C. Douglas Maynard

Addressing Overutilization in Medical Imaging

The growth in medical imaging over the past 2 decades has yielded unarguable benefits to patients in terms of longer lives of higher quality. This growth reflects new technologies and applications, including high-tech services such as multisection computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET). Some part of the growth, however, can be attributed to the overutilization of imaging services. This report examines the causes of the overutilization of imaging and identifies ways of addressing the causes so that overutilization can be reduced. In August 2009, the American Board of Radiology Foundation hosted a 2-day summit to discuss the causes and effects of the overutilization of imaging. More than 60 organizations were represented at the meeting, including health care accreditation and certification entities, foundations, government agencies, hospital and health systems, insurers, medical societies, health care quality consortia, and standards and regulatory agencies. Key forces influencing overutilization were identified. These include the payment mechanisms and financial incentives in the U.S. health care system; the practice behavior of referring physicians; self-referral, including referral for additional radiologic examinations; defensive medicine; missed educational opportunities when inappropriate procedures are requested; patient expectations; and duplicate imaging studies. Summit participants suggested several areas for improvement to reduce overutilization, including a national collaborative effort to develop evidence-based appropriateness criteria for imaging; greater use of practice guidelines in requesting and conducting imaging studies; decision support at point of care; education of referring physicians, patients, and the public; accreditation of imaging facilities; management of self-referral and defensive medicine; and payment reform.

Efficacy of Radionuclide Scanning in Patients With Lung Cancer

Ninety-two patients with histologically proved carcinoma of the lung were studied retrospectively to determine the usefulness of liver, brain, and bone imaging in their examination and treatment. Occult metastatic liver disease was observed in two (5.3%) of 38 asymptomatic patients, while four (6.6%) of 58 neurologically intact patients had abnormal brain scans. Eight (13.6%) of 59 asymptomatic patients had metastatic bone disease. Seven (18.4%) of 38 patients with no clinical evidence of metastatic disease to liver, brain, or bone had at least one type of abnormal radionuclide study. More than half (52.5%) of the patients studied had at least one abnormal scan exclusive of symptoms. Radionuclide imaging is a useful procedure in the initial evaluation and subsequent management of lung cancer.

Value of the Routine Use of the Cerebral Dynamic Radioisotope Study

Abstract The results of 1,165 serial dynamic studies were reviewed. The routine addition of the dynamic study to the static image increased the detection of lesions by 33%. In patients with middle cerebral or carotid disease, the number of abnormal studies was doubled. Meningioma, arteriovenous malformation, and middle-cerebral-artery occlusion produced characteristic patterns on the dynamic study. Specific combinations of dynamic study and static image findings increased the certainty of diagnosis. Decreased perfusion was due to cerebrovascular disease eight times more often than to tumor. The combination of normal perfusion and a positive gamma camera image occurred three times as frequently with tumor as with cerebrovascular disease.

A computer approach to the prediction of spleen weight from routine films.

Plain films have for some time offered a method of estimating spleen size when the organ is visible by reason of surrounding fat, adjacent bowel gas, or radiopaque substances such as Thorotrast or calcium. When visualized on routine radiographs, the lower portion of the spleen is usually seen, but the upper half of the spleen is rarely demonstrable without special technics. This problem has limited the possible approaches to routine spleen measurement. Judging spleen size by the size of the renal outline, estimating the spleen from its width at a uniform distance above the tip, and measuring the vertical length from the midpoint of the spleen tip to its interception with the diaphragm have been proposed (2–4, 8). The difficulty of estimating spleen size by palpation is well known, and the problem of its clinical and radiographic estimation has recently been discussed by Riemenschneider and Whalen (6), who have also proposed a two-dimensional method of measurement. Rosch (7) has likewise recently discussed...

Trauma to the brain and extracranial structures

Over the past 10 years there have been numerous reports in the literature on the value and limitations of the various radionuclide procedures in the investigation of patients following head trauma. 1–3 This review contains an amalgamation of the currently known information concerning the usefulness of these procedures in the different clinical entities that may result from trauma to the brain and extracranial structures. The intravenous cerebral dynamic study and the static brain image have successfully been employed in the diagnosis of patients with subdural hematomas, epidural hematomas, intracerebral hematomas, and contusions of the brain. Properly employed, these studies may be utilized as screening procedures, and in isolated incidences may provide the definitive diagnosis. The problems associated with positive static images as a result of skull and scalp trauma will also be considered. Radioisotope cisternography has also been found to be of clinical value in the localization of cerebrospinal fluid leaks resulting from trauma and in the evaluation of disturbed CSF flow following head injuries.

Update on the Diagnostic Radiologist Employment Market: Findings Through 2004

OBJECTIVE The objective of this article is to summarize the latest information concerning the diagnostic radiologist employment market. MATERIALS AND METHODS Three sources of data are presented and compared with previous data: vacancies in academic radiology departments as of July; the ratio of job listings to job seekers at a major placement service; and the number of positions advertised in Radiology and the American Journal of Roentgenology. RESULTS Vacancies in academic radiology departments averaged 3.9 in 2004, down 29%, and decreased for all subspecialties as compared with 2001, but the number of vacancies remained very similar to that for 2003. Job listings per job seeker were 1.1 in 2004, stable over the past 2 years but at the lowest level since 1997. The overall number of positions advertised declined by 14% in 2003 compared with 2002 and by an additional 17% in 2004, reaching the lowest level since 1998. In 2004, 45.3% of positions advertised were academic. Comparing 2003-2004 with 2001-2002, all geographic regions exhibited absolute declines in advertisements except the Northeast, which showed a 1.5% increase. Absolute increases occurred for musculoskeletal and emergency radiology positions. Statistically significant proportional decreases occurred for general radiology, vascular/interventional radiology, and pediatric radiology. CONCLUSION Three separate data sources confirm a substantial and broad-based multiyear decline in the strength of the demand for diagnostic radiologists, with some shifting in relative demand for subspecialties. It is not clear if the decrease continued in 2004 or if 2004 demand was similar to that of 2003. Data are relative and do not indicate the employment market is weak in absolute terms.

Brain Scanning in the Pediatric Age Group

Between January 1964 and January 1967, 130 children had brain scans with Technetium‐99m pertechnetate at the North Carolina Baptist Hospital. There were 38 positive scans among this group; 25 children were proved to have intracranial neoplasms and the brain scan localised 20 (80 per cent) of these. Of the 14 tumors located in the posterior fossa, 13 were visualised for an accuracy of 93 per cent. Only 7 of 11 supratentorial tumors were demonstrated (63 per cent accuracy). Other lesions, such as A‐V malformations, cerebral infarction, brain abscesses and meningitis gave positive scans.

Platelet survival and sequestration patterns in thrombocytopenic disorders.

51Cr-labeled homologous platelets and external surface scanning were used to measure platelet survival and sequestration in 11 patients with idiopathic thrombocytopenic purpura (ITP), 2 with systemic lupus erythematosus, 4 with drug-induced thrombocytopenia, 3 with leukemia, and 7 with proliferative hypersplenism. The various spleen-to-liver count ratios were categorized to show the relative roles of spleen and liver in platelet sequestration: hepatic, hepatosplenic, and splenic. Splenectomy was performed in 19 corticosteroid-resistant patients: in ITP patients with predominant splenic sequestration patterns, results tended to be favorable; in those with hepatosplenic patterns, unpredictable; in those with hepatic sequestration, unresponsive.

Statistical Relationship of Brain Scans, Cervicocranial Dynamic Studies, and Cerebral Arteriograms

The authors compared rapid sequence cervicocranial camera images, scans, angiograms, and pneumograms in 146 cases of neurological disorder. It was found that use of imaging is justified as a screening procedure prior to performance of routine radionuclide brain scanning. Further information is offered in a significant number of cases, particularly when this single study is compared with information obtained by cerebral angiography and pneumography. Additionally, the rapid sequence images, when studied with the brain scans, may help establish such diagnoses as arteriovenous malformation, tumor, or infarction.

Role of the scan in bronchogenic carcinoma.

The introduction of the pulmonary perfusion scan in 1963 led to the investigation of its value in many pulmonary diseases. Several reports of its use in bronchogenic carcinoma have been published but the final role of the lung scan is yet to be determined. From information currently available it appears that scan patterns with bronchogenic carcinoma are variable; hilar lesions generally produce greater changes than do peripheral ones; normal scans occur with central as well as peripheral lesions but are more common with the latter; changes observed on the lung scan are frequently of greater magnitude than those seen on routine chest radiographs; as a diagnostic screening tool the scan may occasionally localize hilar lesions missed by routine chest X rays; it cannot be used as a definitive test for resectability or nonre-sectability but generally the larger the perfusion defect the more extensive the surgery required and the more likely the lesion is to be nonresectable; it gives the physician some idea of function of both the involved and the uninvolved lung; and it can be used to follow the response to therapy.