Radiologists, communication, and Resolution 5: a medicolegal issue.

Resolution 5, adopted by the American College of Radiology, sets forth principles of direct communication that are important to every radiologist. This article reviews pertinent court decisions that affect radiologists and illustrates the importance of Resolution 5. In recent cases in state courts, liability standards have focused on four areas: negligence based on failure to personally inform clinicians of the diagnosis, ability of the jury to decide whether the radiologist's actions were appropriate, provision of information to the correct person, and necessity for expert testimony to define urgency. An important factor in liability cases appears to be the judgment of the radiologist in selection of the correct individual to receive the radiology report. The authors believe that electronic communication devices (eg, voice mail and fax machines) may potentially breach confidentiality and that such devices should therefore be used sparingly. Verbal communication by the radiologist to the referring physician, in addition to a written report, should avoid liability and improve quality of care for the patient.     

Imaging characteristics of the subdural evacuating port system, a new bedside therapy for subacute/chronic subdural hematoma

The Subdural Evacuating Port System is a new device intended to simplify the treatment of subacute/chronic subdural hematomas. The appearance of the winged canula positioned with its tip in the diploic space overlying the subdural space should allow the radiologist to identify it correctly. Its radiographic features are described here to help the radiologist comment on appropriate placement, and avoid mistaking it for a misplaced subdural drain.     

Ambiguous genitalia: Diagnosis,evaluation, and treatment

The pediatric radiologist plays a significant role in the evaluation and the treatment of infants with ambiguous genitalia. On the first day of life, an investigation should be initiated that includes studies, in particular a sonogram, to demonstrate the presence or absence of a uterus, and a genitogram to define the presence of a vagina. Once gender assignment has been made, information regarding the size of the vagina and its position in regard to the urogenital sinus becomes essential to the pediatric urologist when planning a course for reconstruction. Herein we break down intersex states into four major categories: female pseudohermaphroditism, male pseudohermaphroditism without müllerian structures, and male hermaphroditism with müllerian structures and true hermaphroditism. The role of the radiologist in each of these states is discussed.     

Ambiguous genitalia: diagnosis, evaluation, and treatment.

The pediatric radiologist plays a significant role in the evaluation and the treatment of infants with ambiguous genitalia. On the first day of life, an investigation should be initiated that includes studies, in particular a sonogram, to demonstrate the presence or absence of a uterus, and a genitogram to define the presence of a vagina. Once gender assignment has been made, information regarding the size of the vagina and its position in regard to the urogenital sinus becomes essential to the pediatric urologist when planning a course for reconstruction. Herein we break down intersex states into four major categories: female pseudohermaphroditism, male pseudohermaphroditism without müllerian structures, and male hermaphroditism with müllerian structures and true hermaphroditism. The role of the radiologist in each of these states is discussed.     

Ewing-Sarkom,fibrogene Tumoren,Riesenzelltumor, Hämangiom des Skeletts

Radiological imaging only reflects the anatomy and its pathological abnormalities. Therefore, the radiologist should be able to recognize the basic features of the pathological anatomy of bone tumors. This can only be learned working closely with a pathologist who is experienced in this field. On the other hand, the pathologist needs from the radiologist their diagnostic assessment with information on size, location, aggressiveness and the existence of a bone tumor’s matrix, of the whole lesion, because he usually only receives a small part for examination in the form of a biopsy. In this article, the features and fundamentals (standards) of radiological–pathological cooperation as the mainstay for a precise diagnosis in bone tumors are outlined. The radiological appearance and the histopathological features behind it are presented for Ewing’s sarcoma, fibrogenic tumors, giant cell tumor, and hemangioma of the bone.     

Magnetic Resonance Imaging of Cysts,Cystlike Lesions,and Their Mimickers Around the Knee Joint

While interpreting routine magnetic resonance imaging (MRI) of the knee joint, a radiologist may encounter various cystic lesions such as ganglion, synovial, and meniscal cysts, among others. In some cases, MRI may demonstrate cystlike lesions around the knee due to fluid distention of normal bursa and recesses, the diagnosis of which should not be difficult if a radiologist is familiar with their characteristic location and MRI appearance. In addition, there are cyst mimickers such as hematomas, abscesses, vascular lesions, and neoplasms around knee joint that may pose a diagnostic challenge on routine MRI. Due to their atypical location and variable morphology, contrast administration is helpful as the enhancement pattern aids to differentiate them from cysts and cystlike lesions. This pictorial essay aims to classify cysts, cystlike lesions, and cyst mimickers in and around the knee joint based on their anatomic location and highlight their characteristic MRI features.     

Radiologist,obstetric patient,and emergency department provider survey: radiologist-patient interaction in the emergency department setting

The aim of this study was to evaluate the feasibility and acceptance of a model of direct interaction between radiologist and patients in the emergency department (ED) setting. The study population was comprised of pregnant patients accrued in a non-consecutive prospective manner from June 2014 to September 2015, who had an obstetrical ultrasound performed in the radiology department of an inner-city tertiary care hospital at the request of the ED. The feasibility and approval of direct communication between radiologist and patient were evaluated by means of a questionnaire presented by an independent observer to the ED provider, patient, and radiologist. The exam enrolled 54 patients. Ultrasound (US) exam results were divided into (31) normal live intrauterine gestation (group 1), (7) abnormal failed intrauterine gestation or ectopic pregnancy (group 2), and (16) indeterminate pregnancies that could not be placed in the former categories and may require a follow-up exam (group 3). Forty-five (83 %) ED providers approved of the radiologist’s direct communication with patients. Fifty (93 %) patients stated a better understanding of the radiologist’s role in their care after than before the interaction. The radiologists found the interaction with patients to be positive in 52 (96 %) cases. Direct communication between radiologist and patient yielded a good acceptance by the radiologist, ED provider, and patient. More importantly, after the encounter, the vast majority of patients reported a better understanding of the radiologist’s role in their care.     

Breast imaging: pitfalls, controversies, and some practical thoughts

Early detection of breast cancer by mammography depends on the production of excellent images and competent interpretation. Some of the more important pitfalls encountered with and controversies about mammography are presented in this article. In many cases, the radiologist is unable to declare whether the mammogram is unequivocally normal or abnormal and instead should aid the clinician in formulating rational management options for the woman. Practical options for some of these very complicated problems are proposed.     

Medical student attitudes toward radiology. A multi-institutional survey

A questionnaire was administered to 238 students at four institutions before and after a radiology clerkship to evaluate student attitudes regarding radiology as a career, radiologist expertise, and clerkship expectations. There was no statistically significant difference among the clerkships, although they varied in types of experience, geographic location, and size. After the clerkship, the students agreed more strongly that the radiologist should be involved in patient workup, screening of requests, interpretation of emergency room films, and consultations. A significant change in attitude could be identified after the four-week experience, indicating a desire for the radiologist to have a more active role as imaging consultant.     

Barium enema after biopsy: current practice and opinion

Current research shows that sigmoidoscopy or endoscopy together with a superficial mucosal biopsy taken with a fibreoptic-type instrument should not delay the subsequent performance of a barium enema. Rigid biopsy instruments are less controllable and may take 'deep', full-thickness bites when superficial biopsies are attempted. After such a biopsy, an enema should be delayed at least 7 days to allow re-epithelialisation. Neither of these two approaches is common practice as shown in our survey of British radiologists and clinicians. The radiologist should be responsible for performing the barium enema but the survey shows that there is a difference of opinion over who should be responsible for any complications arising from it. Close contact between the referring clinician and radiologist should be maintained at all times.     

Screening mammography, public perceptions, and medical liability

PURPOSE: To outline the most common sources of raising malpractice claims in screening mammography and to discuss the related medical litigation issues in the light of the evidence-based medicine. METHODS AND MATERIAL: Electronic and manual search of the relevant literature. RESULTS: The most common cause of malpractice is the delayed diagnosis of breast cancer. The plaintiff must establish that the radiologist was negligent and the delay in diagnosis caused injury to the patient. Literature shows that mammography does not always detect breast cancer, and even skilled radiologists may periodically miss malignant lesions. Also, delay in diagnosis does not always affect treatment and prognosis. Over-promotion of screening mammography has made disproportionately difficult for a defendant radiologist to prevail in a malpractice lawsuit. Thus, screening mammography is at stake, although it saves lives. The public and legal system should be educated about biological processes, medical practice, and the limitations of screening mammography. CONCLUSION: If mammography is to survive medical litigation and continue to save lives a major reform in public perception, in the stance of the mass media, and in the ability of legal system to understand medicine is required. Physicians and medical associations have an important role to play.     

Shoulder: what the orthopaedic doctor needs to know

Diagnosing shoulder pathology accurately requires both clinical expertise and the ability to interpret and correlate radiographic studies. Variational anatomy of the shoulder combined with the complexity of physical examination makes this difficult. Physical examination of the shoulder often leaves the surgeon with more than one working diagnosis. Imaging studies of the shoulder are more valuable if used to confirm a working diagnosis as opposed to reading the study in a vacuum. Clinical correlation should also be considered for any and all findings on an imaging study. Collaboration of the surgeon and the radiologist is essential in reducing the number of over-reported findings that are clinically insignificant. The surgeon should directly communicate with the radiologist as to his or her working diagnosis and the goal of the study. In this way the surgeon and radiologist become superior diagnosticians.     

Neck masses in children

Infants and children with neck masses frequently present to the radiologist for further evaluation. The role of the radiologist is to differentiate between conditions using imaging modalities such as ultrasound with colour Doppler, CT and MRI. Where appropriate, the radiologist will also stage lesions for management purposes and aid in guiding aspiration or biopsy. This paper presents a pictorial review of paediatric neck masses and their imaging features. Particular emphasis is applied to the anatomical site of the mass to aid in differential diagnosis. It must be emphasised that the radiological findings should always be interpreted in conjunction with the patient's age, the clinical history and the findings on physical examination.     

Uterine smooth-muscle tumors with unusual growth patterns: imaging with pathologic correlation

OBJECTIVE: This essay illustrates the salient features of variant smooth-muscle tumors on multiple imaging techniques with correlative pathology. We describe how recognition of these features allows the radiologist to distinguish a uterine leiomyoma variant from the classic fibroid or a leiomyosarcoma. Finally, we highlight the role of the radiologist in triaging these patients to surgical versus medical management and in surgical planning. CONCLUSION: Parasitic leiomyoma, intravenous leiomyomatosis, disseminated peritoneal leiomyomatosis, and benign metastasizing leiomyoma show key features on multiple imaging techniques that correlate with pathology findings. In the appropriate clinical setting, the radiologist should include these unusual lesions in the broader differential diagnosis of smooth-muscle tumors and, in certain cases, aid in surgical planning.     

Who writes guidelines,and who should?

AIM: To confirm or refute the impression that diagnostic radiology was often not represented on guideline writing committees, despite the fact that guidelines often made statements with implications for radiological practice. MATERIALS AND METHODS: We took two approaches. Firstly we examined all published Scottish Intercollegiate Guidelines Network (SIGN) guidelines and extracted the disease topic, the number of authors and peer reviewers, the number that were radiologists, and independently decided whether, given the content, radiologist input at the writing or review stage was necessary. We also searched for all guidelines on management of stroke worldwide (a single disease topic with major radiological implications) and extracted the proportion of authors that were radiologists. RESULTS: Of 47 SIGN guidelines on different diseases, 11 (23%) had a radiologist in the authorship (13/594, 2.2% total authors), and 5/47 (11%) had a radiologist specialist reviewer (10/529, 1.8% total reviewers). Independent review of the guidelines' content suggested that 76% of guidelines should have had a radiologist author and 91% a radiologist reviewer (discrepancy 53% and 80% respectively). Amongst 22 guidelines on acute stroke management in the world literature with 202 authors (where stated), there were only two radiologists (1%), both on one guideline which was specifically to do with imaging of stroke (5% of all stroke guidelines identified). CONCLUSION: Diagnostic radiology is poorly represented on guideline writing committees, although frequently guidelines have implications for radiological practice. Radiologists should try to be more involved in guideline production.     

The subscapularis: anatomy,injury, and imaging

The subscapularis is the largest and most powerful of the rotator cuff muscles and fulfills an important role in glenohumeral movement and stability. The spectrum and implications of subscapularis muscle or tendon injury differ from injury to other rotator cuff components because of its unique structure and function. Diagnosing subscapularis injury is clinically difficult and assessment of subscapularis integrity may be limited during arthroscopy or open surgery. Diagnostic imaging plays an important part in diagnosing and evaluating the extent of subscapularis injury. The radiologist should be aware of the anatomy of the subscapularis, the variations in muscle or tendon injury, and the potential implications for treatment and prognosis.     

The x-ray clinical picture and evaluation criteria of implantable cardioverter-defibrillator systems]

Since the first implantation of an automatic cardioverter defibrillator (ICD) in February 1980, the therapy of ventricular tachyarrhythmia has been changed drastically. The original therapy with antiarrhythmic agents has been increasingly replaced by the implantation of the ICD. The radiologist should be aware of the different types of ICDs and their normal appearance, because thorax radiography is often used during regular routine follow-up of the ICD system. The different types of ICDs, their normal radiological appearances, the indications and the implantation technique are discussed in the present study. The radiologist has to interpret the radiographs with respect to the electrodes, the device and changes in heart configuration. Major migration of electrodes is visible, but the detection of little changes in configuration is only possible with the help of serial radiographs. If extraperitoneal placement of the device is suspected, an ultrasound examination should be obtained. An important complication for the radiologist is a possible deactivation of some devices by electromagnetic interference.     

Concordance between a gastrointestinal consultant radiologist,a consultant radiologist and qualified reporting radiographers interpreting abdominal radiographs

IntroductionRadiographers can accurately report musculoskeletal and chest radiographs, but there is paucity of research comparing the performance of reporting radiographers (RRs) with consultant radiologists when interpreting and reporting abdominal radiographs. This study assessed interobserver agreement in the clinical setting between reporting radiographers and a consultant radiologist compared to an expert gastrointestinal radiologist in a District General Hospital. Major discordant reports affecting patient management were also examined.Methods126 abdominal radiographs reported by 3 RRs in clinical practice were randomly selected and reported by a consultant radiologist and index gastrointestinal radiologist. The reports of the RRs and consultant radiologist were compared against the reports made by the index radiologist for agreement by a colorectal consultant surgeon. All 126 reports were scored as being in either complete agreement, minor disagreement or major disagreement which would have resulted in a change to patient management.ResultsThere was no significant difference in overall agreement between the consultant radiologist (CR) and RRs when compared to the index radiologist (CR: n = 90/126, 71.4% and RRs: n = 94/126, 74.6%. p = 0.57). Major disagreements were found, but there was no significant difference between both groups (CR: n = 23/126, 18.3% and RRs: n = 17/126, 13.5%. p = 0.30).ConclusionRRs can report abdominal radiographs to a comparable level of agreement as a consultant radiologist in the clinical setting. There was no significant difference in reports deemed to affect patient management.Implications for practiceThis study addresses the gap in assessing the performance of RRs reporting abdominal radiographs. This small scale study indicates that radiographers could provide additional support in the reporting of abdominal radiographs. This would help to reduce radiologist workload and enhance the role of the reporting radiographer.ClassificationAgreement between reporting radiographers and radiologists interpreting and reporting abdominal radiographs.     

Ehlers-Danlos-Syndrom und bilaterale, dystrophe Brustkalzifikationen

Diagnostic investigations of mammary glands, which are routinely undertaken prior to a planned liver transplantation, can place high demands on the radiologist. The article describes a case of known Ehlers-Danlos syndrome, where it was essential that the radiologist was sufficiently informed over the past history, possible previously made images and typical presentation forms of microcalcification for corresponding findings from the breast diagnostics.     

Straight and rotational instability patterns of the knee: concepts and magnetic resonance imaging

The role of the musculoskeletal radiologist of the twenty-first century is not satisfied by the simple enumeration of findings on imaging studies. In this day of turf battles over the right to interpret images, in the interest of service to referring clinicians, and the optimal care of the patient, it is the responsibility of the radiologist to ascend to a higher level of sophistication in the understanding of the pathology encountered and the implications of our diagnoses. As demonstrated in this overview of the clinical and imaging approach to complex injuries of the knee, it is clear that the physical examination assessment of this patient population can be quite challenging. With a detailed understanding of anatomy, pathology, and what abnormalities change the management of the patient, the radiologist can alert the clinician to potential pitfalls in diagnosis. Neither the clinician nor the radiologist should be satisfied with a single diagnosis, for this introduces the potential of overlooking an associated injury that could preclude the return of a normally functioning articulation.