Medical practices

Rapid advances in communications and computing technology have opened up new opportunities for clinical teleradiology. The quality of teleradiology reporting, when carried out properly, is on par with onsite reporting, and offers the potential for increased accuracy and improved patient outcomes. Local and international industry organisations and professional bodies are creating standards, policies and protocols for every aspect of teleradiology in response to concerns about the use of this technology. The key factor for the long-term success of teleradiology has been identified as a commitment to ensuring duty of care to patients (encompassing high-quality service and patient safety) is the first priority. Evidence indicates that increased use of teleradiology will be a step forward if managed well, but requires a commitment to excellence, patience and perseverance.

Julian Adler MB BS(Hons), FRANZCR · Chris Yu MB BS, FRANZCR · Mineesh Datta MB BS, FRANZCR

To the Editor: This letter of lament was prompted by a recently overheard complaint by a first-year intern to her colleagues that radiologists were not “obeying” her! Her comment led us to review her last five imaging requests (“orders”). After discussion with other radiologists, three of these requests were considered inappropriate. Major reasons for inappropriate imaging investigations are lack of knowledge, fear of litigation, inadequate supervision, patient expectations, and being unaware of or uninformed about risks of ionising radiation. Inappropriate use of diagnostic computed tomography is especially worrisome. The trend towards requesting inappropriate imaging continues despite the many articles on this subject in the medical literature.1,2 Many publications have promoted judicious use of imaging sources.3 It is regrettable that clinicians do not make use of radiological expertise when faced with a diagnostic/imaging dilemma. This is especially so in hospitals when radiologists are available 24 hours a day every day of the year! In private practice and general practice, radiologists are only a telephone call away! The issues of communications with radiologists and matters of courtesy have previously been aired in this journal.4 The diagnostic imaging pathways developed at Royal Perth Hospital (by Professor R M Mendelson) in conjunction with the Western Australian Health Department are available freely on the Internet.5 Monitoring of this site indicates that the free access has been taken up by many clinicians overseas but it remains underused by Australian doctors. The perceived difficulties in communication and access to advice or information can be corrected by use of the telephone, email and Internet. After all, the goal for all of us is to provide the best care for our patients. It seems to us that the word “order”, which has replaced “request”, for imaging may be responsible for the change in attitude of the referring doctors! We urge all clinicians and medical journals to reintroduce the word “request” when communicating with imaging departments and radiologists.

Turab Chakera · Makhan S Khangure

A 53-year-old woman presented with a 2-day history of epigastric pain. She had mild tenderness over the right upper quadrant and epigastrium, with no peritonism. A chest x-ray revealed free gas under the diaphragm (Figure, A; arrows). A computed tomography scan confirmed a large pneumoperitoneum but no hollow-viscus perforation; the uterus was filled with gas (Figure, B; arrow). On further questioning, the patient recalled that the pain began after she sat on the gas outlet of a pneumatic spa. She was managed conservatively and discharged uneventfully. Air introduced through the gynaecological tract is a non-surgical cause of pneumoperitoneum. Distension of the uterus with gas on imaging can be a clue to diagnosis.

Yu Xuan Kitzing · Sam McCormack

A 62-year-old woman presented with left frontotemporal pain, scalp tenderness and raised levels of inflammatory markers. Temporal arteritis was considered likely, and symptoms resolved with prednisone therapy. This delayed diagnostic bone biopsy until a soft tissue abscess formed, and Pott's puffy tumour associated with Prevotella osteomyelitis of the frontal bone was diagnosed. This case highlights the value of early histopathological examination, and is a reminder of a condition seen frequently in the pre-antibiotic era. Clinical recordA 62-year-old woman was referred with a 6-month history of spontaneous left frontotemporal scalp pain. Initially, the pain was associated with a soft swelling over the scalp and resolved within 6 weeks. It recurred 4 months later, without associated swelling, localised to the left frontal region and became progressively more severe, disturbing the patient’s sleep. She remained systemically well and had no history of fever, sinusitis, dental infection or diabetes mellitus. Investigation by the patient’s general practitioner revealed raised erythrocyte sedimentation rate (130 mm/h; reference range [RR], < 20 mm/h), C-reactive protein (66 mg/L; RR, < 3 mg/L) and alkaline phosphatase (121 U/L; RR, 25–100 U/L). There was no paraprotein in the serum or urine. A plain radiograph revealed apparent osteolysis (Box, A) and a bone scan revealed intense uptake of technetium-99m-methylenediphosphonate in the skull (Box, B). A computed tomography (CT) scan confirmed diffuse lucency in the left frontal bone, without evidence of underlying sinusitis. These radiological and scintigraphic features suggested osteoporosis circumscripta cranii (the lytic phase of Paget’s disease of the skull), although the raised inflammatory markers were inconsistent with this diagnosis. A specialist opinion was sought. At review, the patient was afebrile and results of physical examination were normal except for marked tenderness over the left temporal region, raising the possibility of giant cell arteritis. Urgent temporal artery biopsy was arranged while the patient began oral prednisone therapy (80 mg per day). Her condition improved dramatically — the pain was alleviated and levels of inflammatory markers decreased — but no histological evidence of vasculitis in the temporal artery was found. A presumptive diagnosis of biopsy-negative giant cell arteritis was made, and oral corticosteroid therapy was continued with a tapering regimen. Prophylactic trimethoprim–sulfamethoxazole (320 mg/1600 mg twice per week) was administered to prevent Pneumocystis infection; concurrently, bisphosphonate therapy was begun (40 mg alendronate per day) for suspected osteoporosis circumscripta cranii. The occurrence of two separate pathological processes was considered improbable, and a skull biopsy for definitive diagnosis was discussed with the patient. However, she was reluctant to undergo further invasive testing because of the rapid symptomatic improvement. She was monitored clinically and biochemically at regular intervals while the prednisone dose was reduced over the following 6 months. Throughout this period, she remained pain-free and systemically well, with normal levels of inflammatory markers. Six months after initiation of corticosteroid therapy, while the patient was taking 10 mg of prednisone per day, she developed a tender fluctuant swelling over the left frontal region of the scalp. The swelling enlarged rapidly, and a CT scan revealed a 6 × 11 × 4.5 cm collection overlying the left frontal bone (Box, C). Neurosurgical consultation and exploration of the swelling were arranged. During exploratory surgery, copious malodorous pus was drained and a biopsy sample of the underlying skull, which appeared discoloured, was taken. A pure growth of Prevotella sp., an anaerobic gram-negative rod-shaped bacterium, was isolated on culture of the pus. The organism was identified as either Prevotella melaninogenica or Prevotella oralis. Histopathological examination of the biopsy sample revealed infiltration of the marrow spaces by neutrophils (Box, D), and the presence of plasma cells with admixed fibrosis (Box, E), consistent with concurrent acute and chronic osteomyelitis. The diagnosis was revised to Prevotella osteomyelitis of the frontal bone with associated soft tissue abscess (Pott’s puffy tumour). Prednisone and alendronate were withdrawn, and the patient was treated with intravenous antibiotics for 6 weeks. As the organism was penicillin-resistant, clindamycin (600 mg four times per day) was administered for 2 weeks, and this was followed by ertapenem (1 g per day) as outpatient therapy. The intravenous antibiotics were combined with oral metronidazole (400 mg three times per day) and were followed by treatment with oral clindamycin (300 mg four times per day) for another 6 weeks. The patient’s condition responded rapidly to medical management and she remained clinically well with normal levels of inflammatory markers at 12-month follow-up. A subsequent CT scan of the calvaria showed resolution of the lytic changes without bony sequestrum. DiscussionAnaerobic organisms predominate in head and neck infections, occurring in a mixed growth in more than 90% of dental, oral and neck space infections.1 Clinically relevant anaerobes include the gram-negative rods Bacteroides, Prevotella, Porphyromonas, Fusobacterium and Bilophila, and gram-positive rods (eg, Clostridium, Actinomyces and Propionibacterium) and cocci (eg, Peptostreptococcus).1 Despite frequently being found in mixed bacterial populations, Prevotella sp. was isolated as a pure growth in our patient. Although trimethoprim–sulfamethoxazole therapy (used as Pneumocystis prophylaxis in our patient) is generally thought to lack useful activity against anaerobes,1 it may have suppressed the infection. Osteomyelitis of the skull is uncommon; recognised clinical syndromes include frontal bone osteomyelitis secondary to frontal sinusitis, and skull base osteomyelitis associated with malignant otitis externa. Skull osteomyelitis may also result from direct inoculation during surgery or occur in association with retrograde septic thrombophlebitis.2 Haematogenous seeding of bacteria in the skull is rare. Although our patient had no clinically or radiographically recognised sinusitis or history of dental instrumentation or infection, it is likely that the organism originated in the oral cavity or frontal sinus. The duration of the history suggests that chronic osteomyelitis may have accounted for our patient’s initial symptoms, but, if present, Paget’s disease of the skull may have predisposed to bacterial seeding. Paget’s disease is a reported risk factor for osteomyelitis of the jaw.2 Pott’s puffy tumour is a complication of frontal osteomyelitis that was first described by Sir Percival Pott in 1760.3 It appears as a circumscribed swelling on the forehead, representing a subperiosteal abscess that forms when infection breaks through the frontal bone.2 Epidural abscess, subdural empyema, brain abscess and cortical vein thromboses have been described in association with Pott’s puffy tumour. It was predominantly seen in children and adolescents before the widespread availability of antibiotics.2,4 In our patient, the administration of corticosteroids masked the underlying anaerobic infection until dose tapering permitted an abscess to form. Our patient illustrates a diagnostic challenge. It seemed unlikely that two unrelated diagnoses would account for a single presentation, but the prompt clinical response to corticosteroids led to a delay in diagnostic bone biopsy. The final diagnosis of frontal bone osteomyelitis with subperiosteal abscess is a reminder of a condition seen commonly in the pre-antibiotic era. Radiography and computed tomography (CT) scans, and bone biopsy specimens, of a patient with Pott’s puffy tumour associated with Prevotella osteomyelitis of the frontal bone A: Plain radiograph of the skull before corticosteroid therapy, showing patchy osteolytic areas in the frontal cranium. B: Delayed skull spot views on a bone scan before corticosteroid therapy, showing accumulation of technetium-99m-methylenediphosphonate. C: CT scan of brain (using intravenous iopamidol contrast medium) after 6 months of corticosteroid therapy showing a large collection over the left frontal bone. D: Bone biopsy specimen taken after 6 months of corticosteroid therapy, showing infiltration of the bone marrow spaces by neutrophils and scattered osteoclastic giant cells adjacent to the bony trabeculae, indicating active inflammation (haematoxylin and eosin stain; original magnification, × 400). E: Bone biopsy specimen taken after 6 months of corticosteroid therapy, showing plasma cells with admixed fibrosis, indicating chronic inflammation (haematoxylin and eosin stain; original magnification, × 400).

Lyndal J Tacon MB BS · Jonathon F Parkinson MB BS · Bernard J Hudson FRACP, FRCPA · Janice M Brewer MB BS, FRCPA · Nicholas S Little MB BS, FRACS · Roderick J Clifton-Bligh FRACP, PhD

A 50-year-old man presented with cough, wheeze, intermittent haemoptysis and progressive dyspnoea. He had no relevant past history. On examination, he was hypoxic but haemodynamically stable. Results of routine blood tests, including full blood count, urea and electrolyte levels, and erythrocyte sedimentation rate, were within normal ranges. Pulmonary function tests confirmed severe airway obstruction and diffusion impairment. A chest x-ray revealed multifocal areas of nodularity and consolidation in both lungs (Figure, A). A computed tomography scan showed thickening and calcification of the bronchial walls with multiple cavities and nodules throughout both lungs (Figure, B). A virtual bronchoscopy revealed irregular narrowing of the right main bronchus (Figure, C; arrows), and a bronchial biopsy confirmed pulmonary amyloidosis (light-chain type). Pulmonary amyloidosis occurs in three forms: tracheobronchial (the most common, which is limited to central airways and which this case exemplifies), diffuse and adenopathy-associated.1 Nearly all cases are of the light-chain type.2 Treatment is difficult and controversial; repeated bronchoscopic resection is conventional,3 but the role of external beam radiotherapy in tracheobronchial amyloidosis has also been described.4

Kshitij Mankad · Michael J Darby

To the Editor: In his exploration of the health advocacy potential of modern clinicians, Gruen1 observes that the public first needs to be convinced that “the profession has its own house in order”. Unfortunately, one room in that house accommodates one of the serious health threats identified by the author: terrorism. Currently, over 95% of the world’s radiopharmaceuticals are generated from highly enriched (bomb-grade) uranium (HEU), an unnecessary nuclear weapons proliferation hazard.2 Prompt conversion of the global medical isotope supply chain to low enriched uranium (LEU, containing less than 20% uranium 235, so not viable for weapons production) is technically feasible.3 Clinicians are thus uniquely placed to advocate conversion to the use of LEU, while pressuring their imaging and isotope providers to end reliance on HEU, thereby blocking one of the most vulnerable pathways to producing a “terrorist bomb”. But, as Gruen suggests, we can do even more through “collective advocacy” to address the much larger nuclear threat: that is, the 26 000-plus nuclear weapons remaining in the arsenals of Russia, the United States, the United Kingdom, France, India, Pakistan, Israel, China and North Korea. While a sophisticated terrorist group armed with home-manufactured nuclear weapons could devastate a few cities, the existing nuclear-armed states have the capacity to destroy between tens and thousands of urban centres and their populations within a few short hours. Worse still, recent research indicates that 100 Hiroshima-sized (ie, “small”) nuclear weapons exploded on major cities would be capable of precipitating a “nuclear winter” that could persist for 10 years.4 The dispersal of carbonaceous material into the stratosphere from major urban firestorms could dramatically reduce terrestrial sunlight, lower surface temperatures by several degrees, shorten the growing season, reduce rainfall and trigger global famine. One billion deaths from starvation is a realistic assessment of the consequences.5 Such a catastrophic scenario is within the firepower capacity of all currently nuclear-armed nations except North Korea. A new generation of medical students and young physicians has launched several initiatives over the past few years to challenge this threat, including the Nuclear Weapons Inheritance Project and Target X (http://www.ippnw-students.org). Most recently, International Physicians for the Prevention of Nuclear War launched the International Campaign to Abolish Nuclear Weapons (http://www.icanw.org), whose goal is to establish a nuclear weapons convention to eliminate all nuclear weapons once and for all. By ending our reliance on bomb-grade HEU in medical imaging, we can certainly begin to put our own house in order. But let’s also follow Virchow’s lead: let’s “engage with the broader social concerns that cause illness and harm”,1 get active for our patients’ — and our own — wellbeing, and help prevent a global nuclear pandemic.

Bill Williams

A 51-year-old woman presented with a 2-day history of left iliac fossa pain. Axial and coronal computed tomography images (Figures) revealed a linear intraluminal foreign body (arrows) impacted in the wall of a blind-ended loop of small bowel over the midline, consistent with a fishbone in a Meckel diverticulum. Small bowel dilatation due to ileus (D) and inflammatory stranding in the peritoneal fat (S) were also present. Surgery revealed pinpoint bowel perforation caused by a 2 cm long fishbone, from Pampus argenteus (silver pomfret), in a 5 cm long Meckel diverticulum.

To the Editor: I read with interest the letter by Lim and colleagues on anorexia nervosa and senna misuse.1 I have seen abnormal whole body bone scans in patients with severe eating disorders of exactly the same pattern (except for the avid bilateral apical lung and gastric uptake) as the case described. However, I disagree with the interpretation of the bone scan. There was increased periarticular tracer uptake involving long bones. The pattern was not that of hypertrophic osteoarthropathy (HOA). The pattern in HOA is linear tracer uptake by the periosteum, particularly along the distal ends of long bones.2 The scan in the case reported did not show uptake of this pattern, despite radiological evidence showing periosteal reaction and new bone formation of the tibia and fibula at the ankle. The pattern exhibited in this patient was more consistent with metabolic bone disease (increased tracer uptake by the ends of long bones periarticularly, the axial skeleton, calvaria, mandible, sternum and “beading” of costochondral junctions, with faint, or absent, renal uptake),3 although not all of these features were present in this case. Metastatic calcification of the gastric wall (not mentioned by the authors) and upper lobes of the lung was present in this patient. Metastatic calcification of the lungs can be diffuse4 or localised (most commonly) to the upper lobes, as in this case.5 With regard to the bone mineral density results in this case, the authors state that the lumbar and femoral neck T scores were elevated (1.2 and 1.3, respectively). The normal range of the T scores is ± 1.0 standard deviation of young adult normal values.6 Elevated bone mineral density measurements are generally not of pathological significance and are therefore clinically not relevant. In my experience they are usually decreased, and are often osteoporotic, in patients with severe eating disorders.

Andrew F McLaughlin

To the Editor: Computed tomography (CT) of the chest is superior to chest x-ray as an imaging modality of the lungs, mediastinum, pleura and the chest wall,1 and its use is increasing for a range of diagnostic and therapeutic applications.2 There are clear indications for the appropriate use of chest CT, and adherence to these can reduce cost, workload, procedure-related complications and radiation exposure. Our group recently analysed referrals for chest CT from general practice, and found that the scan was clinically helpful in only 12%, and inappropriate in 68%.3 We thus examined the indications for ordering CT of the chest, and the associated outcomes in hospital inpatients, who had been referred for chest CT by general physicians. Two respiratory physicians retrospectively reviewed the clinical files, the CT request form, and previous and current imaging of 47 consecutive non-surgical patients admitted to Cairns Base Hospital between 1 January and 1 July 2005. One illustrative patient’s case is described in the Box. The impact of the chest CT on the patient’s clinical outcome was assessed. We used the imaging guidelines of the Royal Australian and New Zealand College of Radiologists (RANZCR) as the standard for evaluating appropriate ordering of chest CT.4 Overall, chest CT was appropriately ordered in 26 of 47 patients (55%). The correct type of scan (contrast, non-contrast or high resolution) was requested for 38 of the 47 patients (81%). In 25 of the 26 appropriately ordered scans (96%), the patient’s physicians had compared the CT scan with previous chest x-rays and recorded this in the file; this was done for only 11 of the 21 inappropriately ordered scans (52%; P = 0.001). Further useful information that had not been detected by other means was obtained from the CT scan (compared with chest x-ray alone) in 26 of 47 patients (55%, comprising 25 of 37 [68%] in the subgroup in whom the CT had been ordered appropriately and one of 10 [10%] in the group ordered inappropriately; P = 0.01). Management was changed as a result of CT scanning in 19 of 47 patients (40%): 18/26 (69%) in the appropriately ordered CT group and 1/21 (5%) in the inappropriately ordered CT group (P = 0.001). The correct type of CT scan led to a higher incidence of change in management (18 of 38 patients; 47%; P = 0.046). We encourage all doctors to use the RANZCR guidelines, or web-based imaging pathways such as those developed by Royal Perth Hospital <www.imagingpathways.health.wa.gov.au> to ensure better clinical practice. An illustrative case of acute respiratory illness from the study A 41-year-old woman with a past history of asthma was admitted to hospital with moderately severe right-lower-lobe pneumonia. She responded to antibiotic and bronchodilator therapy and was discharged on Day 6 with no complications. During her admission she had five chest x-rays and high-resolution computed tomography (HRCT) of the chest to rule out empyema; all of these showed consolidation with a small effusion. In outpatient follow-up, she had two further chest x-rays and HRCT of the chest repeated once during Week 3 because of “slowly resolving” shadows. Assessment and comment: The imaging guidelines of the Royal Australian and New Zealand College of Radiologists4 recommend that further imaging is indicated for clinical deterioration, complications, or slow recovery. Thus, this patient did not need computed tomography (CT) scanning, as none of these criteria were met. Had CT been indicated, conventional CT, and not HRCT, would have been the correct choice. A repeat chest x-ray with a lateral view at discharge and at 6 weeks would have been the appropriate management in this patient.

Askin Gunes · Lloyd J Ridley · Graham Simpson

Medico-legal radiology. William S C Hare. Sydney: Churchill Livingstone, 2007 (ix + 201 pp). ISBN 978 0 7295 3831 2. Emeritus Professor W S C (Bill) Hare had a long and distinguished career in clinical radiology, including a term as President of the Royal Australian and New Zealand College of Radiologists and Chair of Radiology at the University of Melbourne and the Royal Melbourne Hospital. In retirement, he has continued an active medicolegal practice as well as his writing. This latest book draws on both his personal experience and an extensive review of the extant literature. The first chapter, “Lawmakers and legal processes”, is as succinct a summary of the structure and practice of the law as I have seen. The second chapter, “Radiologists and the law”, examines how both statute and civil law can impinge on doctors in general and radiologists in particular, and the roles doctors can take in legal proceedings (ie, as defendant or as expert witness). The third chapter deals briefly with no-fault and fault-based systems of compensation for iatrogenic injuries, and looks at why patients sue, who they sue, the results of litigation and the impact of the cost of litigation on medical indemnity insurance premiums. Chapter four is a brief primer on how to interpret diagnostic images — a seven-page summary that would make valuable reading for any student or recent graduate, or indeed any doctor who needs to make sense of such images. The fifth chapter, on writing reports, is pure gold. When a defence organisation runs an expert witness seminar, attendees are desperate to learn how to manage themselves in court. But most will write dozens of reports for every time they actually go to court, and the quality of their report will have a great influence on whether they need to be called at all. Doctors generally write poor reports, because few seek instruction on how to write good ones. For radiologists, Professor Hare has now, in just nine pages, written the definitive primer. The remaining 10 chapters deal systematically with the major areas of medicolegal concern in radiology and conclude with a chapter on necroradiology (the title Hare adopts for radiological examination of the dead). Each chapter deals separately with litigation arising from diagnosis and litigation related to procedures. Each chapter ends with a series of dot-pointed “suggestions” which radiology registrars would be well advised to commit to memory! This is a relatively short, well written book. While written in an Australian context, the “suggestions” have application to any radiologist anywhere in the world.

Paul Nisselle

To the Editor: We were interested to read the article on health services research (HSR) in Australia,1 and the previous editorial and articles on health technology assessment (HTA).2-5 In contrast to Australia’s prominent role in applying HSR and HTA to new pharmaceuticals, there has been very little local development of these techniques in evaluating new diagnostic technologies. The Quality Use of Diagnostic Imaging program of the Royal Australian and New Zealand College of Radiologists recently examined the introduction of new imaging technologies in Australia, with particular attention to Medicare Benefits Schedule funding. The major findings were: Delays of up to 7 years between the emergence of evidence for benefit from a new technology and Medicare listing. A large part of this delay was in the period before application to the Medical Services Advisory Committee (MSAC). A lack of significant permanent infrastructure for evidence-based assessment and prioritisation of new imaging technologies. This is in stark contrast to the situation for new pharmaceuticals and surgical procedures. Where some published evidence of clinical efficacy exists, but does not meet MSAC requirements, there is no mechanism to trigger targeted trials on questions of safety, efficacy, and cost-effectiveness. The generation of such evidence is costly, but, arguably, cost-effective in the longer term. Data collection by the Australian and New Zealand Association of Physicians in Nuclear Medicine during the interim funding of positron emission tomography has cost $2.5 million. This “coverage with evidence” approach is used in other countries, like the United States and the United Kingdom, to generate relevant evidence about the performance of emerging technologies when this does not exist in the published literature The current restriction of MSAC reviews to examining existing evidence, rather than sponsoring projects designed to provide specific relevant evidence, ensures continuing delays in the approval of new technologies for Medicare funding.

Nicholas J Ferris · Stacy K Goergen · Makhan S Khangure

Teleradiology is like a “two-edged sword” that requires careful consideration and balancing, needing uniform standards to guide quality care while ensuring patient safety The rapid and secure transfer of x-ray and diagnostic imaging studies around the world is being facilitated by new technologies, such as picture archiving and communication systems (PACS), high-speed Internet access, and secure virtual private networks. This transfer of images, usually for assessment by a radiologist at a geographically remote site from where the images were obtained, is known as teleradiology.1-4 Domestic and international teleradiology is practised by individuals and imaging practices (private radiology groups and corporate practices), as well as teleradiology groups in Australia. Based on the 2006 Royal Australian and New Zealand College of Radiologists (RANZCR) Workforce Survey,5 about 67% of Australian radiologists use teleradiology in their daily work: 92% within their own state, 22% between states, and 1.7% internationally. The international teleradiology workflow is bidirectional, with Australian imaging studies being reported overseas and overseas imaging studies being reported in Australia. Clinical teleradiology has advantages, but there are also potential problems and pitfalls. However, in teleradiology, as in any use of radiology, the provision of high-quality, appropriate clinical care and accountability must remain of utmost importance, and this principle should guide teleradiology’s further development. In Australia, there is an escalating demand for diagnostic imaging services. The RANZCR anticipates that demand will greatly outstrip current supply in the radiologist workforce for at least the next 5 years. Further, this ever-increasing demand on diagnostic imaging services is accompanied by an increasing complexity of studies and a continued expectation that they will be reported promptly, 24 hours a day, 365 days a year. Given the geography and demographics (including radiology workforce demographics) of Australia, the benefits of using teleradiology are clear. Teleradiology can provide remote interpretation for rural and regional communities; second subspecialist opinion; workload balancing for diagnostic imaging staff; education; research; and clinical/quality audits.6,7 Out-of-hours interpretation, when local radiology services are unavailable, may also be of great benefit to patients if urgent advice is required. Similarly, however, several potential pitfalls are evident. One key pitfall relates to the “distancing” of the radiologist from patients clinically, as well as geographically — a trend that is already increasing with onsite services, and may only intensify with teleradiology. Radiologists have minimal influence over referrals that occur under a capped diagnostic imaging Medicare budget for billed services or in the public hospital sector. Apart from technological considerations, current legislation, reimbursement schedules and workload demands also exacerbate the increasing distancing of radiologists from clinicians and patients. Reporting radiologists may have little or no clinical or contextual patient information or direct communication with the clinician caring for the patient, resulting in image interpretation occurring in isolation, rather than provision of an integrated expert opinion. However, if this pitfall is avoided, specialist radiologists can make a pivotal contribution to clinical decision making and management — clinicoradiological discussions can result in a change of clinical diagnosis in 50% of cases and a change in treatment in 60% of cases discussed.8 Using radiologists and diagnostic imaging wisely could reduce the burden on the entire health system by not only improving diagnosis and management but also by reducing unnecessary and repeated radiation exposure, thus optimising overall patient care. Other potential problems relate to technical and professional considerations. Transfer of images may result in less than optimal image quality, hampering interpretation. If images are sent overseas, it is possible that the reporting radiologist may not be trained to the same standard as radiologists in Australia. We need to acknowledge that when English is not a radiologist’s primary language, there may be increased potential for error. Indemnity may not be guaranteed, and protection for patients may not be available.2-4,6,9,10 Perhaps the most serious concern relates to the potential evolution of medical services, including teleradiology, as commodities instead of community services. The globalisation of health care has never been more evident than in international teleradiology. The emerging globalisation of health care generally1-4,11 and, more specifically, the progressive corporatisation of radiology providers and the prospect of commoditisation of radiology services9,12 are on our doorstep. To contain cost, maximise efficiency and meet shareholders’ expectations, health care providers increasingly use teleradiology to outsource services.3,4,9,12 In some countries, out-of-hours on-call teleradiology has fully matured, and teleradiology companies are turning to daytime and subspecialty segments to further grow their market share.9 Some observers have noted that teleradiology could be treated as a commodity and traded with forward contracts.12 This concept of forward trading of medical services seems to be quite divorced from more traditional philosophies of the practice of medicine, and, at the very least, the public at large and those who pay for these services should be made aware of this trend. From a community perspective, if teleradiology is viewed purely as a technical service, with no consideration given to the quality, appropriateness or relevance of the interpretation service, nor to patient safety; if it is driven purely by cost and workforce pressures, convenience, or desire for market share, then this would be highly undesirable. Even within Australia, it is possible that commercial leveraging may occur, resulting in disruption to local radiologists, the local clinical diagnostic imaging team, and community service provision if cost-cutting and market share are primary motives for the introduction or further development of teleradiology.2,9,13 Thus, where a local clinical radiology service exists, compelling advantages for patient care would need to be identified to justify the additional provision of teleradiology services. However, when teleradiology can facilitate good patient care, this is an excellent outcome of the application of this technology. Teleradiology, both domestic and international, can be considered a “two-edged sword”, requiring careful consideration and balancing. The rapid growth of teleradiology and the globalisation of health care have led to the need for a set of uniform standards to protect consumer rights, define responsibilities, enable inter-jurisdictional recognition, ensure quality and safety, and enable benchmarking.6,13,14 Accordingly, the International Radiology Quality Network (IRQN)13 has developed a set of international clinical teleradiology principles to guide quality care and ensure patient safety. Australian representatives actively contributed to this development, and the RANZCR has adapted the IRQN principles in a position statement applicable to Australia and New Zealand.15 In general, these principles emphasise that the entire focus of international clinical teleradiology (as for radiology in general) must be solidly based on “what is good for the patient”. For example: the correct imaging procedure should be performed; images should be of a high quality and transmitted accordingly; communication must be made between the treating team and the (appropriately credentialled and indemnified) radiologist, providing a high level of clinical information; images must be interpreted in light of the full clinical history and available previous imaging; and the radiologist’s interpretation of the images and medical opinion must be communicated clearly and in a timely manner. The position statement also addresses specific, serious concerns, including security (eg, sites should comply with all nationally specified data protection standards) and ethics (a system should be in place to document electronic “fingerprints” of interpreting radiologists, to prevent “ghosting” of reports). The position statement will be updated regularly, with additional input sourced from the RANZCR Quality Use of Diagnostic Imaging Program teleradiology projects and the RANZCR Standards of Practice and Accreditation Committee, as well as IRQN updates. Any practice or hospital considering the use of domestic or international clinical teleradiology will be well served to be guided by these principles, and must, at all times, maintain a principal focus on high-quality patient care. With time, the regulatory, legal and ethical framework applicable to teleradiology may well flow on to other medical disciplines.

Lizbeth M Kenny MB BS, FRANZCR · Lawrence S Lau MB BS, FRANZCR

A positron emission tomography scan of this patient’s lymphoma revealed a surprisingly “Australian” distribution of disease.

Colin K F Tan · Tim Y Demetriades

“Kelly Laerdal”, age unknown, but repeatedly resuscitated, was scheduled for a chest x-ray to investigate the metallic contents of the thorax, with the aim of understanding why resuscitation manikins might differ in their susceptibility to electromagnetic interference in electrocardiogram recording.1 Besides some minor electronic components, the image shows a prominent cardiac massage pressure point, gives a hint of shoulder joint junctions, and shows exactly where the auscultation regions (covered by loudspeakers) are located — a “must know” for every advanced cardiac life support student.

Wolfgang Lederer · Martin Breiteneder · Michael Rieger · Christoph J Schlimp

In April 2004, Melbourne’s Peter MacCallum Cancer Centre, Australia’s only stand-alone dedicated cancer hospital, became the first Australian site to offer digital mammography (DM). In the first year of DM operation, 1208 mammograms were performed on 1157 women; 17 new cases of invasive carcinoma and six new cases of ductal carcinoma-in-situ (DCIS) were detected; and 30 hook-wire needle localisations were conducted in 29 patients. We developed a unit policy to manage indeterminate microcalcifications newly demonstrated on DM that were not previously detected by conventional screen-film mammography (CM): those believed to have malignant morphology were recommended for biopsy, and those without were recommended for 6-month DM follow-up to confirm microcalcification stability. DM detected 56 new stand-alone microcalcifications (18 suspicious and 38 indeterminate). Tissue diagnosis of 12 suspicious microcalcifications yielded four cases of DCIS and one of atypical ductal hyperplasia. Of the indeterminate microcalcifications, 35 have demonstrated stability at DM follow-up to date, over a mean period of 23.6 months. From our experience, we believe DM’s superior demonstration ability uncovered microcalcifications previously undetected by CM, rather than microcalcification progression. We suggest that routine review with DM, rather than biopsy, is appropriate management when new indeterminate microcalcifications without malignant characteristics are identified by DM.

Emma Pun MMed, FRANZCR · W F Eddie Lau BPharm, FRANZCR · Robin Cassumbhoy FRANZCR · Anthony J Taranto FRANZCR · Alexander G Pitman BMedSci, FRANZCR

A 45-year-old man presented with frequent palpitations. Clinical examination and electrocardiogram were unremarkable. Transthoracic echocardiography suggested asymmetrical septal hypertrophy, although the acoustic windows were poor. Transoesophageal echocardiography revealed a broad false tendon within the left ventricle, extending from the basal septum to the apical lateral wall (Figure). Holter monitoring showed frequent premature ventricular complexes, indicating right bundle branch block morphology. The incidence of false tendons — fibromuscular intracavitary bands anatomically distinct from the valvular cusps — is 0.4% to 3.0%.1 They may be associated with malignant ventricular arrhythmias, which should be excluded before making a diagnosis of benign premature ventricular complexes in a healthy patient.1 Transoesophageal echocardiogram: the arrow shows the false tendon from the basal septum to the apical lateral wall of the left ventricle (LV).

Robin A P Weir · Henry J Dargie · Iain N Findlay

To the Editor: I congratulate the Journal for publishing the article by Smith and Baird on the radiographer’s role in radiological reporting.1 It demonstrates the Journal’s objectivity by providing an opportunity to examine a health service model that, if carefully implemented and evaluated, may enhance outcomes in diagnostic imaging within a clinically useful timeframe. It is quite understandable that the Royal Australian and New Zealand College of Radiologists (RANZCR) would move quickly to defend its professional jurisdiction. However, in their editorial published in the same issue of the Journal,2 Kenny and Andrews, representing the RANZCR, seem to have overlooked the contribution of the Smith and Baird article to the development of new models of health care delivery. Further, their defence ignores the reality that, in the Queensland public hospital system, for example, diagnostic imaging is conducted in 108 centres but radiologists are only present at eight of those centres. The past three decades have seen rapid technological change, resulting in an array of diagnostic and interventional imaging modalities and providing a challenge to 21st century radiologists. However, plain radiographic images were being interpreted by non-radiologists for two or more decades before the medical specialty evolved.3 Alerting rural general practitioners and junior medical officers in emergency departments to abnormal features on plain films is a work practice that radiographers have always performed. Image interpretation in plain radiography is a skill they are exposed to every day of their working lives. Formal postgraduate training would develop that skill and formalise the practice. The nurse practitioner model developed because of identifiable health care service deficiencies, particularly in vulnerable, underserved communities.4 Similar service gaps exist in diagnostic imaging. The maldistribution of radiologists in Australia will never change, for economic and lifestyle reasons. There will never be a radiologist to supervise, advise, report findings and communicate results of plain radiographs at 3 am in a provincial hospital — nor in a metropolitan emergency department, for that matter. The radiographer will be there, however. It is time that due recognition be given to radiographers and enhanced training provided. The RANZCR, as the responsible body of medical professionals, owes it to the communities that they are unable to serve.

Wayne J Nuss

To the Editor: On the basis of the recent traumas experienced by the United Kingdom in rolling out its Modernising Medical Careers program, you warn the Royal Colleges to “resist political pressure to solve medical manpower problems created by governments”.1 Kenny and Andrew,2 representing the Royal Australian and New Zealand College of Radiologists (RANZCR), clearly link the need to cope with increasing demand for diagnostic imaging with the drive to allow non-medical staff to develop roles previously reserved for the medically qualified — and they oppose much of this. Meanwhile, Smith and Baird3 argue cogently — and supported by evidence, rather than conjecture — that there is a place for allied health professionals with appropriate training and education to take on some of the more traditional medical roles. Each group could be arguing from a position of self-interest. The representatives of the RANZCR (surprisingly) do not mention reimbursement of radiologists,2 while university teachers advocate a wider role for their institutions.3 The arguments are further mired by the assumption that role development or delegation is and should only be driven by unmet service demand. That need not be. Smith and Baird,3 in describing many of the UK developments, correctly assume that service demand is a driver, but that is not always the case. In diagnostic and therapeutic radiography in many parts of the UK, such as Scotland, the process of role development is seen as a natural progression in training and work practice that allows individuals to develop the skills they are capable of using. This is not merely a process reserved for areas of understaffing. In fact, medical staff have extra roles — in training, mentoring and supervising. They are also able to free up time for more demanding medical work. Notably, resistance to such change (of which I see very little in therapeutic radiography) is not confined to medical staff: major opposition is often expressed by radiographers and their managers. Thus, the process of role development of all clinical staff requires close cooperation between all professional and educational bodies. That is a proper role for a medical college — rather than that of a trade group protecting its patch or resisting change. Personally, I find it highly enjoyable to practise with experienced, motivated nursing and allied health colleagues who have been trained to perform these enhanced tasks.

Alan Rodger

To the Editor: The views of Mendelson and Murray1 regarding inappropriate use of diagnostic imaging and how it might be reduced are timely and important. Unless governments, doctors, the medical imaging industry and consumers acknowledge the significant barriers to Mendelson and Murray’s proposed changes, the number of inappropriate tests will grow. The authors argue that radiologists need to be more active in vetting requests. This is often hindered by the lack of relevant clinical information from referrers about the indications for tests. Broadhurst et al2 found that 34% of unselected Australian requests for shoulder ultrasound contained “no tangible information to assist the radiological examination”. Surveys of doctors in the United Kingdom found that their knowledge of the radiation delivered by various imaging tests, relative to that of a chest x-ray, was poor.3 This lack of knowledge makes it difficult, if not impossible, for doctors to inform patients about the risks and benefits of an imaging test. The Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists was set up in 2004 to develop a knowledge base of evidence-based best practice in radiology. To date, it has commissioned over 25 quality-related projects in areas such as development of information for consumers, best practice standards for radiology requests, and audit–feedback analysis of radiation dosage in paediatric computed tomography. The QUDI Program and the National Institute of Clinical Studies have sponsored fellowships in evidence implementation, training radiologists in the art and science of supporting clinicians’ use of evidence-based, appropriate diagnostic imaging. The results of QUDI projects are used in strategies to improve the use of radiology. The Australian Medical Association is advocating that general practitioners have access to magnetic resonance imaging, arguing that it would reduce costs and radiation exposure.4 However, this does not address the issue of appropriate consultative referral, and has the potential to simply add to the burgeoning diagnostic imaging budget rather than directly benefiting patients. A multifaceted approach to change is required, involving the referrer, the consumer and the entire radiology industry. This must be based on best-practice, patient-focused use of radiology. Radi-ologists are central to providing advice on the most appropriate imaging procedures and reducing the burden of inappropriate imaging. This is likely to require changes to practice and to legislation.

Lizbeth M Kenny · Stacy K Goergen · Catherine J Mandel

To the Editor: The authors of the editorial “Towards the appropriate use of diagnostic imaging”1 canvass possible strategies to improve the appropriateness of requests for diagnostic imaging. One strategy that research suggests may be effective is feedback provided by the providers of diagnostic services.2,3 Discussion of the feedback could, and should, be supported by federal government funding, perhaps via Divisions of General Practice, and should attract continuing professional development points for the general practitioners involved.

Oliver R Frank

In reply: We thank Kenny and colleagues for their comments and congratulate the members of the Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists on their continuing efforts. We are also grateful to Frank for his constructive suggestion. We entirely agree that a multifaceted approach is needed to improve the appropriateness of referral for diagnostic imaging. We believe that the majority of general practitioners are willing to be educated and guided with regard to their referring practices. However, to do so they require up-to-date guidelines that are easily accessible in electronic form, based on evidence and consensus, practicable and able to be integrated into their everyday desktop applications,1 much like pharmaceutical guidelines are currently. The QUDI Program has chosen to focus on producing guidelines on selected topics, while we, with our “Diagnostic Imaging Pathways”,2 have chosen to work towards a more comprehensive clinical decision support and educational application. Of course, the two approaches are entirely complementary. It also behoves radiologists, at an individual level, to interact with their referrers, to vet requests (ensuring that requests are appropriate and contain adequate clinical information, as emphasised by Kenny and colleagues) and act as the consultants they were trained to be. Sometimes this may be to their short-term economic detriment. However, one hopes that such short-term disadvantage would be countered in the longer term by greater professional satisfaction and a better relationship with referrers, who are likely to remain loyal to those radiologists on whom they can rely for advice and education in addition to trustworthy image interpretation.

Richard M Mendelson · Conor P J Murray

Their value in modern medical education needs to be reaffirmed Arguably the greatest claim to fame of the renowned English surgeon John Hunter was not his outstanding contribution to anatomy and surgery but the remarkable collection that now forms the Hunterian Museum in London.1 Hunter’s collection is testimony to his passion for science and his aptitude for self-directed enquiry, independent study and life-long learning. These attributes are now cherished cornerstones of modern medical education. Yet it is the adoption of these educational principles in modern medical curricula that is contributing to the demise of the time-honoured medical museum. No doubt Hunter would be saddened and dismayed at the plight that has befallen some of our wonderful collections of pathology specimens, medical and surgical artefacts and memorabilia. Most of these collections, which are housed in medical schools and teaching hospitals, were for a long time the exclusive province of medical students. Unfortunately, these repositories of medical history and the manifestations of disease are increasingly neglected, closed or under threat of closure.2 There are many reasons for this turn of events, including dramatic changes in medical education and medical practice over the past few decades, as well as financial problems common to all health care delivery systems. Medical museums (which include museums of pathology, anatomy and nursing) are perceived to be expensive facilities that do not have a well defined role in modern medical education and training. This is particularly so in graduate-entry medical courses and highly integrated courses, where it is often hard to identify the anatomy and pathology components of the curriculum sufficiently distinctly to be able to link them to museum-related study activities. Increasingly, medical students are sent to rural hospitals and practices remote from the central medical school (and museum) to gain clinical experience and encourage rural practice. In these environments, there is little opportunity to actually see “diseased tissue” as displayed in museums, or to pursue museum-related study activities. Reduced funding for medical education in a number of countries, including Australia,3 has diminished the survival prospects of medical museums. Additionally, the acquisition of new specimens, particularly specimens of human disease, has become a major problem. This is in part due to major advances in surgical techniques and the striking decline in the number of autopsies,4 so that acquisition of pathology specimens suitable for presentation and display has become near impossible. This has occurred in parallel with changes in the pattern of disease in developed societies, which have had an impact on the acquisition of specimens of infectious diseases (eg, tuberculosis, osteomyelitis and meningitis). Surgical specimens and donated bodies for anatomy dissection have been used by some medical schools to overcome the shortage of appropriate disease specimens. Unfortunately, changes to legislation on human tissue in various countries have made it so onerous and time-consuming to comply with the legislation that many pathology laboratories avoid retaining tissue.5 With the diminution in the museum’s traditional role in teaching medical students, museums that have survived and thrived have had to reinvent themselves. For example, the Museum of Human Disease at the University of New South Wales (UNSW), Sydney, has diversified its activities and no longer just provides specimens for use in tutorials and practical classes. Satellite museums have been established at the major teaching hospitals, so that students on secondment to remote teaching hospitals still have access to pathology specimens for study and for use in examinations. The museum at UNSW and several other university museums have also made their collections available online and/or in compact disk format. Students can now have the option of either visiting the museum or accessing its collection of specimens via the Internet. Several museums, such as those at the University of Western Australia, the University of Melbourne and UNSW, also have community education programs for high-school students and other interest groups. These have been enormously popular. For example, the Museum of Human Disease at UNSW now receives over 20 000 visits each year from high-school students. This has not only lifted the public profile of these museums and their medical schools, but has also provided additional funds to help support other museum activities. To survive in the increasingly difficult environment of medical education, it is important that museums become integrated into the new medical curricula. The value of pathology museums as a teaching resource should be recognised and emphasised. This is a particularly important issue, because some people see museums as a relic of the past that is dispensable. How can we promote the survival of these museums? Medical practitioners can help by supporting and promoting medical museums, as well as by doing volunteer work for, donating to and attending these wonderful repositories of our history. All those involved in medical education should stress the value of careful observation of disease and disease processes, on display in our museums, as a core learning activity. Fostering the public’s interest in disease by making medical museums more accessible will also contribute to the survival of this threatened species. Students and volunteers in the Museum of Human Disease, University of New South Wales.

Denis Wakefield MD, FRACP, FRCPA

Objective: Design, setting and participants: Prospective, consecutive series of 633 studies on 595 patients referred to a major teaching hospital for ventilation/perfusion (V/Q) scanning for suspected acute PE between September 2004 and November 2005. Ventilation scintigraphy was performed using technetium-99m Technegas, and V/Q results were interpreted in conjunction with Wells scores.Main outcome measures: Likelihood of PE for each Wells score interval; overall prevalence of PE.Results: The likelihood of PE for a given Wells score in our study was not significantly different from the likelihood in the original study by Wells et al. Scores of < 2 in our study were associated with a 4% risk of PE, scores between 2 and 6 with a 13% risk, and scores > 6 with a 67% risk. The overall prevalence of PE in our study was significantly less than that in the original study (9% v 16%; P < 0.01), attributable to a significantly larger proportion of our patients having scores of < 2 (66% v 40%; P < 0.0001).Conclusion: The Wells score remains a robust clinical tool for stratifying the likelihood of PE. Patients with Wells scores of > 2 warrant imaging assessment for PE, but for those with scores < 2, further imaging may be problematic.

Kenneth S K Yap MB BS, FRACP · Victor Kalff MB BS, FRACP, FACC · Alla Turlakow MB BS, FRACP · Michael J Kelly MB BS, FRACP