Diagnostic Imaging brings you daily coverage of SIIM 2021 virtual annual meeting.

SIIM 2021 Virtual Annual Meeting: May 24 - 27, 2021

Jodi Miller is Director, Market Development of FUJIFILM Sonosite

It can do a lot—in a lot of different settings. Perhaps that’s why clinicians and administrators have embraced point-of-care ultrasound (POCUS) ever since it arrived in clinical settings in the U.S. in the early 

A low-cost, pain-free, user-friendly modality, POCUS can be used at the bedside, in the ED, ICU, OR, and in the field. It allows users to quickly diagnose a host of conditions, and it can help with procedural guidance. Its many benefits cannot be denied. No doubt, POCUS is a multi-faceted tool—the Swiss army knife of healthcare— that is in high demand.

That said, it’s important to assess the strengths and limitations of the technology, and to evaluate the appropriate settings and best applications for POCUS. In addition to evaluating the pros and cons of POCUS, this article will also explore new and growing use cases for the modality. 

POCUS is a smart investment for most hospitals as it is portable, and can be shared among departments if necessary—making it a practical and affordable modality. Moreover, POCUS is lightweight, easy-to-use, and can be utilized in a wide array of applications and practices, such as emergency medicine, critical care, anesthesiology and orthopedics/sports medicine.

As we learned during the height of COVID-19, POCUS is easier to clean and disinfect than many of the major modalities. Moreover, because POCUS can be performed by physicians during rounds at the bedside of COVID-19 patients, it is a modality that can help minimize exposure of COVID-19 to hospital staff. 

While the technology presents many benefits, providers do need to be vigilant when assessing product capabilities. POCUS systems vary, and some have more advanced features and functions than others.

Reliability varies as well. With some POCUS systems the battery life could be limited, limiting usefulness at the point of care or in the field. That’s a problem for busy clinical teams, especially in an emergency setting.

While POCUS is utilized in many departments of a hospital, perhaps nowhere is it more prevalent than in the emergency department (ED).

Historically, EDs have been the fastest adopters of POCUS. A 

 team compared recent studies of POCUS use in the United States and estimated that POCUS availability in U.S. community EDs increased from 19% to 33% to 52% over a six-year period. 

It is interesting to note not just where POCUS is being used, but also how it is being used.

 update, the American College of Emergency Physicians identified 5 main areas of POCUS scope of practice in the emergency department setting. These include both cardiac and non-cardiac POCUS applications. The five areas include resuscitation, diagnosis, procedural guidance, signs/symptom evaluation, and therapeutic or monitoring indications. 

With five key uses in the ED alone, it is no wonder providers find POCUS to be a valuable tool and a worthwhile investment.

Beyond emergency medicine, other specialties that regularly utilize POCUS include anesthesiology, critical care and some musculoskeletal-based specialties. In resident programs, these physicians learn how to use ultrasound technology but also must understand when to choose POCUS versus another diagnostic tool. Residents are also trained in the proper documentation of POCUS procedures.

Finally, POCUS is seeing evolving use cases, and is starting to be more commonly used by anesthesiologists for diagnostic perioperative care.

, events such as pneumothorax, hypovolemia, cardiac dysfunction, pericardial and pleural effusions, gastric fullness, abdominal bleeding, and pulmonary edema are just a few of the scenarios that are omnipresent in the perioperative setting.

From a patient care standpoint, why should the skill set for bedside evaluation change simply because the patient entered the perioperative environment? Rather, POCUS can—and more and more, is—playing a key role in helping anesthesiologists to detect and evaluate the causes of these conditions.

Cardiac POCUS might help the user to identify severe aortic stenosis in a patient scheduled for urgent hip surgery with the detection of a new murmur. Or, pulmonary point-of-care ultrasound might allow one to differentiate obstructive airway disease versus congestive heart failure exacerbation in patients with both comorbidities and increasing oxygen requirements.

Simply put, the use of POCUS can guide anesthesiologists to more effectively determine which patients can be safely taken directly to the operating room and which need to be delayed for more extensive testing before surgery.

article by a practitioner at New York’s Hospital for Special Surgery,

 anesthesiologists also use POCUS to better assess why a patient may be unstable after surgery and more rapidly diagnose and manage those patients. The technology delivers helpful information about the baseline function of the heart and lungs before urgent or emergent surgery. This type of insight improves the anesthesiologists’ ability to manage patients in the critical time surrounding surgery.

Another interesting application of ultrasound is the use of the technology in pain management, which is often linked to staving off opioid addiction in certain patients.

According to the U.S. Centers for Disease Control, the amount of prescription opioids sold in the U.S. nearly quadrupled since 1999, yet there has not been an overall change in the amount of pain that Americans report. As a result, nearly 247,000 Americans lost their lives to overdoses from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—between 1999 and 2019.

To combat this problem, many providers have found an alternative. They use ultrasound technology to insert nerve blocks to specific sites of the body ahead of time—when and where pain relief is needed most to enable precise relief for patients suffering from acute pain, a safer alternative to prescribing opiates.

Finally, POCUS is emerging as a valuable technology when it comes to the diagnosis and treatment of critical care patients.

Perhaps at no time was this more evident that during the darkest days of the COVID-19 pandemic. Many providers relied on lung ultrasound to assess respiratory failure in COVID-19 patients. The fact is, the technology has been proven for this purpose for over a decade. In one 

 study, lung ultrasound at the bedside showed an accuracy of 90.5% in diagnosing the cause of acute respiratory failure in critically ill patients. 

Moreover, multi‐organ point‐of‐care ultrasound (POCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FOCUS) as a clinical adjunct played a significant role in the triaging, diagnosis and medical management of COVID‐19 patients. In fact, experts from 

 countries on 6 continents attest to this fact and suggest the use of ultrasound in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID‐19. 

While POCUS is clearly a powerful technology that benefits providers and patients, it requires a solid understanding of how and when to use it.

Unfortunately, unlike ED physicians, primary care doctors, physician assistants and some other new users of POCUS may not have credentialing criteria and guidelines while in medical training programs. Residency programs and health systems are starting to make POCUS education a top priority. Vendors can help, too, as a resource for training—with workshops, online resources, hands-on product training, and re-training when software upgrades occur.

Vendors should be a valuable resource for education and training, especially during a time of COVID and social distancing.

, Fujifilm Sonosite customers can explore richly-designed point-of-care ultrasound courses that include webinars, 3D videos, case studies, built-in testing, and reference materials. Sonosite Institute is entirely online—making it an ideal resource during the pandemic. What’s more, all educational materials are now available in English, Spanish, French, German, Japanese and Chinese.

Healthcare providers know that there is also a need for better credentialing processes. Credentialing is relevant to POCUS because the 

 passed a resolution in 1999 recommending that credentialing decisions be determined by specialty-specific guidelines. 

Different departments and/or different hospitals within one health system may have different credentialing processes. This presents the challenge of how to best credential POCUS users across the system. 

 feel it is best for providers to develop and implement a centralized POCUS process to ensure consistent credentialing, privileging, and competency across the entire health system. 

Here again, vendors can be of help if they offer a workflow solution that gives providers control over their POCUS education and credentialing. For example, with Fujifilm Sonosite’s Synchronicity, providers can design their own credentialing programs to help meet local and national standards and requirements. 

Demand for Better Workflow, Documentation and Data Archiving

One area where POCUS technology has growing needs is within data archiving, workflow and reporting. POCUS vendors that provide an IT solution can be instrumental in helping support customers with these developing needs.

Providers should seek out solutions that allow them to archive POCUS images in the PACS and in the patient’s electronic health record (EHR). Healthcare organizations should look to partner with a vendor that delivers an IT solution that helps POCUS users store and share images across the care continuum.

Moreover, POCUS can present some administrative challenges. For example, in fast-paced ED settings it can be hard to capture POCUS billing—often leaving the exam unbilled altogether.

Consistent POCUS clinical documentation is also needed to minimize billing errors, enforce compliance and make reporting faster and easier. Ultrasound systems that work in conjunction with a robust workflow solution help providers maximize financial return. For example, with a simplified reporting process that ensures all exams are compliant with billing requirements, providers capture all allowable revenue—helping to boost an organizations’ bottom line.

, can solve all of these problems—from secure archiving to proper billing to better reporting and communication.

It’s difficult to find another modality that can do so much for so many medical areas. Ultrasound has become an integral modality in emergency medicine in the U.S. in the last two decades and has established itself as the standard in the clinical evaluation of the emergency patient.

Today, many other specialties rely on POCUS. 

 estimates that on average a general practitioner’s office performs anywhere from 131 to 601 ultrasound examinations annually. And now, more than ever before, POCUS is evolving as an invaluable tool for anesthesiologists in perioperative care and in the diagnosis and treatment of critical care patients. 

As a non-invasive technology, POCUS has proven to be a safe, cost-effective, and powerful tool for diagnosis and for the guidance of interventional procedures within many clinical environments.

Most providers would likely agree that when it comes to utilizing POCUS, the benefits far outweigh the limitations. Moreover, many of those limitations —a need for better credentialing, enhanced workflow, and, most importantly, reliable technology—can be offset by working with a manufacturer who is as committed to service and support as they are to product quality. 

Articles

Known as the  "Swiss Army knife" of healthcare, point-of-care ultrasound—or POCUS—has come a long way. 

The Evolution of Point-of-Care Ultrasound

Case submitted by Runalaila I. Soofi, M.D., via 

What is your diagnosis on this CT of the neck? 

Image IQ Quiz: Odd Visualization on Neck CT

Over more than five years of follow-up, thin-walled unilocular thymic cysts, as initially defined by magnetic resonance imaging (MRI), never developed irregular wall thickening, mural nodularity or septations, according to a study recently published in 

. The cysts, however, did show mural calcification, along with change in size, computed tomography (CT) attenuation and MRI signal intensity over the same period.

“Our investigation highlights the intrinsic and longitudinal characteristics of unilocular thymic cysts that contribute to their misinterpretation as thymic neoplasms and lymphadenopathy at CT,” wrote Wariya Chintanapakdee, M.D., Chulalongkorn University in Bangkok, Thailand, and colleagues.

In this retrospective study, the researchers evaluated the imaging characteristics and longitudinal change of unilocular thymic cysts on CT and MRI over time. All chest MRI studies showing thymic cysts between July 2008 and December 2019 were included. If initial CT showed a thymic lesion, the patient was referred for MRI for characterization and the baseline MRI indicated a cystic lesion. 

The researchers evaluated 244 chest MRI studies in 140 patients with 142 unique cysts and 392 CT examinations. The median follow-up duration was 2.2 years, but a subcohort of 33 patients and 34 cysts underwent CT and/or MR imaging follow-up for more than five years. 

The results in the subcohort showed that unilocular thymic cysts can arise de novo, as did with one of 34 cysts. Additionally, volume changed in 91%, T1- weighted MRI signal intensity changed in 67% and CT attenuation changed in 43%. Further, 16% of cysts had or developed mural calcifications. In 98% of thymic cysts, wall enhancement was present at MRI, with a median wall thickness of two millimeters. The results of the full study cohort of 142 unilocular thymic cysts matched those of the subcohort.

The authors explained that fluctuation in thymic cyst characteristics over time may be due to chronic recurrent intralesional hemorrhage and subsequent resorption. “The variable CT attenuation, MRI signal characteristics, cyst wall thickness, occasional findings of T1 and/or T2 hypointensity of the thymic cyst wall, wall calcification and intracyst fluid levels that we found support this hypothesis,” the authors wrote.

Limitations to the study included the absence of pathologic proof of benignity in all but the two lesions that were resected and proven to represent thymic cysts.

“Awareness of the variable imaging characteristics and behavior of thymic cysts over time should help guide clinical management. In indeterminate cases, imaging surveillance or surgical resection may be appropriate to exclude malignancy,” the authors wrote.

Awareness of the variable imaging characteristics and behavior of thymic cysts over time should help guide clinical management. 

Unilocular Thymic Cysts May Rarely Undergo Malignant Transformation 

A 78-year-old patient presents with chest pain. Can you make the diagnosis?

Image IQ Quiz: 78-Year-Old With Chest Pain

I’m not a big “art” person. I know what I like, but I’m also very much aware of what I don’t. I’m unafraid to opine that a particular item just isn’t art in my eyes. Randomly splashing paint on a canvas, for instance, is unimpressive, whether done by me or some guy whose name demands adulation and millions of dollars for his mess.

And yet, some would argue, sufficient previous achievements in the art-world by that guy serve to put his slop on a level far beyond anything I could create—even if I just happened to create identical paint-splashes. Is it fair? No, but regular readers of this column will know what I think of that particular F-word.

Similarly, when Elon Musk says something that anybody else could (and, indeed, many have), rightly or wrongly it gets a lot of attention. Early this month, for instance, he tweeted “Time is the ultimate currency.” To date, that got well over 468,000 “likes,” 76,000 retweets, and 32,300-something comments.

Now, some of that was fueled by his involvement with cryptocurrency. When your mere words can make intangible things like Bitcoin and Dogecoin soar or plummet in value, people pay attention to those words. Maybe even hope to ride on your coat-tails to their own fame and fortune.

Nevertheless, quips like “time is money” are far from new. The actual phrase is credited to Benjamin Franklin, but a brief online search on the matter turned up Antiphon, a Greek orator who wrote “the most costly outlay is time” somewhere around 430 BC.

It’s surely older than that, because it seems like most people personally reach that conclusion sooner or later in their lives (whether or not they sum it up in a pithy way that gets others’ attention). You can spend your limited time to earn potentially-unlimited money…not so much the other way around.

Which is, really, one of the reasons you have to pay (or otherwise coerce) most people if you want them to work for you. You are “compensating” them for the time they’re spending on your behalf, time they might have preferred to use on other things.

There’s no small amount of mental gymnastics that goes on as people try to convince themselves and one another that arranging the time they spend working in certain ways will be better than others. Healthcare is no exception, and in radiology (especially telerad) we get particularly creative.

Most consider a “good” work schedule to be the inverse of when they’d like to be free to do other things. That is, they want to sleep at night, they want to have weekends and holidays off so they can see friends and family that have similar schedules, and they’d prefer not to have to wake too early or stay up too late. Presto: Monday through Friday, 9-5 is what a lot of people consider “normal.”

Some fields, like healthcare, make that a nigh-unobtainable Holy Grail. People get sick and injured 24-7, 365. So we find ways to cover those numerous other hours and days using rotating call-schedules, eniority schemes where folks work progressively less of the hours they dislike as time goes on, and shift-differentials, which pay better for less-desired times so people self-select to fill them.

As mentioned above, teleradiology has been particularly clever about all of this; once you stop depending on your workforce physically showing up, or indeed living in the area at all, your options greatly increase.

Firstly, when you’ve got a roster of hundreds of rads rather than a handful, there’s much more potential for redundancy and schedule overlap. Let’s say, for example, that 1 in 10 rads are willing to work purely nocturnally: If your radgroup is only 10 strong, that’s one guy you might have to cover all the nights. But if your group numbers 400, now there are 40 to provide coverage.

Second, when there’s a nation- (or world-) wide pool of remote telerads to draw from, the chances increase that just about any schedule you offer will have takers. Nobody local wants overnights? Somebody on the other side of the globe could cover those hours as daytime work. 7-on, 7-off nights? 7-on, 14-off? Weekends only? Name your scheme…or, alternatively, be receptive when telerads come out of the woodwork proposing things you haven’t thought of that might work for you.

Naysayers will turn up, too: In our social-media world, the “stop liking what I don’t like” crowd is far from shy about decrying the opinions and preferences of others. Want to work 9-5, M-F without nights or weekends? Expect others to call you things like “selfish” and “unrealistic,” even if you’ve already baked in the notion that this might lower your comp and exclude you from partnership tracks. Decided that 7-on, 7-off nights works for you? Be prepared for criticism that you are feeding the Evil Corporate Forces of teleradiology, and that you’ll be burned out in a couple of years.

The fact remains that only you can really know what working-schedule would best suit you…and that might change over time. My first job, working in a psych clinic during summers in college, had a 1-9pm routine. That was perfect for me; I could stay up late with friends every day after work, and then sleep in the next morning without consequence. Or I could go running at night after work was done, when it was cooler and there were fewer cars on the road.

But if you offered me those hours now? Ugh, no thanks. I’d never be able to have dinner at a normal hour with friends/fam, or indeed do much of anything with my evenings.

When I joined a corporate telerad in 2011, their 7-on, 7-off nocturnal schedule was fine for me: I lived alone, and had a million ideas about how I’d use the 26 weeks of time off each year. Fast-forward a few years, however, and I came to hate having half of my holidays and weekends spoken for. My current job, with comparatively-few weeks off per year but most weekends/holidays free, was a change I eagerly made.

For rads on the job-seeking end of things, I’d suggest regularly (re)visiting this subject in honest introspection. What schedule do you really want, versus what you can tolerate? How’s that likely to change in the visible future? Does the job you’re considering really suit you, now or in a couple of years? If you find yourself thinking, “I can put up with it because…” that’s a warning-sign.

And for would-be employers, it’s worth remembering that your scheduling needs don’t exist in a vacuum. The less flexible you’re willing to be in getting it filled, the fewer candidates you’ll have to choose from.

Work-life balance in healthcare? It's possible (really). 

Tempus Monetæ 

Ultra-high-resolution CT (UHR-CT) may be more accurate than 

 for evaluating coronary artery stenoses in severely calcified vessels, a new study suggests. 

, included 15 patients enrolled between November 2019 and May 2021, with an average age of 67 and a history of coronary artery disease who underwent UHR-CT within 30 days prior to cardiac catheterization.

“We believe our data show promise that ultra-high-resolution CT (UHR-CT) with 0.25 mm detector width can overcome a major limitation of coronary CT, i.e., the limited interpretation of the coronary artery lumen in the presence of severe calcification,” Armin A. Zadeh, MD, PhD, MPH, director of cardiac computed tomography and associate professor of medicine at Johns Hopkins University, told Diagnostic Imaging.

Among the 15 patients included in the study, 13 were men, nine had obesity and six were without stents and had average calcium scores of 1,205. There were 20 prior stents placed among eight participants.

UHR-CT studies were acquired using prospective scan triggering using a 70%–99% exposure window for all but one participant, who had a mode switch to full R-R imaging due to a premature ectopic beat.

Click to Read More of the Latest Research on CT

Image noise was significantly greater with UHR-CT compared with conventional CT (50.9 ± 7.8 [standard deviation] versus 19.5 ± 8.3, P < .01), resulting in lower signal-to-noise and contrast-to-noise ratios. Still, UHR-CT had high diagnostic confidence scores (4.3 ± 0.9). 

Sensitivity and specificity for UHR-CT versus invasive angiography were 86% (19 of 22) and 88% (56 of 64), respectively (95% CI: 65%, 97% and 77%, 95%, respectively).

“Our initial experience with this technology suggests that UHR-CT yields better diagnostic performance than conventional CT in this challenging population,” Zadeh said.

Previous research using 64 detectors CT has shown that patients with severely calcified coronary artery disease, including calcium scores of 600 or higher the presence of stents, had much lower test specificity (56% and 57%). The study authors suggested that at least one-third of patients referred for invasive coronary angiography would benefit from UHR-CT based on high calcium scores or prior stent placement.

“Providers may be interested in knowing about this technology for cases with high coronary calcium scores or coronary stents,” Zadeh said.

The study was limited by an eight-month delay in enrolling participants due to the COVID-19 pandemic. Other limitations included that it was a single-center study that lacked a dedicated core laboratory assessment, data on conventional image reconstruction represented a simulation of images and the analysis did not include advanced noise reduction algorithms.

“We will continue our study and will provide more detailed data at its conclusion,” Zadeh said.

By decreasing the size of the detector element, UHR-CT quadruples resolution compared with conventional models, Sujata M. Shanbhag, MD, MPH, staff cardiologist and Marcus Y. Chen, MD, director of cardiovascular CT at the National Heart, Lung and Blood Institute of the National Institutes of Health wrote in a 

They noted the limitations of coronary CT angiography in patients with advanced cardiovascular disease, with visualization impaired by blooming artifacts, beam hardening and partial volume effects from dense calcification and stent struts, and called the UHR-CT study “an important step in actualizing the potential impact of advanced spatial resolution and its application to a patient population with advanced CAD.”

Patients suspected of having coronary stenoses may benefit from ultra-high-resolution CT, according to a recent study that showed high diagnostic confidence in severely calcified coronary atherosclerotic disease.

Ultra-High-Resolution CT May Overcome Limitations in Evaluating Coronary Artery Stenoses

Understanding the potential for breast cancer in transgender women can help health care providers recommend appropriate screening, get a timely diagnosis, and reduce health care disparities among this vulnerable population, a recent review concluded.

, examined common breast imaging findings in transgender women, recent data on the association between feminizing hormone therapy and breast cancer, and guidelines for breast cancer screening.

“Transgender women commonly use hormone therapy. Although data are limited, there is growing evidence that hormone therapy increases the risk of developing breast cancer compared to cisgender men,” authors Lauren Green, M.D., assistant professor of clinical radiology, and Thomas Lienhoop, M.D., diagnostic radiology resident of the University of Illinois told Diagnostic Imaging.

The study called for development of consistent screening guidelines for transgender women, along with increased awareness of the relevant imaging features and special health care needs to improve care and reduce disparities.

“We were surprised to find there were several conflicting guidelines for breast cancer screening in transgender women, likely because these guidelines are based on expert opinion informed by limited data,” Green and Lienhoop said.

RELATED: 6 Steps to Better Imaging for Transgender Patients

Limitations of existing data include small sample sizes, short duration of follow-up and variable dose and duration of hormone therapy.

The American College of Radiology and the Society of Breast Imaging published 

 in June, to address the heightened risk for transgender women and other minorities.

The review noted a variety of hormone therapies that many transgender women continue for life, facilitating breast development and other physical changes such as body fat redistribution, decreased muscle mass, and decreased terminal hair growth.

The review highlighted eight case reports of fibroadenoma in transgender women, suggesting that these benign breast tumors might be more common in transgender women than in cisgender men because of hormone use and breast development.

While breast cancer among transgender women is rare, the review noted multiple case reports. The most commonly reported cancer is invasive ductal carcinoma. Conditions with elevated estrogen levels have been associated with increased risk for breast cancer in cisgender men. Studies finding an increased risk for breast cancer in women taking estrogen for five or more years suggest transgender women taking feminizing hormone therapy also may be at increased risk for breast cancer after four or five years.

Breast augmentation surgery is common among transgender women and should be taken into consideration for imaging, which could include implant-displaced views and screening for silicone implant rupture. The review also noted four published cases of breast implant-associated anaplastic large cell lymphoma among transgender women.

“More research with large cohorts and long-term follow-up is needed to characterize the nature of breast cancer and risk of hormone therapy in transgender women,” Green and Lienhoop said. “Because breast cancer is relatively rare in this group, further research may benefit from a centralized database or multicenter trials compiling populations.”

Health care providers also should consider health care disparities faced by transgender women related to stigma, discrimination and lack of access.

“Providers can help address disparities by ensuring their practices are safe and inclusive and by familiarizing themselves with the specific health care needs of this group,” Green and Lienhoop said.

Previous studies have highlighted a need to improve transgender women’s access to competent and compassionate care.

 in the American Journal of Radiology found that nearly three-quarters of transgender and non-binary patients reported at least one negative encounter with imaging services.

A team of experts led by Hannah Perry, M.D., a diagnostic radiologist with the University of Vermont Medical Center, recently published six steps to help radiologists provide the best care possible to this group, including making the office welcoming, asking about pronouns, creating gender-neutral spaces and a comfortable exam environment, improving radiology education and implementing sensitivity.

Feminizing hormone therapy may increase the risk of breast cancer in transgender women, a growing body of research suggests, underscoring a need for health care providers to understand the risks, breast imaging features, and health care needs of this demographic.

Understanding Breast Imaging Features of Transgender Women Is Key to Improving Care

The Pelvic Floor Disorders Consortium (PFDC) has published consensus definitions and interpretation templates for 

The report was published simultaneously in four specialty journals: 

Female Pelvic Medicine and Reconstructive Surgery Journal

“The report provides a framework for pelvic floor experts in multiple disciplines to understand how a patient needs to prepare for a pelvic floor MRI and what to expect,” lead author Brooke Gurland, MD, colorectal surgeon and clinical professor of surgery at Stanford Pelvic Health Center told Diagnostic Imaging. “The report provides explanation as to what is being measured and why and the level of agreement between specialists.”

It is endorsed by the American Society of Colon and Rectal Surgeons, Society of Abdominal Radiology, International Continence Society, American Urogynecologic Society, International Urogynecological Association, and Society of Gynecologic Surgeons.

The PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders included 24 experts from around the world representing a wide range of relevant clinical specialties, including colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists and physiotherapists. It was established to support collaboration among the specialties, evaluate educational programs, create clinical guidelines and algorithms, and promote high quality care.

The specialists involved in the creation of the report bring unique perspectives and approaches to their work diagnosing and managing patients with pelvic floor conditions. They participated in preliminary working group phone calls and worked in pairs including a radiologist and a clinical specialist researching published literature on assigned relevant topics and points of controversy. Their collective preliminary report was presented at the Pelvic Floor Consortium Expert Meeting on June 2, 2019, in Cleveland, Ohio. Participants voted to establish consensus and additional research was conducted to address questions before proposed recommendations were advanced for review, editing and final approval.

“The committee members who participated were all volunteers working after hours in addition to regular jobs,” Gurland said. “Volunteers were in different time zones and countries. Finding time for committee meetings and then working on the manuscripts requires hours of extra work. I am always amazed for the dedication of my colleagues to improve patient care.”

Their efforts created a universal set of recommendations and language for technique, interpretation and reporting of magnetic resonance defecography (MRD), which uses magnetic resonance imaging during defecation to evaluate rectal function. MRD provides detailed information to understand the cause of incontinence, constipation and pelvic organ prolapse. It includes multicompartment visualization with high contrast resolution allowing for the evaluation of three pelvic floor compartments during defecation.

The working group brought multidisciplinary input to efforts to standardize MRD technique, which has been limited by differences in nomenclature and reporting across subspecialties along with different definitions of conditions and thresholds for grading severity, which have hindered effective communication among clinicians.

The templates and techniques provided by the report serve as the minimum requirements for MRD, and clinicians can add specific patient indications, provider preferences and local practice patterns to their assessments.

“This provides them with a framework for MRI reporting so we have a common language and expectations as to the baseline information to include in the report,” Gurland said.

The report covers general considerations such as patient positioning, contrast medium considerations, and technique and reporting/grading of relevant pathology and includes the degree of consensus for each recommendation. The report stresses the importance of patient education to ensure cooperation. It includes images and detailed descriptions and recommendations for identifying and grading abnormalities such as dyssynergia, rectocele, intussusception, and rectal prolapse.

“Next steps include validating posterior compartment findings with clinical findings for improving diagnostic accuracy,” Gurland said.

The report provides a universal set of recommendations and language for technique, interpretation and reporting of magnetic resonance defecography and is endorsed by six medical societies.

Multidisciplinary Group Publishes Recommendations for Magnetic Resonance Defecography

34-Year-Old with Fibrous Dysplasia, Femur Pain and Possible Pathologic Fracture

Case: A 34-year-old patient presents with fibrous dysplasia, right femur pain and a possible pathologic fracture.

Mazabraud syndrome is a polyostotic form of FD with extraskeletal soft tissue myxomas 

Maffucci syndrome is a polyostotic form of FD

McCune-Albright syndrome consists of polyostotic FD with endocrinopathies and café-au-lait spots

Cherubism consists of fibro-osseous jaw lesions, but are genetically distinct from FD

A 34-year-old patient presents with right femur pain with a possible pathologic fracture and fibrous dysplasia. 

Image IQ Quiz: Patient Presents with Fibrous Dysplasia, Right Femur Pain

A couple of weeks ago, my lady and I attended a “food truck festival” event on the grounds of a nearby shopping-outlet. No idea how many years this thing had been going on, but the organizers hadn’t learned very much in the process. All of the logistics that could matter were poorly executed, if addressed at all.

That included parking. There’s no shortage of space on all sides of the outlets, which want to have capacity for as many shopping-visitors as possible. Driving into the place, however, there wasn’t a single sign to direct attendees to the side where the event was. Further, each parking area was set up so there would be one, maybe two ways in/out for hundreds of parking-spots.

So, once a visitor had enough of the event and decided to leave, s/he’d discover that extracting a vehicle from the place was a nightmare, because there was already a traffic-jam of other vehicles trying to do the same thing…and good luck getting any of those frustrated people to hang back and let you ahead of them in line towards the exit. There was also no telling where the lineup began. Lots of people couldn’t even back their cars out of their spots.

On the way towards our car, we encountered another would-be departee who’d been staffing a solar-panels booth at the event. Their purpose was to talk up the technology and enlist people for a home-visit, estimate, etc. One of those “you pay nothing and your electricity bills will drop” affairs that you’ve probably heard of.

I’d looked into it years ago and found that, at least in my case, I would most definitely be paying…enough that they offered me financing. Due to details of my particular house, power usage, etc., not a good deal at all. I knew it would be a waste of everybody’s time to talk with the solar-panel gal, and was more interested in getting to my vehicle so we could get on with the interminable wait to escape…

…but my lady engaged her in conversation, so I went along and didn’t mar the pleasantries by telling the gal she was barking up the wrong tree. Turned out she had the same first name as my lady’s younger sister, and I forget what other commonalities. A few minutes later, we proceeded on our way.

Not long after, we’d gotten in position to try breaking into the line of cars leading towards the exit…and lo and behold, the car situated to take pity on us and let us in was driven by the solar panel gal. We gave her big ol’ grins and a wave, and she had no real excuse not to let us go. Escape-time and stress were thus drastically reduced for us.

Had we not taken the time to be friendly and maybe let her think she was wooing customers, we would just have been other faces in the crowd, and there would have been no reason for her to let us in. Unbeknownst to us at the time, our chatting with her was an investment that yielded dividends in our quest to escape the parking-lot.

Rare as it is for the turnaround on such an investment to be so quick, I’ve found it to be a not-uncommon phenomenon: Be good to people, do nice things, and you might just find yourself rewarded for it down the line.

Phrased another way by an erstwhile residency-mate, consoling a peer about some downturn in the job-market or other negative forecast on future professional success: If you’ve put in the time and effort, sooner or later you’ll have something coming back to you.

It takes a little leap of faith to make this work. What you don’t want to do is keep careful tabs on who you did what favor for, how and when you expect them to repay you, etc. Not only does that greatly increase the effort you’re investing, it will make you very aware of—and possibly bitter about—all of the times you don’t see yourself repaid. Plus, other people pick up on that very quickly and come to know that any favor from you comes with strings attached.

Instead, think of it more as “casting your bread on the waters.” You don’t know how, when, or if you’ll see dividends…and you might not even recognize them when they come your way. They might simply seem to be pennies from heaven.

Freely give of your time to other rads in your group for curbside consultations. Help techs out when they have logistical issues. Be generous with advice and feedback to other rads, even med students earlier in their careers than you who are seeking guidance. One of them might someday be in a position to help you.

Maybe payback won’t come directly from them to you. Perhaps the rad you assist at no direct benefit to yourself will be inspired to follow your example, and help others. The circle of “paying it forward” could eventually come back to you, and you’d never know that you got it started.

Or maybe nothing specific is ever done that “pays you back.” Maybe the goodwill you generate just serves to boost your overall likability and value in the eyes of others. A boost that permanently improves your relations with them (and any witnesses to your socially-giving nature). Maybe that, in turn, pays dividends now and then…or maybe it just makes them that much nicer for you to be around in the future.

I’ve written previously in this column of the concept of “reciprocity.” We social animals are hard-wired to give back when we perceive we’ve been given to…and expect the same from others. If we can emphasize the former…even start the cycle by being the first to give…and not worry so much about the latter, it has the potential to create a positive-feedback loop that does nice things for us when we least expect them.

Follow Editorial Board member Eric Postal M.D., on Twitter:

If you’ve put in the time and effort, sooner or later you’ll have something coming back to you.

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