[Interdisciplinary tumor boards in the radiological routine : Current situation based on an online survey in Germany]. / Interdisziplinäre Tumorkonferenzen in der radiologischen Routine : Statuserhebung basierend auf einer Online-Befragung in Deutschland.

PURPOSE: Interdisciplinary tumor boards are periodical conferences, where optimal individual therapy plans are developed among medical experts with different specializations. The presence of a board-certified radiologist is medically indispensable in almost all relevant boards. In order to systematically evaluate the current workload for radiologists caused by these boards, we evaluated the current situation within German radiology to obtain numbers for future personnel planning. MATERIALS AND METHODS: We performed an online survey. We invited all 33 German university chairmen and 50 randomly selected head physicians of radiology at level 3 hospitals to participate. RESULTS: We had a participation rate of 79% (26/33) at university hospitals and 56% (28/50) at of level 3 non-university hospitals. The average total number of tumor boards was 3.3/day or 16.7/week at university hospitals and 2.6/day or 13/week at level 3 non-university hospitals. We calculated an average time considering preparation and execution as well as the average number of boards of 33.1 h/week for university hospitals and 18.2 h/week for level 3 hospitals. This results in a 78.8% workload for a board-certified radiologist at a university hospital (regular weekly work time 42 h) and 45.5% work load for level 3 hospitals (regular weekly work time 40 h). CONCLUSION: "Speaking radiology" as in interdisciplinary tumor boards represents a fundamental matter of course in radiology. The active participation in boards accomplished by radiologists improves evidence-based patient care. However, given the prevailing scarcity of resources in medicine, the data collected here regarding personnel costs for clinical radiology for participation in tumor boards must be taken into account in future discussions on personnel compensation.

[Acceptance of medical apps and e­books among German radiologists]. / Akzeptanz von Medizin-Apps und E­Books unter deutschen Radiologen.

PURPOSE: Smartphones, tablet PCs, mobile applications (apps) and electronic book files (e-books) affect our lives in private and job-related settings. The aim of this study was to analyze the behavior of radiologists on smartphones, tablet PCs and e­books and to investigate its effect on their daily work. MATERIALS AND METHODS: An online survey containing of 23 questions was conducted using Survey Monkey© ( www.surveymonkey.com ). The invitation to the survey was done using the newsletter of the German Radiological Society (DRG). The acquired data was automatically stored by the software and then analyzed using descriptive statistics. RESULTS: In total, 104 radiologists (29% female) participated in the online survey. Of these, 93% and 96.5% owned a smartphone or a tablet PC, respectively, and 72% and 67% used medical apps and e­books, respectively. Through their use, 31% found moderate and 41% found enormous improvement in their daily work. A majority of participating radiologists would be willing to pay an increased user fee for optimized apps or e­books. CONCLUSION: With currently only moderate individual benefit of mobile medical apps and e­books, there is a widespread need for optimally configured apps and e­books with a correspondingly high market potential. KEY POINTS: (1) Radiologists use smartphones (93%) or tablet PCs (96.5%); (2) 72% of radiologists use a smartphone or tablet PC for medical material; (3) 53% of radiologists report significant assistance from or a high value of the mobile medical applications used; (4) There is a willingness to pay a license fee for optimized mobile applications or e­books.

Impact of multidetector computed tomography on the diagnosis and treatment of patients with systemic inflammatory response syndrome or sepsis.

OBJECTIVES: To evaluate the impact of CT scans on diagnosis or change of therapy in patients with systemic inflammatory response syndrome (SIRS) or sepsis and obscure clinical infection. METHODS: CT records of patients with obscure clinical infection and SIRS or sepsis were retrospectively evaluated. Both confirmation of and changes in the diagnosis or therapy based on CT findings were analysed by means of the hospital information system and radiological information system. A sub-group analysis included differences with regard to anatomical region, medical history and referring department. RESULTS: Of 525 consecutive patients evaluated, 59% had been referred from internal medicine and 41% from surgery. CT examination had confirmed the suspected diagnosis in 26% and had resulted in a different diagnosis in 33% and a change of therapy in 32%. Abdominal scans yielded a significantly higher (p=0.013) change of therapy rate (42%) than thoracic scans (22%). Therapy was changed significantly more often (p=0.016) in surgical patients (38%) than in patients referred from internal medicine (28%). CONCLUSIONS: CT examination for detecting an unknown infection focus in patients with SIRS or sepsis is highly beneficial and should be conducted in patients with obscure clinical infection. KEY POINTS: • Evaluation of patients with obscure clinical infection is a challenging task. • CT examination of patients with SIRS or sepsis seems to be beneficial. • CT examination confirmed suspected diagnosis in 26% of patients. • CT examination yielded a new infection focus in 33% of patients. • CT examination changed therapy in up to 32% of patients.

Preoperative differentiation of thyroid adenomas and thyroid carcinomas using high resolution contrast-enhanced ultrasound (CEUS).

BACKGROUND: To evaluate the impact of high-resolution contrast-enhanced ultrasound (CEUS) in combination with Color Coded and Power Doppler Sonography (CCDS/PD) in the preoperative differentiation of thyroid adenomas and thyroid carcinomas. METHODS: A total of 101 patients (55 female, median age 54 years) underwent surgery for thyroid adenoma and thyroid carcinoma. CCDS/PD and CEUS were performed in all patients by an experienced examiner using a multifrequency linear transducer (6-9 or 6-15 MHz) and were digitally stored. Reading of the ultrasound images was performed by two experienced radiologists in consensus. A histopathological evaluation was obtained as standard of reference in all patients. RESULTS: Altogether, 75 thyroid adenomas and 26 thyroid carcinomas were detected. Mean diameter of thyroid adenomas and thyroid carcinomas was 27 mm and 32 mm, respectively. The differences in microcirculation of thyroid adenomas and thyroid carcinomas were statistically highly significant (p <  0.01). Representative features for thyroid adenomas were either no wash-out or wash-out with persisting edge in late phase, for thyroid carcinomas a complete wash-out in late phase. Thus, a calculation of sensitivity, specificity, positive and negative predictive value of 81% , 92% , 97% and 63%, respectively, for the differentiation of benignity and malignancy was possible. CONCLUSIONS: Dynamic evaluation of microcirculation using CEUS and CCDS/PD enables a more reliable preoperative discrimination between thyroid adenomas and thyroid carcinomas.

Hand-carried and high-end ultrasound systems are equally inferior to abdominal radiography and multidetector computed tomography in the diagnosis of pneumoperitoneum.

PURPOSE: Pneumoperitoneum (PP) is a severe finding in emergency departments. Its quick and correct diagnosis is indispensable for the further treatment of patients. The aim of this study was to analyze the clinical value of abdominal ultrasound performed with a modern hand-carried ultrasound (HCU) device as well as with a high-end ultrasound (HUS) system in the diagnosis of PP in patients with acute abdominal pain. MATERIALS AND METHODS: 31 patients with acute abdominal pain were enrolled in this study irrespective of their underlying disease, and examination with a latest generation HCU and a newest generation HUS was performed. Diagnosis of PP was based on findings of multidetector computed tomography (MDCT) and abdominal radiography (AR) as the standard of reference. The study was carried out by two independent and experienced examiners unaware of the diagnosis made by MDCT or AR. RESULTS: In five (16 %) patients PP was identified by MDCT and AR. Examination with HCU was calculated with a sensitivity and specificity of 80 % and 81 %, respectively. Examination with HUS yielded a sensitivity and specificity of 80 % and 89 %, respectively. CONCLUSION: PP can be detected by HCU and HUS with almost equal accuracy in patients with acute abdominal pain but both methods are inferior compared to MDCT and AR. However, HCU and HUS can accelerate the triage of patients and help to make decisions regarding the necessity of further examinations without the need for radiation and while reducing economic and logistic resources. KEY POINTS: 1. Pneumoperitoneum (PP) is a severe finding in emergency departments. 2. Hand-carried (HCU) and high-end (HUS) ultrasound systems can be helpful in detecting PP. 3. Abdominal radiography (AR) and multidetector computed tomography (MDCT) are superior in detecting PP. 4. HCU and HUS can accelerate the triage of patients. 5. HCU and HUS can be helpful when making decisions regarding the necessity of further examinations.

Preoperative diagnosis of thyroid adenomas using high resolution contrast-enhanced ultrasound (CEUS).

To evaluate the impact of high-resolution contrast-enhanced ultrasound (CEUS), Color Coded and Power Doppler Sonography (CCDS/PD), in the preoperative recognition of thyroid adenomas. A total of 64 patients (36 female, median age 54 years) underwent surgery for thyroid adenoma. CEUS with linear multifrequency probes (6-9 or 6-15 MHz) and CCDS/PD was performed in all patients preoperatively by an experienced examiner and images were stored in PACS. Reading of the ultrasound images was performed in consensus by two experienced radiologists. Histopathology was achieved as standard of reference in all patients. Median diameter of the tumor lesions was 27 mm. 31 nodules were found on the left side. In B-Scan mode 13 (20%) adenomas showed complex cystic echo pattern and 44 (69%) had a complete and sharp hypoechoic edge. 43 (67%) thyroid adenomas had strong hypervascularization in CCDS/PD. In 61 (95%) adenomas early contrast enhancement was present in CEUS and 50 (78%) adenomas proved no wash-out or central wash-out with persisting edge enhancement. In 47 (73%) cases early contrast enhancement was combined with no washout or with central wash-out with persisting edge enhancement. 45 (70%) thyroid lesions had preoperatively been classified as benign lesions correctly. Dynamic evaluation of microcirculation by CEUS and CCDS/PD enables a more reliable preoperative characterization of thyroid adenomas.

Interobserver Agreement in MR Enterography for Diagnostic Assessment in Patients with Crohn's Disease.

PURPOSE: To evaluate the extent to which MRE can be used as an observer-independent, objective imaging method for the diagnosis and evaluation of CD with respect to the detection of inflammatory changes of the small bowel and lymphadenopathy as diagnostic criterion and bowel distension as a quality criterion. MATERIALS AND METHODS: MRE scans of 84 patients (42 female, median age 37 years) were evaluated independently by 4 experienced radiologists. Analysis of inflammatory changes of the bowel wall, lymphadenopathy and adequate bowel distension was conducted separately for the jejunum, ileum and terminal ileum. The Kendall's W-test was used for the statistical comparison of concordance. RESULTS: In a total of 55 patients, inflammatory activity of the bowel wall was detected and MRE was found to have a high interobserver reproducibility concerning inflammatory changes of the intestinal wall (Kendall's W 0.527 - 0.823). Concerning lymphadenopathy (31 cases, 36.9 %), a low to moderate consensus could be shown with a Kendall's W value of 0.402 - 0.505. For the assessment of adequate bowel distension, a moderate concordance between the operators could be found (Kendall's W 0.497 - 0.581). CONCLUSION: MRE has proven high interobserver agreement with respect to the diagnosis of inflammatory disease activity of the bowel as a diagnostic criterion in patients with CD. Concerning adequate bowel distension as a quality criterion of the examination itself and lymphadenopathy as a diagnostic criterion, moderate interobserver agreement could be found. This is thought to have a rather small effect on the diagnostic significance and conclusiveness of the method in the daily routine. KEY POINTS: ▶ MR enterography as observer independent diagnostic procedure in patients with Chron's Disease. ▶ Highest interobserver concordance for the criterion of inflammatory bowel wall affection. ▶ Moderate interobserver concordance for lymphadenopathy and bowel distension.

Percutaneous management of postoperative bile leaks with an ethylene vinyl alcohol copolymer (Onyx).

PURPOSE: The management of postoperative bile leakage is challenging especially if the leak rises from the cut surface of the liver and endoscopic treatment fails. Percutaneous transhepatic treatment of bile leaks with biliary drainage is accepted but often requires long-term placement of the drains and is associated with treatment failures. This series evaluates selective embolization of bile ducts with an ethylene vinyl alcohol copolymer (Onyx) in patients with postoperative bile leaks as an alternative treatment option. MATERIALS AND METHODS: Between January and September 2012, five consecutive patients with persistent postoperative bile leaks underwent percutaneous transhepatic Onyx application and were analyzed regarding procedural management, complications and success rates. RESULTS: The persistent bile leaks were situated at the cystic stump (after cholecystectomy, n = 2), at the cut surface of the liver (after extended liver resection, n = 2) and at the surface of the liver after surgical exploration and perihepatic abscess (n = 1). Bile drainage alone (endoscopic or percutaneous) failed in all patients and open redo-surgery was deemed potentially harmful. Bilomas were externally drained in all patients before Onyx application. For the closure of bile leaks, Onyx was injected through a microcatheter in a previously built coil nest to keep Onyx in place. All bile leaks were initially closed immediately. In the 2nd week after Onyx embolization, 2 patients showed recurrent small bile leaks without clinical symptoms. In the 4th week after Onyx application, all leaks were closed. No complications occurred. CONCLUSION: All leaking bile ducts were initially closed immediately after Onyx application. In the 2nd week after Onyx application, 2 patients showed small bile leaks without clinical symptoms. All leaks were closed in the 4th week after Onyx application.

[MR enterography sequence evaluation for patients with Crohn's disease]. / Sequenz-Evaluation für die MR-Enterografie für Patienten mit Morbus Crohn.

PURPOSE: To evaluate a routine MR enterography (MRE) protocol for patients with Crohn's disease (CD) in order to assess and rank the subjectively most important sequences regarding diagnostic decisions. MATERIALS AND METHODS: We prospectively examined 84 patients (42 male) with known CD using a coronal T2 / T1-weighted balanced SSFP (TrueFISP), axial T2-weighted single shot TSE (HASTE) as well as an axial T1-weighted gradient-echo sequence (2D-FLASH) before intravenous contrast application and a 2D-FLASH sequence with axial and coronal orientation after intravenous contrast application. 4 experienced radiologists subjectively evaluated the sequences independently using a scale between 1 and 5 (1 = excellent; 5 = non-diagnostic) regarding their diagnostic significance for a final radiologic decision. The ranking of the different sequences was statistically tested by the Friedman analysis. RESULTS: The following ranking was found: HASTE sequences were ranked prior to contrast-enhanced axial gradient-echo (2D-FLASH). The third to fifth ranking was TrueFISP, the axial contrast-enhanced 2D-FLASH and the 2D-FLASH without contrast, respectively. Differences between the first and second rank were significant (p < 0.05), and all other differences were highly significant (p < 0.01). CONCLUSION: The stable and fast T2-weighted MR sequences without intravenous contrast represented by axial HASTE and coronal TrueFISP were ranked as number 1 and 3. The examination protocol should be completed by a coronal T1-weighted gradient-echo-sequence after contrast injection, which can be supplemented by an axial acquisition. The T1-weighted gradient-echo sequence without contrast could be omitted.

Interobserver agreement in mr enterography for diagnostic assessment in patients with Crohn's disease.

PURPOSE: To evaluate the extent to which MRE can be used as an observer-independent, objective imaging method for the diagnosis and evaluation of CD with respect to the detection of inflammatory changes of the small bowel and lymphadenopathy as diagnostic criterion and bowel distension as a quality criterion. MATERIALS AND METHODS: MRE scans of 84 patients (42 female, median age 37 years) were evaluated independently by 4 experienced radiologists. Analysis of inflammatory changes of the bowel wall, lymphadenopathy and adequate bowel distension was conducted separately for the jejunum, ileum and terminal ileum. The Kendall's W-test was used for the statistical comparison of concordance. RESULTS: In a total of 55 patients, inflammatory activity of the bowel wall was detected and MRE was found to have a high interobserver reproducibility concerning inflammatory changes of the intestinal wall (Kendall's W 0.527 ­ 0.823). Concerning lymphadenopathy (31 cases, 36.9 %), a low to moderate consensus could be shown with a Kendall's W value of 0.402 ­ 0.505. For the assessment of adequate bowel distension, a moderate concordance between the operators could be found (Kendall's W 0.497 ­ 0.581). CONCLUSION: MRE has proven high interobserver agreement with respect to the diagnosis of inflammatory disease activity of the bowel as a diagnostic criterion in patients with CD. Concerning adequate bowel distension as a quality criterion of the examination itself and lymphadenopathy as a diagnostic criterion, moderate interobserver agreement could be found. This is thought to have a rather small effect on the diagnostic significance and conclusiveness of the method in the daily routine.

Diagnosis of pericardial effusion with a new generation hand-carried ultrasound device in cardiothoracic intensive care unit patients.

BACKGROUND: Technological advances introduced hand-carried ultrasound (HCU) imagers in daily clinical workflow providing several benefits such as fast bedside availability and prompt diagnosis. PURPOSE: To evaluate the diagnostic yield of a latest generation HCU imager compared to contrast-enhanced multidetector computed tomography (MDCT) for the detection of pericardial effusion (PE) in cardiothoracic intensive care unit (ICU) patients. MATERIAL AND METHODS: Thirty-six patients from a cardiothoracic ICU were enrolled to this study irrespective of their underlying disease. All patients were examined with a new generation HCU for the presence of PE. Definite diagnosis of PE was based on findings of MDCT as standard of reference. Statistical analysis was performed using PASW 18. RESULTS: PE was identified in 20 patients by MDCT (prevalence 56%). The HCU examination was carried out technically successfully in all patients. Sensitivity, specificity, positive and negative predictive value of HCU for the diagnosis of PE were 75%, 88%, 88%, and 74%, respectively. CONCLUSION: HCU provides rapid, practical, reliable, and cost-effective diagnosis of PE in patients on cardiothoracic ICU.

[Plain abdominal radiograph - is there any additional clinical value based on the supine projection?]. / Konventionelle Abdomenübersichtsaufnahmen - welchen klinischen Nutzen hat die Aufnahme in Rückenlage?

BACKGROUND: To assess the diagnostic value of an additionally acquired plain abdominal radiograph in supine position. MATERIALS AND METHODS: Two experienced radiologists evaluated retrospectively 2148 consecutive patients having plain abdominal radiographs acquired in a tertiary care center. There were 1385 patients having an erect view and 763 patients with a left lateral decubitus view. All patients had a second examination in supine position. First the radiographs in erect or decubitus view were evaluated regarding the presence and details of pathological changes. After 4 weeks all radiographs including the supine view were evaluated again. Next to pathological changes the additional value of the supine projection was assessed. The results were compared and the additional diagnostic value using the supine view was noted. RESULTS: We evaluated 2148 patients having a plain abdominal radiograph (1325 men, 823 women, mean 58.9 years, range 15-96 years). The average age within the group acquired with left decubitus view was 61.1 years, while patients having an erect view had a mean age of 57.0 years. For the first evaluation we found pathological changes in 10.5% (decubitus view: 13.1%, erect view 9.5%; p = 0.01). The most frequent diagnosis was ileus (7.7%) followed by abdominal free air (2.4%). The results were confirmed during the second reading in 99.2%. In 3.5% (decubitus view 5.8%, erect view 2.2%) more anatomical structures were depicted considering the supine projection and the decubitus/erect projections. The anatomical information was in no case relevant for the diagnosis. CONCLUSION: Having the information of an supine view additionally to an decubitus/erect view increases the depiction of anatomical structures up to 5.8%. Nevertheless there was no additional diagnostic relevant information based on the supine view.