present in any patient of the control group. This finding lasts for approximately two weeks. CONCLUSION: The meningeal enhancement renders immediate postoperative studies inconclusive for the detection of metastatic spread. Consequently, the obligatory tumor staging along the spinal canal should ideally be done prior to the resection of a cerebral tumor.

[Radiofrequency-thermoablation in malignant liver disease]. / Radiofrequenz-Thermoablation maligner Raumforderungen der Leber.

The clinical application of radiofrequency tumor ablation in primary liver tumors and metastatic liver disease is rapidly growing because this technique has proven to be simple, safe, and effective in first clinical studies. Most of the patients with malignant liver disease are not candidates for surgical resection due to localisation or comorbidity, so radiofrequency therapy offers a good alternative for inoperable patients. With this method, high frequency alternating current is delivered to tissue via a needle electrode, the produced heat leads to coagulation necrosis. The largest focus of necrosis that can be induced with the currently available systems is approximately 4 - 5 cm with a single application. The radiofrequency needle is usually placed with US or CT guidance. For follow up examinations CT and MRI can be used, they proved to be equally accurate in the assessment of treatment response.

[Teleconsultation 2001--report of the Teleconsultation Study Circle of the Austrian Roentgen Society (ORG)]. / Telekonsultation 2001--Bericht des Arbeitskreises Telekonsultation der Osterreichischen Röntgengesellschaft (ORG).

In 1997, the working group "Teleconsultation" of the Austrian Roentgen Society (ORG) has performed a first survey about the status of teleradiological applications in Austria. Now, in 2001, a second survey was performed in order to adapt the ORG's approach in this field to the most actual needs. Most of the 38 teleradiological projects in Austria already working or shortly before inauguration are aiming at an improvement of the medical service in favour of our patients (expert consultation, image transfer to doctors requesting radiological examinations, clinical case discussion). However, a small but not unimportant fraction of teleradiology projects in Austria (11%) is performed for replacement of radiologists on duty, therefore for reasons mainly directed to minimising costs for the hospital administration. Other purposes of teleradiology projects, like quality assurance and medical education have even lost their small importance the 1997 survey already has shown. This paper discusses the professional implications from the results of the 2001 survey and the legal framework for the application of telecommunication in diagnostic radiology. The most important goal of all professional activities in radiology is the well-being of our patients, based on the immediacy of the medical profession in accordance with the "physician law".

Successful treatment of invasive mould infection affecting lung and brain in an adult suffering from acute leukaemia.

We describe in detail a 67-yr-old woman who was treated with a cytostatic combination chemotherapy for newly diagnosed common-acute lymphoblastic leukaemia. At the end of induction therapy, the patient acquired invasive mould infection affecting lung and brain. The patient entered complete remission of her leukaemia. Treatment with liposomal amphotericin B was initiated along with surgical excision of the fungal brain abscess. Intrathecal instillation of amphotericin B deoxycholate was started using an Ommaya reservoir because of an anatomical connection between the postoperative cavity and the ventricle. Full dose cytostatic chemotherapy was continued with little delay. A computerised tomography scan of the chest performed 2 months later revealed no fungal abscesses. Magnetic resonance imaging of the brain did not reveal any fungal manifestation. During maintenance therapy/week 69, the patient relapsed from leukaemia. High doses of intravenous liposomal amphotericin B were administered prophylactically. The patient's leukaemia proved refractory to reinduction chemotherapy and the patient died from pneumonia 8 wk later. Post mortem microbiological investigation and histopathological examination of lung and brain tissue did not reveal any macroscopical or microscopical fungal manifestations. This case underlines the feasibility and successful application of combined antileukaemic, antifungal and surgical therapy in a patient with acute leukaemia.

MR imaging of the knee in marathon runners before and after competition.

OBJECTIVE: To evaluate the findings in MRI-studies of the knee in recreational long-distance runners after competition and to assess the reversibility of the findings. DESIGN AND PATIENTS: Eight recreational long-distance runners underwent MRI studies of the knee before, immediately after and 6-8 weeks after taking part in the Vienna City Marathon. The studies were evaluated regarding alterations of pre-existing lesions and new pathological findings. RESULTS: In six runners without major pre-existing alterations no negative effects were experienced. In one runner with pre-existing grade III alterations of the menisci, signs of progressive osteoarthritis were experienced 2 months after the competition. In all other cases increased meniscal signal alterations and minor signal changes in the bone marrow after the race were transitory. CONCLUSION: In healthy individuals no negative long-term-effects were experienced. Pre-existing high-grade lesions of the menisci might be a predisposing risk for osteoarthritis, triggered by the stress of long-distance running.

MR imaging for the preoperative planning of sphincter-saving surgery for tumors of the lower third of the rectum: use of intravenous and endorectal contrast materials.

PURPOSE: To evaluate the value of magnetic resonance (MR) imaging with a flexible surface coil in predicting the resectability of tumors in the lower rectum and the feasibility of sphincteral salvage. MATERIALS AND METHODS: In a prospective study, 61 patients with histologically proved primary adenocarcinoma of the lower or middle third of the rectum (<12 cm from the pectinate line) were examined at double-contrast-material-enhanced MR imaging with a circular polarized flexible surface coil. RESULTS: Assessment of anal sphincteral infiltration at MR imaging was excellent, with a specificity of 98% and a sensitivity of 100%. In the determination of tumor infiltration into adjacent organs (T4), the specificity was 100%, and the sensitivity was 90%, with surgical and histologic findings as the standards. While MR imaging showed negative nodes in 40 patients (stage N0 at MR imaging), histologic examination showed negative nodes in 27 patients and positive nodes in 34. At MR imaging, sensitivity was 68%, and specificity was 24%. CONCLUSION: While preoperative staging at MR imaging according to the TNM system still has limited value and accuracy, MR imaging provides the surgeon with valuable information regarding the presence of sphincteral invasion and the surrounding structures in patients with cancers in the lower third of the rectum.

Magnetic resonance imaging of perianal fistulas: predictive value for Parks classification and identification of the internal opening.

OBJECTIVE: MRI has been reported to be valuable in the investigation of patients with fistula in ano. The aim of this study was to evaluate the results of preoperative magnetic resonance imaging (MRI) in such patients using a surface coil and to compare it with surgical findings. PATIENTS AND METHODS: In a prospective study, 28 patients (19 males, nine females, median age 39 years) with perianal fistula underwent preoperative MRI. Parks classification as well as the identification of an internal opening into the anal canal and/or rectum were compared with the surgical findings. RESULTS: Classification during surgery revealed five extrasphincteric, eight transsphincteric, seven suprasphincteric and eight intersphincteric fistulas. All patients with intersphincteric, suprasphincteric and transsphincteric fistulas were correctly classified by MRI. The comparison of MRI and surgical results revealed a concordance in 27 of 28 (96%) patients in terms of classification (κ 0.95, P < 0.01) and in 21 (75%) patients regarding the identification of the internal opening (sensitivity 63%, specificity 92%). CONCLUSION: Our results indicate that MRI of perianal fistulas with the use of extra-anal surface coils can accurately assess the surgical anatomy. It is a rapid, well-tolerated technique which might play an important role in the management of perianal fistula.

[Endovascular brachytherapy for the prevention of recurrence after PTA]. / Endovasculäre Brachytherapie zur Rezidivprophylaxe nach PTA.

PURPOSE: Recurrent stenosis after PTA is caused by intimal hyperplasia and constrictive arterial remodeling. In experimental and first clinical studies, ionizing radiation has demonstrated its potential to control excessive intimal proliferation. We wanted to evaluate the safety, feasibility and efficacy of endoluminal irradiation after PTA and/or stent implantation. MATERIAL AND METHODS: From September 1996, 24 patients (24 lesions) who had a stenosis or occlusion measuring more than 5 cm in length in the superficial femoral artery or a restenosis after PTA underwent endoluminal irradiation. An isodose of 14 Gy was applied to the vessel wall using an Ir-192-HDR afterloading unit. The radiation was tolerated well; the additional time needed for the procedure was 30-45 min. RESULTS: In a mean follow-up time of 15 months we found a cumulative patency rate of 60%. No side effects were observed. CONCLUSION: Endovascular brachytherapy is a safe and brief procedure. In our selection of patients, a patency rate of approx. 40% after 1 year has to be expected. Thus, these first results are promising, although first published studies of endoluminal irradiation in peripheral vessels with stent implantation showed higher patency rates. No randomized data are currently available. We conclude that endovascular irradiation should be performed together with stent implantation in long lesions or recurrent stenosis after PTA, in order to control not only excessive intimal proliferation but also constrictive arterial remodeling.