Appendicitis at the millennium

Acute appendicitis is a common clinical problem. Accurate and prompt diagnosis is essential to minimize morbidity. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Helical computed tomography (CT) and graded compression color Doppler ultrasonography (US) are highly accurate means of establishing the diagnosis. These imaging modalities have now assumed critical roles in the treatment of patients suspected to have appendicitis. The purpose of this article is threefold: to provide an update on new information regarding the pathophysiology, clinical diagnosis, and laparoscopic treatment of acute appendicitis; to describe the state-of-the art use of CT and US in diagnosing this disease entity; and to address the role of medical imaging in this patient population.     

Thorax: new millennium vascular imaging

In recent years the technological development of computed tomography (CT) and magnetic resonance (MR) has promoted new improvements in diagnosis by means of imaging. In particular the introduction of multislice CT and MR angiography (MRA) has broadened the non-invasive diagnostic possibilities in the vascular study of the thorax. The new technological developments of CT and MR enable functional studies as well. Recent studies have demonstrated that CT and MR are as accurate in finding the vascular anomalies as digital subtraction angiography, while they are more precise in recognising possible associated pathologies which modify therapeutic treatment (for example of the trachea, bronchi, oesophagus etc.). There are many vascular structures in the thorax which need to be considered (aorta, pulmonary and coronary arteries, pulmonary veins, vena cava). The field of associated pathologies is also broad, and includes congenital vascular anomalies, vascular malformations, aorta dissection, vascular compression syndromes, atherosclerotic stenosis or occlusions, and pulmonary embolism. In pulmonary embolism some authors have demonstrated the utility of CT, in showing pulmonary segmental perfusion defects, and MRA, in identifying sub-segment pulmonary embolism. In this paper we analyse the most important CT and MR applications for the study of vascular thoracic diseases and compare them with other diagnostic techniques. We also evaluate the morpho-functional capabilities of CT and MR in this field.     

Feeding the world in the new millennium

Food production per head in the world as a whole has begun to level off in the last decade, while the world population continues to grow, risking malnutrition, perhaps even starvation, civil unrest and environmental damage. Very little more land suitable for agriculture is available, and the factors behind the 'green revolution' may not produce further increases. Genetically modified crops offer the possibility of increased yields, but also present major problems. In developing countries, where yields are well below what is theoretically possible, the best approach may be better management by small farmers through improvements in their traditional methods. Much more financial support for and research in agriculture is needed, together with more equitable distribution of existing production and an end to trade practices designed to make the rich richer.     

Feeding the world in the new millennium

Food production per head in the world as a whole has begun to level off in the last decade, while the world population continues to grow, risking malnutrition, perhaps even starvation, civil unrest and environmental damage. Very little more land suitable for agriculture is available, and the factors behind the ‘green revolution’ may not produce further increases. Genetically modified crops offer the possibility of increased yields, but also present major problems. In developing countries, where yields are well below what is theoretically possible, the best approach may be better management by small farmers through improvements in their traditional methods. Much more financial support for and research in agriculture is needed, together with more equitable distribution of existing production and an end to trade practices designed to make the rich richer.     

Pediatric radiology at the millennium.

PURPOSE: To evaluate the current practice of and job market for pediatric radiologists in the United States and Canada with a 1998 survey and compare findings with those of surveys from 1980 and 1989. MATERIALS AND METHODS: Surveys were mailed to the 728 active members of the Society for Pediatric Radiology. Questions covered professional practice, subspecialization, and involvement in evolving technologies. A pediatric radiology help-wanted index was generated from a diagnostic radiology help-wanted index. RESULTS: Increasing involvement in the interpretation of computed tomographic, ultrasonographic, and magnetic resonance images was found among the 57% (411 of 728) of the members who responded. The attainment of a certificate of added qualification in pediatric radiology was found in nearly three-fourths of the membership, and 85% (348 of 408) had completed a fellowship. More than half of the respondents were involved in interventional procedures amid a continued increase in volume; 24% (100 of 409) of the membership, as compared with 7% in the 1980 survey, was practicing in a community or "other" setting. Subspecialization within pediatric radiology had diminished, and there was a larger percentage of female pediatric radiologists, particularly among the newest members. The job market was robust, having recovered substantially since the middle 1990s. CONCLUSION: The practice of pediatric radiology has evolved, with increasing involvement in advanced techniques and modalities, as well as a greater presence in community settings. The help-wanted index supports the recent discussions of a personnel shortfall.     

Radiology at the turn of the millennium

Herein, the authors (a) review the status of the specialty; (b) report and analyze the various areas in which progress has occurred, namely, conventional radiology and picture archiving and communication systems (or PACS), ultrasonography, computed tomography, magnetic resonance imaging, interventional radiology, and nuclear medicine; and (c) discuss the problems radiology faces as it enters the new millennium. The problems are those facing medicine as a whole, as well as those threatening the future of radiology. These include the following: Will there be a need for radiologists in the future? Will radiology be too costly to be affordable? How can turf wars and fragmentation be solved? Possible remedies are suggested. Positive aspects are discussed in the light of the challenge to demonstrate value. Medical imaging is entering the new millennium with a solid record of recent advances in digital, cross-sectional, and interventional radiology. These advances have made the specialty indispensable in the treatment of patients. Careful statesmanship will be needed to solve the many problems that face medicine as a whole and radiology in particular.     

Radiology system evolution in the new millennium

For many decades the practice of radiology grew slowly in America and was largely a secondary function under the control of hospitals. In more recent times it has vastly expanded its array of diagnostic, interventional, and therapeutic abilities. There is increasing consumer logic for direct access. Motivations have grown to create large independent entities with broadly diverse capabilities in order to succeed in the new millennium. Most regional markets are evolving rapidly in terms of managed care penetration, health system formation, physician practice consolidation and aggressive purchaser behavior by employers and consumers. To understand the enormity of healthcare evolution, it is useful to look at the industry's paradigm shifts in recent decades. Virtually every aspect of organizational infrastructure, delivery approaches, and the business environment has evolved markedly during the past fifty years. These changes will accelerate. To succeed financially, radiology groups must strengthen their market positions, technical capabilities, continuums of care and geographic dominance. Equally important is the wisdom of diversifying incomes into related services and businesses that provide additional related revenues. Key factors for successful development include facility market growth, full coverage of managed care contracts, high efficiency and aggressive diversification. A fully evolved system generates significant revenues and profitability by protecting and strengthening its financial position in this environment. That is accomplished through the development of strategically located radiology groups, aggressive alliances with medical practices in allied disciplines, and managed radiology departments and facilities for partner health systems. Organizational success ultimately depends on the ability to accept capitated payments under risk-bearing arrangements. The strategic business plan should be organized with the appropriate levels of detail needed to establish executive focus and priorities. These should be woven into operational and capital budgets to reflect expectations of the revenues, expenses and investments tied to the plan. While formidable, all of these objectives are realistic and can be accomplished if the right decisions are made. Initially, the entity's principle business objective is to formulate and begin implementation of methodical yet aggressive strategies for growth that are sensitive to sustaining high levels of quality patient care. The next phase features mergers with large, independent radiology practices in key geographic areas and successful acquisition of smaller practices. The objective of the final phase is to aggressively expand into select metropolitan areas with regional coverage and full teleradiology capabilities. High levels of market strength and financial performance are necessary to succeed. Passive limitations to small geographic areas and narrow practices will undermine their market position and dissolve financial strength with no hope of recovery. Only the dominant systems will survive and prosper.     

MR imaging of tumor microcirculation: promise for the new millennium

Dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) is a method of imaging the physiology of the microcirculation. A series of recent clinical studies have shown that DCE MRI can measure and predict tumor response to therapy. Recent advances in MR technology provide the enhanced spatial and temporal resolution that allow the application of this methodology in the management of cancer patients. The September issue of this journal provided a microcirculation section to update readers on this exciting and challenging topic. Evidence is mounting that DCE MRI-based measures correlate well with tumor angiogenesis. DCE MRI has already been shown in several types of tumors to correlate well with traditional outcome measures, such as histopathologic studies, and with survival. These new measures are sensitive to tumor physiology and to the pharmacokinetics of the contrast agent in individual tumors. Moreover, they can present anatomical images of tumor microcirculation at excellent spatial resolution. Several issues have emerged from recent international workshops that must be addressed to move this methodology into routine clinical practice. First, is complex modeling of DCE MRI really necessary to answer clinical questions reliably? Clinical research has shown that, for tumors such as bone sarcomas, reliable outcome measures of tumor response to chemotherapy can be extracted from DCE MRI by methods ranging from simple measures of enhancement to pharmacokinetic models. However, the use of similar methods to answer a different question-the differentiation of malignant from benign breast tumors-has yielded contradictory results. Thus, no simple, one-size-fits-all-tumors solution has yet been identified. Second, what is the most rational and reliable data collection procedure for the DCE MRI evaluation? Several groups have addressed population variations in some key variables, such as tumor T(1)0 (T(1) prior to contrast administration) and the arterial input function C(a)(t) for contrast agent, and how they influence the precision and accuracy of DCE MRI outcomes. However, despite these potential complications, clinical studies in this section show that some tumor types can be assessed by relatively simple dynamic measures and analyses. The clinical scenario and tumor type may well determine the required complexity of the DCE MRI exam procedure and its analysis. Finally, we suggest that a consensus on naming conventions (nomenclature) is needed to facilitate comparison and analysis of the results of studies conducted at different centers. J. Magn. Reson. Imaging 10:903-907, 1999.