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Δευτέρα, 23 Απριλίου 2018

Radiology and Errors

In the days of active consumerism , reducing credibility of  medical profession and  informed decision making , it is vital to   understand the  scenario, and act accordingly (instead of the usual  , I  am very good  and do not make mistakes,  while others less knowledgeable  than me,  make all the mistakes  !). An excellent write up submitted by Dr MGK Murthy, Sr Consultant Radiologist


A mistake is  a mistake.(  neither it is mine (make me guilty!)  nor yours (makes me arrogant!), and  it need not be owned.

"I would give great praise to the physician whose mistakes are small, for perfect accuracy is seldom to be seen. "Hippocrates 

"Errors in judgement  must occur in the practice of an art  which consists largely in balancing the probabilities "  Sir William Osler ( considered Father of modern medicine , 1849-1919)

From a practical point of view  once an abnormality has been pointed out  and a lay person can see it , it is not easy to convince that  a Radiologist  who is trained for the job and paid  for seeing it , should be exonerated for missing it.

  1. In all branches of medicine , there is an  inevitable element of patient exposure  to problems arising from human error ,and this is increasingly subject of bad publicity , often skewed towards an assumption that perfection is achievable , and any error or discrepancy represents wrong and must be punished!

Unfortunately the public (and hence the   executive &judiciary) frequently expects a medical investigation will produce "the correct answer" all the time .

  1. Radiology involves decision making under conditions of uncertainty , and therefore can not  always produce  infallible interpretations of reports . Interpretation of human picture (radiology in essence) is not a  binary process ; the answer is not always  normal or abnormal , cancer or not etc

         Final report is  often influenced by many variables  , not least among them , available clinical/ other information  at the time of reporting .

  1. With respect to radiology investigations , the use of the word  "error" is often unsuitable .It is more appropriate to  concentrate on "discrepancies " between a report and a retrospective review of a film or outcome .

  1. "Opinion" may be defined as " a conclusion  arrived at,  after some  weighing of evidence , but open to debate or suggestion" and hence radiology reports are not expected to be incontrovertible

       Somewhere between  clear cut errors and the inevitable difference of opinion in interpretation of a picture , is an arbitrary division defining the limit of  professional acceptability .

  1. Approximately about 1 billion radiological  investigations are carried  out across the globe annually, and  literature quoted ,average error rate of 4% (across all modalities ,  though range is 2-20%  in a large 20 year review study)is considered as acceptable , making an appx 40 million radiological investigations suspect  for their utility.

          A large study at  MGH, Boston ( 2010 ) suggested   after  a double blinded study (of abdominal CT scans)   an inter observer  difference of appx 26%(between two different  similarly trained Radiologists  )  and(ironically! )intra observer (same person reading the same pictures at different times ) rate higher  at 30%. We can safely say hence "we  differ more with ourselves than with others!

          Another  recent  global  study has revised the figure of  "real time"   error rate in day to day  radiological practice averaging at 3-5%.

  1. The factors for the discrepancies  are many including  the time of viewing the  film (4 secs is considered as  optimal for Chest x ray viewing and any prolongation (visual dwell )  would lead to higher false +ve or -ves/ system related  parameters including  acquisition parameters / Technique used OR  available data at the time  / work load of the day / mental frame of the Radiologist / Viewing  conditions  etc etc

  1. Common experience  in radiology suggests  that many errors are of little or no significance to the patient and some significant errors  remain  undiscovered

  1. Perfection =  An  imaginary state or quality  distinguished from the actual by an element of known as excellence , an attribute  of the critic .

        Legal basis for negligence  involves a breach of standard of care , which is usually defined as "care exercised by an average physician  of similar knowledge , skill  and ability under similar conditions"

  1. In conclusion, there is an absolutely  unavoidable human factor at work in review of films/ images  ; some abnormalities ( even obvious ones ) would be missed ; the mere fact that  a Radiologist  misses an abnormality, does not constitute malpractice ; and also  not all radiographic misses are excusable ;

              Therefore the focus of attention  should be on  issues   such as Proof of competence , habits of practice, and use of proper   techniques. A few simple steps  would mostly reduce , if not eliminate the so called errors or discrepancies. 

  1. Train  technician to  obtain adequate  history / clinical data ,  and  make him /her  the preliminary reader of the images with ref to the   clinical question(you may or may not agree with the  opinion, at least   it can  facilitate your  second look at his region of interest ). I have immensely benefitted from such interactions  (if one is blessed  to have PGs , they suit the role brilliantly)

  1. Start your report with the clinical question and why is the investigation ordered

  1. Answer the findings in relation to the question ,+vely or -vely in the very  first paragraph  itself

  1. Do not use diagnostic terms in the findings (for eg : glioblastoma/ cancer etc). Instead use only anatomical descriptions .

  1. Impression/ conclusion should bring  abbreviated  highlights of +ve findings in relation  to the clinical question  and a suitable confirmatory or exclusive investigation (preferably radiological) should be offered (with the words as would help to give legal  leverage  to the clinician/ patient  to act  appropriately)

  1. Rest of the study shows …. Should be next conclusion (brief … and not copy paste the Findings ) , with a similar suitable advice of other investigations if necessary.  Conclusion should use diagnostic terms /  reflect  one opinion about disease and not  an echogenic  …. Etc  . one can take the help of , could rep…. in view of …… etc

  1. Comparison with old  images should follow ,  expressing various components  including the effect of therapy/ progression of  the disease  findings etc

  1. Always proof read your report with the help of your data entry operators( who would even confirm that you have reported the correct patient , i.e. images and report belong to the same individual/ investigation done is  what the clinician ordered  etc)

  1. Do not try to  make report as if one has studied the tissue  and not a picture ! Murphys law states  "if something can go wrong , it WILL go wrong)

  1. Spend  a few minutes summarizing your days work before departure, rather than  feeling  sorry at a later stage ( a bit  of unpaid  time at work can keep our dopamine/ serotonin/ oxytocin levels(happy guys)  high enough to feel contended)
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Corrigendum to “Clinical and pathological analyses of tuberculosis in the oral cavity: report of 11 cases” [Oral Surgery oral medicine oral pathology oral radiology 2018;125: 44-51]

It is very nice to see the reprint version of our paper titled "clinical and pathological analyses of tuberculosis in the oral cavity: report of 11 cases" published in Oral Surgery Oral Medicine Oral Pathology Oral Radiology (2018;125: 44-51). Unfortunately, an important statement of "Wu-tong Ju and Yong Fu contributed equally to this paper" is missing in the reprint version, which was presented in our manuscript and the proof. Although the sequence of author list is correct, the statement should be added in the reprint version of paper because Yong Fu and Wu-tong Ju contributed equally to this paper.

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A novel voxel based homogeneity index: Rationale and clinical implications for whole-brain radiation therapy

A homogeneity index (HI) measures the uniformity of a dose distribution within a given target volume. Traditional HIs only use a limited number of dose–volume histogram data-points for calculation. A voxel-based homogeneity index (VHI) is proposed which utilizes the entire information of the three-dimensional dose distribution. We compared the VHI with existing HIs and analyzed if VHI results were associated with treatment outcomes in patients who underwent therapeutic WBRT.

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Knowledge transfer for surgical activity prediction



Lack of annotated training data hinders automatic recognition and prediction of surgical activities necessary for situation-aware operating rooms. We propose using knowledge transfer to compensate for data deficit and improve prediction.


We used two approaches to extract and transfer surgical process knowledge. First, we encoded semantic information about surgical terms using word embedding. Secondly, we passed knowledge between different clinical datasets of neurosurgical procedures using transfer learning.


The combination of two methods provided 22% improvement of activity prediction. We also made several pertinent observations about surgical practices based on the results of the performed transfer.


Word embedding boosts learning process. Transfer learning was shown to be more effective than a simple combination of data, especially for less similar procedures.

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Role of interventional radiology in the management of musculoskeletal soft-tissue lesions


The lesions of the soft tissues are rare and extremely heterogeneous; even if the surgical treatment is usually the standard therapy, the role of the interventional radiology (IR) in this field is growing up for multiple reasons. First, because the imaging alone usually is not able to ensure a definitive diagnosis, IR has a basic role in the staging: the percutaneous biopsy is infact an irreplaceable step. Moreover, biopsy is necessary not only for histologic evaluations but also for the biochemical and molecular studies. Furthermore, the proved safety and effectiveness of IR in a multiple oncologial applications prompt a wider use also in this field.

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Relationship between interstitial lung disease and oesophageal dilatation on chest high-resolution computed tomography in patients with systemic sclerosis: a cross-sectional study



Oesophageal dilatation (OD) has been implicated in the pathogenesis of interstitial lung disease (ILD) in systemic sclerosis (SSc). The aims of this study were to explore the association of the OD and SSc-ILD on chest high-resolution computed tomography (HRCT), and to establish a cutoff point for the OD suggestive for the presence of a significant lung involvement.


The widest oesophageal diameter (WOD) was obtained on axial HRCT images. The parenchymal abnormalities on HRCT were coded and scored according to Warrick method. Patient-centred measures, pulmonary function tests and the single breath carbon monoxide diffusing capacity of the lung (DLco) were also obtained. Multivariate regression analysis was performed to identify factors associated with oesophageal diameter.


126 subjects with SSc were included. The mean (± SD) WOD was 13.5 (± 4.2) mm, and in 76 (60.3%) participants WOD was ≥ 11 mm. SSc patients with ILD had larger oesophageal diameters than those without lung disease (19.4 vs. 14.1 mm, p < 0.001). We observed a high correlation between WOD and gastro-oesophageal reflux disease questionnaire (GerdQ) (r = 0.886, p < 0.001), Borg score (r = 0.705, p < 0.001), and Warrick score (r = 0.614, p < 0.001). WOD negatively correlated with DLco (r = − 0.508, p < 0.001). Multivariate analysis demonstrated positive associations between WOD and GerdQ (p < 0.0001), Borg score (p < 0.0005), and total Warrick score (p = 0.019).


An increased oesophageal diameter (> 11 mm) on chest HRCT is associated with pulmonary and oesophageal symptoms, more severe ILD, and lower DLco.

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Could 68-Ga PSMA PET/CT become a new tool in the decision-making strategy of prostate cancer patients with biochemical recurrence of PSA after radical prostatectomy? A preliminary, monocentric series



To evaluate the impact of gallium68 PSMA-11 (HBED-CC)-PET/CT on decision-making strategy of patients with relapsing prostate cancer (PC) presenting a second biochemical relapse after radical prostatectomy (RP) and salvage RT or salvage androgen deprivation therapy (ADT).

Materials and methods

40 patients were retrospectively analyzed. All of them had received prostatectomy. Thirteen out of 40 were addressed to gallium68 PSMA-11 (HBED-CC)-PET/CT for a biochemical relapse after RP, 14/40 after a salvage RT and 13/40 after salvage or adjuvant ADT. The PSA level ranged between 0.1 and 1.62 ng/ml (median value: 0.51 ng/ml). We studied the impact on the decision-making process of a multidisciplinary tumor board of additional data obtained from gallium68 PSMA-11 (HBED-CC)-PET/CT.


Thirty-one out of 40 evaluated patients showed positive findings at gallium68 PSMA-11 (HBED-CC)-PET/CT (77.5%). Of them, five were positive in the prostatic bed, nine in the pelvic nodes, twelve in nodes outside the pelvis and eight at bone level. Nine patients presented two different sites of relapse (22.5%). Gallium68 PSMA-11 (HBED-CC)-PET/CT data changed the therapeutic approach in 28 patients (70%).


Gallium68 PSMA-11 (HBED-CC)-PET/CT can be a useful tool in the restaging of post-RP, RT or ADT patients presenting biochemical relapse of PC and it could change the decision-making process in up of 70% of these patients. Prospective, larger series are needed to establish the correct role of this very promising tool in the staging and therapeutic approach of PC patients.

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Effective deep learning training for single-image super-resolution in endomicroscopy exploiting video-registration-based reconstruction



Probe-based confocal laser endomicroscopy (pCLE) is a recent imaging modality that allows performing in vivo optical biopsies. The design of pCLE hardware, and its reliance on an optical fibre bundle, fundamentally limits the image quality with a few tens of thousands fibres, each acting as the equivalent of a single-pixel detector, assembled into a single fibre bundle. Video registration techniques can be used to estimate high-resolution (HR) images by exploiting the temporal information contained in a sequence of low-resolution (LR) images. However, the alignment of LR frames, required for the fusion, is computationally demanding and prone to artefacts.


In this work, we propose a novel synthetic data generation approach to train exemplar-based Deep Neural Networks (DNNs). HR pCLE images with enhanced quality are recovered by the models trained on pairs of estimated HR images (generated by the video registration algorithm) and realistic synthetic LR images. Performance of three different state-of-the-art DNNs techniques were analysed on a Smart Atlas database of 8806 images from 238 pCLE video sequences. The results were validated through an extensive image quality assessment that takes into account different quality scores, including a Mean Opinion Score (MOS).


Results indicate that the proposed solution produces an effective improvement in the quality of the obtained reconstructed image.


The proposed training strategy and associated DNNs allows us to perform convincing super-resolution of pCLE images.

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Approach to 1st Year in Radiology Residency

Sharing a short video to welcome and orient Post graduates who have opted for Radiology this year through NEETPG in India.

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