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.

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.

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.

Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT.

PURPOSE: To determine whether computed tomographic (CT) scans and attenuation measurements on contrast material-enhanced and nonenhanced CT scans could be used to characterize adrenal masses, in particular, to characterize these lesions by using adrenal washout characteristics at contrast-enhanced CT. MATERIALS AND METHODS: Eighty-six patients (49 men, 37 women; age range, 29-86 years; mean age, 72 years) with 101 adrenal lesions depicted at contrast-enhanced CT underwent delayed (mean, 9 minutes) enhanced scanning. Seventy-eight patients also underwent nonenhanced CT. Mean diameter of the benign lesions was 2.1 cm (range, 1.0-4.2 cm); mean diameter of the malignant lesions was 2.3 cm (range, 1.0-4.1 cm). Region-of-interest measurements were obtained at nonenhanced, dynamic enhanced, and delayed enhanced CT and were used to calculate a relative percentage washout as follows: 1 - (Hounsfield unit measurement on delayed image / Hounsfield unit measurement on dynamic image) x 100%. RESULTS: Ninety-nine of 101 lesions were correctly characterized as benign or malignant with a relative percentage washout threshold of 50% on delayed scans; benign lesions demonstrated more than 50% washout; and malignant lesions, less than 50% washout. Two benign lesions demonstrating less than 50% washout were characterized as benign by using conventional CT. CONCLUSION: Calculation of relative percentage washout on dynamic and delayed enhanced CT scans may lead to a highly specific test for adrenal lesion characterization, reduce the need for, and possibly obviate, follow-up imaging or biopsy.

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.

Prevalence and significance of gallbladder abnormalities seen on sonography in intensive care unit patients.

OBJECTIVE: We evaluated sonographic abnormalities of the gallbladder other than acalculous cholecystitis across a broad range of intensive care unit (ICU) patients. SUBJECTS AND METHODS: Fifty-five consecutive patients (age range, 18-94 years old; mean age, 56 years; 33 men, 22 women), who were admitted to the ICU with a variety of diagnoses, underwent sonography of the gallbladder twice a week. Patients with gallbladder calculi were excluded from the study. The gallbladder was examined for the recognized sonographic features of acalculous cholecystitis: gallbladder wall thickening, gallbladder distention, intramural gallbladder lucencies (striated gallbladder wall), pericholecystic fluid, gallbladder sludge, and Murphy's sign. These findings were correlated with clinical and laboratory parameters that are associated with acalculous cholecystitis: fever, WBC, liver function tests, levels of serum bilirubin, mechanical ventilation status, and administration of parenteral nutrition, narcotic analgesics, antibiotics, and pressor agents. RESULTS: Eleven of the 55 patients were found to have gallbladder calculi and were excluded from the study. Thirty-seven (84%) of the remaining 44 patients had at least one sonographic abnormality while in the ICU. Twenty-five (57%) of the 44 patients had as many as three abnormalities found on sonography, and six (14%) of 44 patients had four or five sonographic findings of gallbladder abnormalities while in the ICU. No statistically significant correlation was found among any of these sonographic abnormalities and the clinical and laboratory parameters. CONCLUSION: Gallbladder abnormalities are frequently seen on sonography in ICU patients, even if these patients are not suspected of having acalculous cholecystitis; therefore, sonography appears to be of limited value in diagnosing acalculous cholecystitis in ICU patients.

Adenocarcinoma of the head of the pancreas: determination of surgical unresectability with thin-section pancreatic-phase helical CT.

OBJECTIVE: This study was conducted to evaluate newly introduced criteria for unresectability of pancreatic cancer with thin-section pancreatic-phase helical CT. MATERIALS AND METHODS: Twenty-five patients with adenocarcinoma in the head of the pancreas underwent thin-section pancreatic-phase helical CT. The major peripancreatic vessels were categorized on a scale of 1-4, according to the degree of circumferential involvement by tumor. The maximum diameters of the small peripancreatic veins--gastrocolic trunk, anterosuperior pancreaticoduodenal vein, and posterosuperior pancreaticoduodenal vein--were recorded. Findings on CT were compared with the results of surgery in each patient. RESULTS: Sixteen patients had surgically resectable tumors, and nine patients had surgically unresectable tumors. CT and surgical correlation was available for 98 major peripancreatic vessels; 85 were resectable and 13 were unresectable. Of category 1 vessels, 72 (97%) of 74 were resectable at surgery. Of category 2 vessels, 12 (71%) of 17 were resectable. One (50%) of two category 3 vessels and none (0%) of five category 4 vessels were resectable at surgery. CT showed a dilated gastrocolic trunk in two patients; one of these patients had a surgically resectable tumor, but the other patient had a surgically unresectable tumor. CONCLUSION: In patients with adenocarcinoma in the head of the pancreas, the degree of circumferential vessel involvement by tumor as shown by CT is useful in predicting which patients will have surgically unresectable tumors. A dilated gastrocolic trunk should not be used as an independent sign of surgical unresectability.

Pancreatic-phase versus portal vein-phase helical CT of the pancreas: optimal temporal window for evaluation of pancreatic adenocarcinoma.

OBJECTIVE: Our objective was to use helical CT to compare the enhancement attenuation values of pancreatic adenocarcinoma, adjacent normal pancreas, and critical vascular structures during the pancreatic phase and portal vein phase. SUBJECTS AND METHODS: Forty-one patients with pathologically proven pancreatic adenocarcinoma underwent dual-phase thin-section dynamic helical CT using a pancreatic-phase and portal vein-phase protocol. The scan delay after initiation of the contrast bolus was 40 sec for the pancreatic phase and 70 sec for the portal vein phase. Attenuation values after i.v. contrast administration were calculated during both phases of scanning for normal pancreas, pancreatic tumor, celiac axis, superior mesenteric artery, superior mesenteric vein, splenic vein, and portal vein. Quantitative values were assessed using regions of interest. RESULTS: Mean differences of enhancement between tumor and normal pancreas were significantly greater in the pancreatic phase (57 H) than the portal vein phase (35 H) (p = .0001). Enhancement values of all the critical vascular structures were also significantly greater in the pancreatic phase than the portal vein phase (p < .001). CONCLUSION: With dynamic thin-section helical CT, pancreatic-phase scanning provides greater differences in contrast enhancement between normal pancreas and pancreatic tumor and between pancreatic tumors and surrounding critical vascular structures than does portal vein-phase scanning.

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.

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.

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.

Characterization of adrenal masses using unenhanced CT: an analysis of the CT literature.

OBJECTIVE: Unenhanced CT scanning can reliably characterize incidentally detected adrenal masses when observers use density measurements of the adrenal gland. However, controversy exists as to the optimal density threshold required to differentiate benign from malignant lesions. This study attempts to establish a consensus by performing a pooled analysis of data found in the CT literature. MATERIALS AND METHODS: Ten CT reports were analyzed, from which individual adrenal lesion density measurements were obtained for 495 adrenal lesions (272 benign lesions and 223 malignant lesions). Threshold analysis generated a range of sensitivities and specificities for lesion characterization at different density thresholds. RESULTS: Sensitivity for characterizing a lesion as benign ranged from 47% at a threshold of 2 H to 88% at a threshold of 20 H. Similarly, specificity varied from 100% at a threshold of 2 H to 84% at a threshold of 20 H. CONCLUSION: The attempt to be absolutely certain that an adrenal lesion is benign may lead to an unacceptably low sensitivity for lesion characterization. The threshold chosen will depend on the patient population and the cost-benefit approach to patient care.