New era radiology of the esophagus

In our modern era, the radiologist is no longer content merely to discern abnormal shadows; he must correlate the radiologic finding with clinical and physiologic findings. With this in mind, the radiologist must be familiar with pertinent data from the patient's history, physical examination and laboratory studies to aid not only in structuring the examination of the patient but also in interpreting the radiologic findings.     

Sonographic evaluation of the rotator cuff: correlation with arthroscopy

High-resolution real-time sonography has been reported as a non-invasive means of evaluating the integrity of the rotator cuff. Fifty-two patients underwent both sonographic and arthroscopic evaluation of the rotator cuff. There were 42 men and 10 women with an average age of 47 years (range 28-71 years). The duration of shoulder pain averaged 24 months (range 3 months to 9 years). Thirty-five rotator cuff tears were noted arthroscopically. Twenty-seven of the tears were diagnosed by sonography for a sensitivity rate of 77%. Eleven of the 17 intact rotator cuffs were normal by sonography for a specificity rate 65%. The overall accuracy of sonography was 73% and the predictive value of a positive sonogram was 82%. Sonography appears to be a good initial screening examination in evaluating the integrity of the rotator cuff. It is noninvasive and relatively inexpensive. Technical limitations of this technique as well as the experience of the radiologist in performing and interpreting the examination play a major role in the accuracy of this test. As instrumentation improves and as experience in using this technique increases, we expect the accuracy of sonography in detecting tears of the rotator cuff to continue to improve.     

Better surgery and better selection for adjuvants--still the key to improving outcomes in rectal cancer

In reviewing the current issues in rectal cancer management the word specialist recurs again and again. The modern hospital requires consultants with special interest in each of the key stages of decision making: Clinical assessment--usually the surgeon MRI. Fine slice individually orientated phased array coil studies with a specially trained radiologist. CT--now routine for metastases Neo-adjuvant therapy. Special interest in the disease in both clinical and medical oncology is essential. Surgery: The challenges of the distal pelvis make it increasingly unacceptable for surgeons without a "special interest" to operate on mid and low cancer. Histopathology: The lessons of Professor Quirke have brought the specialised histopathologist out of his laboratory into the cruel role of "surgical auditor"--providing circumferential margin examination plus naked eye, TME quality assessment. This gives us two invaluable measurable short-term goals improving the quality for surgical practice. When a hospital can provide special interest doctors in all these fields and when they co-operate in a constructive manner the modern colorectal MDT can lead the way for the whole field of cancer management. It remains a probability that the use of high definition improved quality video based teaching of surgical technique is the single most effective weapon that we have in our battle against this most challenging of malignanvies.     

Complications after percutaneous transluminal angioplasty and vascular surgery

Percutaneous transluminal angioplasty (PTA) is an accepted technique in the treatment of occlusive vascular disease. We report complications associated with balloon catheter dilatation and their treatment in the period from 1. 1. 1986 to 31. 3. 1990. Complications were found at the site of dilatation and the site of insertion of the catheter, mostly in the pelvic and femoral region. Surgical correction was successful in all patients, however three patients died postoperatively of acute myocardial ischemia. To avoid these complications close co-operation between the radiologist performing the dilatation and the vascular surgeon managing the complications should be assured.     

Tips and traps in spinal cord pathology

While reviewing major pathological conditions, the radiologist must learn to adapt his technique to the indication and look for multifocal lesions. In conditions involving malformation, transdural cord herniation and diastematomyelia may be discovered late. In vascular diseases, a dural arteriovenous fistula with perimedullary venous drainage is the most common vascular malformation and a source of diagnostic error. On discovering a medullary cavity, the radiologist needs to know when to discount focal distensions of the ependymal canal and how to detect tumoral syringomyelia. In the case of a tumour, he should know the characteristics of common tumours such as astrocytomas, ependymomas, haemangioblastomas and cavernomas. In inflammatory diseases, he should know when a brain examination is required. When faced with images appearing to show a tumour, he should consider the possibility of pseudotumours and in particular of granulomatoses.     

Visceral angiography. A community hospital experience.

Selective visceral angiography is well within the ability of small community hospitals. If carefully performed by a well-trained interested radiologist, the procedures carry negligible morbidity and mortality. These studies can provide an exact diagnosis, a working differential or at least enough data to plan a surgical approach with accuracy. Nine cases in which the angiographic diagnosis was vital to the patients' care have been presented.     

Routine Radiographs After Total Joint Arthroplasty: Is There Clinical Value?

BackgroundRoutine radiographs have historically been obtained during routine care after total joint arthroplasty (TJA). However, substantial improvements in surgical technique, biomaterials, and changes in payment models placing greater emphasis on value have occurred. Recently, there has been interest in a transition to performing follow-up visits virtually. The purpose of this study was to assess how frequently patients attend postoperative appointments and the clinical utility of routine radiographs after TJA.MethodsPatients undergoing primary total hip arthroplasty and total knee arthroplasty at a single tertiary institution in 2018 were included. Patients attending scheduled follow-up at 6 to 12 weeks and 1 year were assessed. Retrospective chart review was conducted to determine whether abnormalities were noted on routine radiographic surveillance by the orthopedic surgeons or radiologist and if any radiographic findings altered clinical management.ResultsA total of 938 TJAs were performed, and 885 met inclusion criteria, with 423 (47.8%) total hip arthroplasties and 462 (52.2%) total knee arthroplasties. Eight hundred sixty-five (97.7%) patients attended a follow-up visit at 6 or 12 weeks and 589 (66.6%) attended at 1 year postoperatively. A single radiographic abnormality was detected, occurring at the 6- to 12-week period by the radiologist and interpreted as being an artifact by the surgeon. No additional radiographic abnormalities were detected at 1 year. Information from radiographs did not change clinical management for any patients.ConclusionIn a large cohort of patients, routine radiographic surveillance did not detect any true abnormalities during the first year after primary TJA. For patients without symptoms attributable to the TJA prosthesis, conducting virtual care visits without routine radiographs may be considered.     

Das primäre Seminom

This is a report on three patients with primary mediastinal seminoma. Two patients had no symptoms, and one had had thoracic pain for the last few years. The preoperative diagnosis was thymoma in all cases, and in one patient the radiologist had suspected a seminoma. We removed the tumor after performing median sternotomy (n=2) and anterolateral left thoracotomy (n=1). The presence of a primary gonadal seminoma was excluded with a urological and ultrasound examination. All patients are still alive following adjuvant chemotherapy (n=2; 120 and 8 months) and radiotherapy (n=1; 84 months). Chemotherapy consisted of four cycles of cisplatin, etoposide and ifosfamide or combination therapy with cisplatin, bleomycin and velbe.     

Microvascular Surgery

Methods of anastomosing small blood vessels are presented, together with an account of the authors' own experiences in the field of microvascular surgery. Practical suggestions are made to avoid pitfalls. The modern literature on experimental and clinical applications of microvascular technique in plastic and reconstructive surgery is reviewed. An extensive bibliography is offered as an aid to the interested reader.     

Sonographic differences in venous return between piggyback versus caval interposition in adult liver transplantations

The piggyback technique (PT) is being used more frequently than caval interposition (CI) in adult orthotopic liver transplants (OLT). It is unclear whether PT alters venous return compared with CI, therefore leading to postoperative complications. The aim of our study was to analyze our experience with PT and CI by comparing ultrasound results of hepatic vein flow on the first postoperative day. PATIENTS AND METHODS: This retrospective analysis of consecutive OLTs performed between 2002 and 2005 included data from a single blinded radiologist who reviewed all postoperative day 1 ultrasound examinations. The hepatic vein waveforms were scored as all phasic, all flat, or partially phasic/flat. RESULTS: During the study period, we performed, 465 OLT among which 270 had available ultrasound examinations. The etiologies of liver disease were similar between the PT and CI cohorts, hepatitis C and alcoholic liver disease accounted for more than 60%. Two hundred eight (77%) had undergone PT and 62 (23%) CI. Among the PT, 60% were phasic, 31.1% were partially phasic/flat, and 8% were flat. When a CI was performed, 56.5% were phasic, 35.5% were partially phasic/flat, and 8% were flat. CONCLUSIONS: There was no significant difference between PT and CI with regard to an effect on hepatic vein waveforms on the first operative day. Therefore, there do not appear to be early hemodynamic benefits of performing CI versus PT anastamoses of OLTs. Further studies may be needed to determine whether long-term sequelae follow the piggyback technique.     

Evaluation of methods for detecting venous reflux. Perspectives in venous insufficiency

Using 793 limbs with nonobstructive venous reflux, we evaluated a number of techniques used for the assessment of venous reflux. The venous Doppler examination was found to be a reliable screening tool with excellent sensitivity and good specificity. Photoplethysmography was 97% sensitive in patients with ambulatory venous hypertension; however, in milder forms of reflux, it was less sensitive. The major drawback of photoplethysmography was the large number of false-positive results obtained. Ambulatory venous pressure measurement and another pressure-based technique, Valsalva-induced foot venous pressure measurement, defined overlapping but different normal and abnormal limbs. Descending venography, when performed as described by Kistner et al, was found to be a reliable tool to assess reflux with more than a 90% sensitivity. The horizontal technique of performing descending venography and nucleotide descending venographies had unacceptably low sensitivity and were abandoned. Features of venous reflux as outlined by these modern technical tools are described.     

Posterior intertransverse fusion assessed clinically and with biplanar radiography

Summary Biplanar radiography was used to assess bony union after intertransverse fusion. The patients were assessed clinically and the fusion status was compared with the clinical result.Posterolateral intertransverse fusion was shown to be capable of fusing the motion segment almost completely. However, the strictly measured fusion rate was only 27%, but this increased to 91% when partial fusions were included. The fusion rate from conventional plain films assessed by the radiologist was 82%, which is similar to other reports. On clinical examination, a satisfactory result was obtained in 82%, but there was no clear correlation with fusion status.T. Suzuki MD was the 1983 Joseph Trueta Travelling Fellow from the Department of Orthopaedic Surgery, Tohoku University 1-1, Seiryo machi, Sendai 980, Japan     

How good are newly qualified doctors at digital rectal examination?

Aim Digital rectal examination (DRE) is an essential skill which all newly qualified doctors should have. There is evidence in the literature that junior doctors lack this important examination technique. The aim of our study was to determine, with the help of a questionnaire, the abilities of foundation year 1 (FY1) doctors to perform DRE. Method A questionnaire was developed and sent to newly qualified FY1 doctors qualified in two universities (Nottingham and Sheffield) within the first 4 weeks of starting as a FY1 doctor. Results Ninety (75%) out of 120 questionnaires were completed. Most FY1 doctors had very little experience in performing DRE on a patient, and 68 (76%) had performed less than 10 procedures prior to qualification. Very few of these doctors had their clinical findings on DRE checked by a senior doctor (n = 7, 8%). Comparing DRE with other forms of examination, newly qualified doctors were most confident at groin hernia examination followed by testicular examination. They were least confident with vaginal examination and DRE (ANOVA P = 0.0082). Conclusion Digital rectal examination is frequently performed by the most inexperienced doctor and may not be verified by a more senior colleague. More training and supervision of junior doctors are required both prior to qualification and during the early stages of their medical career.     

Deep learning to automate Brasfield chest radiographic scoring for cystic fibrosis

BackgroundThe aim of this study was to evaluate the hypothesis that a deep convolutional neural network (DCNN) model could facilitate automated Brasfield scoring of chest radiographs (CXRs) for patients with cystic fibrosis (CF), performing similarly to a pediatric radiologist.MethodsAll frontal/lateral chest radiographs (2058 exams) performed in CF patients at a single institution from January 2008–2018 were retrospectively identified, and ground-truth Brasfield scoring performed by a board-certified pediatric radiologist. 1858 exams (90.3%) were used to train and validate the DCNN model, while 200 exams (9.7%) were reserved for a test set. Five board-certified pediatric radiologists independently scored the test set according to the Brasfield method. DCNN model vs. radiologist performance was compared using Spearman correlation (ρ) as well as mean difference (MD), mean absolute difference (MAD), and root mean squared error (RMSE) estimation.ResultsFor the total Brasfield score, ρ for the model-derived results computed pairwise with each radiologist's scores ranged from 0.79–0.83, compared to 0.85–0.90 for radiologist vs. radiologist scores. The MD between model estimates of the total Brasfield score and the average score of radiologists was −0.09. Based on MD, MAD, and RMSE, the model matched or exceeded radiologist performance for all subfeatures except air-trapping and large lesions.ConclusionsA DCNN model is promising for predicting CF Brasfield scores with accuracy similar to that of a pediatric radiologist.     

Surgery for subclinical breast lesions

Subclinical mammographic abnormalities discovered through screening are subjected to excisional surgical biopsy in order to prove or rule out malignant disease of the breast by histological examination. Close attention should be paid by the surgeon to avoid cosmetically disfiguring scar and failure in excision removal exhibited on postoperative mammogram. Indications for surgical assessment are selected upon suspicious patterns of opacities, clusters of microcalcifications or architectural distortions. Good communication between the radiologist, the surgeon and the pathologist is required for proper management of non palpable lesion. The most adequate lumpectomy technique should be performed with regard to the oncologic risk and cosmetic outcome.     

Bildgebung des Nierenzellkarzinoms

Renal cell cancer is the most frequently encountered malignant tumor of the kidney. The modern imaging techniques computed tomography (CT) and magnetic resonance imaging (MRI) play a vital role in the diagnostic work-up of renal masses. Contrast-enhanced ultrasound (CEUS) is able to visualize subtle enhancement in hypovascular tumors with high sensitivity. Recent advances in multidetector CT (MDCT) enable high resolution imaging of local findings. CT is able to provide large volume coverage of the chest and abdomen within seconds for the assessment of lymph node and distant metastasis staging. Local renal cell cancer staging can be achieved with similar diagnostic accuracy using CT or MRI. Both modalities allow visualization of a tumor’s relationship to the renal collecting system and pelvis, the renal artery and veins including the IVC. It is the radiologist’s task to accurately detect and stage renal malignances in order that each individual patient receives the therapy best suited to them.     

Transtibial amputations

The transtibial amputation is one of the most frequently performed major limb amputations in the United States. The long posterior flap technique has become the most frequently recommended technique; however, the surgeon performing amputations needs to be comfortable with the alternative techniques as well. Situations occasionally do arise where the sagittal or skew techniques may be more applicable. With careful surgery and soft tissue handling, wound healing can be expected in the majority of patients. Aggressive rehabilitation is possible in many patients, and with good prosthetic intervention, return to ambulation at or near the preoperative level of function can be expected in most patients.     

Case selection for spine surgery in the ambulatory setting

Advances in modern anesthetic and surgical technique as well as multimodal pain management have contributed to the ease and feasibility of performing spine surgery on an outpatient basis. Multiple considerations impact a surgeon's ability to successfully perform spine procedures outside of the traditional inpatient setting. While the expertise of the surgeon and perioperative staff plays important roles, case/patient selection is arguably the most important factor driving outcomes in ambulatory spine surgery. A standardized, multidisciplinary approach to preoperative patient evaluation and education is paramount for any spine surgeon performing outpatient procedures.     

A modified Gritti-Stokes amputation: its place in the management of peripheral vascular disease

A modified technique for performing the Gritti-Stokes amputation is described and the results obtained in 247 cases are presented. The mortality rate was 9.3% and healing occurred in 87% of survivors. Using this modified technique the frequently cited criticisms of non-union of the patella and painful stumps were not found to be major problems. The prosthetic problems of amputation at this level are discussed in relation to recent developments in the design of artificial limbs.     

Ultrasonography of the rotator cuff: Analysis of results in a community setting

Forty-six patients underwent ultrasonogrophy evaluation of their shoulder for suspected rotator cuff tears from 1989 to 1992. All ultrasound studies were evaluated by a radiologist (HJH) who was not subspecialty-trained in shoulder ultrasonography. All patients had surgical confirmation of the status of their tendons. A statistical analysis of the accuracy of ultrasound in detecting rotator cuff tearing was performed. The sensitivity was 81%, and the specificity was 100%; there was a positive predictive value of 100% and a negative predictive value of 71%. Using strict sonographic criteria for diagnosing a rotator cuff tear, we conclude that ultrasound can detect intermediate or large rotator cuff tears with great accuracy (19 of 20 shoulders). Accuracy decreases dramatically in the presence of a small tear (six of 11 shoulders). At our hospital the cost of ultrasound examination of the shoulder is 0.19 the cost of magnetic resonance imaging of the shoulder and is 0.62 the cost of a shoulder arthrogrom. Ultrasound of the shoulder should be considered for imaging the rotator cuff because of its accuracy, low cost, and high patient satisfaction. It can be reliably performed by radiologists with state-of-the-art equipment who are interested in and have experience with the procedure.