Radiopaedia Blog: Radiopaedia

UPDATE 9 April 2021: New version of plugin released! Please remove old plugin and install the new one to solve security issue preventing plugin loading and to use updated API.  

Features

• quick upload of DICOM cases from Mac to Radiopaedia
• create a draft case or add to an existing case
• add multiple studies, series and images at once
• high image quality with scrollable stacks
• automatic anonymisation
• automatic gender and age
• optional day numbering for multi-study cases

Requirements

• Mac running Horos or Osirix DICOM viewers
• latest versions of these viewers require OS X
• plugin may work with older versions

We recommend Horos (free) rather than Osirix Lite (free) to avoid "NOT FOR MEDICAL USE" appearing on images.

Installation

• open Horos or Osirix on your Mac (don't have both open) 
• download and unzip the Radiopaedia plugin
• open plugin file using Finder
• click OK to confirm you want to install the plugin
• close Horos (or Osirix) and then open it again
• plugin is now ready for use 

Image Preparation

Before using the plugin for a case it is worth considering if any of the DICOM image series could be quickly improved (eg. cropped, windowed, excess images trimmed) prior to upload. This can be achieved as follows (or see video above):

• open the series you wish to edit in the case viewer
• apply your W/L, pan, zoom, rotation, shutter etc. changes
• for ultrasound it is important to remove identifying text using the shutter
• if you want only some but not all images then use Command ⌘ K to select key images
• click FILE > EXPORT > EXPORT TO DICOM FILES or shortcut Command ⌘ E
• select 'all images of the series' or 'ROIs and key images only' depending on your desire
• if using all images then the sliders can be used to trim excess images from the beginning or end
• enter a 'series name'
• click OK

Your new series will now appear as an extra series within the original study and is ready to be used by the Radiopaedia plugin.

Using the Plugin

• navigate to database view
• highlight the studies or individual study series you want to upload
  • highlighting the patient's name will upload the complete study
  • highlighting an individual series will upload just that component of the study
  • hold down Command ⌘ to select multiple series (eg. PA, axial T2) from within multiple studies (eg. x-ray, MRI) to control what you wish to upload
  • the plugin will automatically place the studies in chronological order irrespective of the order in which they appear in your database view
• click PLUGINS > DATABASE > RADIOPAEDIA to launch plugin
• a small delay may occur as the plugin analyzes your selection

Adding to an existing case

To add your selected images to an existing Radiopaedia case (public, unlisted or draft) simply enter the case rID number into the top of the plugin screen and click UPLOAD. You can find the rID for any Radiopaedia case by expanding the 'case information' box in the case sidebar.

Creating a new draft case

• enter a case title (eg. Glioblastoma)
• select a body system from the drop-down menu
• patient's age at the time of the first study and gender will automatically appear (if known)
• adding presentation and discussion text can help save time later but is optional
• tick the add series titles option if the study has multiple series that are difficult to remember
• tick the add day numbering option if the case consists of multiple studies separated in time
• click UPLOAD to send the case to Radiopaedia

IMPORTANT: During case upload you can continue to use Horos / Osirix but you should not try to upload another case until the current one is completed otherwise this will terminate your upload. For an advanced workaround, see the Tips and Tricks section below.    

Authorizing the plugin 

The first time you upload you will be asked to log in to your Radiopaedia account and authorize the plugin. You'll need to create a free Radiopaedia account if you do not already have one. The plugin will remain logged in for all future uploads unless you click 'logout'.

Reviewing your uploaded case

• on successful upload the case URL will be displayed
• click the URL to open it in your web browser and log in
• check to make sure the case is as you intended
• edit the case to add study findings, planes, phases, quiz questions etc. 
• publish the case (public or unlisted) to share it and use it in playlists

Draft case limits

Radiopaedia is all about sharing cases for educational purposes and therefore we encourage users to make their cases public. All users can have unlimited numbers of public cases and can publish their draft cases at any time. We recognize that some users may which to keep their cases private and therefore we offer unlisted cases for this purpose. Limits exists for the number of draft and unlisted cases you can have at any time as follows:

• standard user: max 10 draft cases, max 10 unlisted cases
• Hounsfield supporter: max 50 draft cases, max 100 unlisted cases
• Curie or Roentgen supporter: max 100 draft cases, max 500 unlisted cases
• Become a Radiopaedia Supporter

Tips & Tricks

• hold down Command ⌘ to select as many relevant series as you like from as many studies as you like (eg. x-ray, CT, MRI) to ensure your case is detailed but efficient
• if uploading a study with many series sequences or phases that are difficult to remember then use the add series titles feature to assist you
• if uploading a study with multiple studies separated in time then use the add day numbering feature to help you know the timeline
• consider storing the rID for successfully uploaded cases into your database comment field (or add the cases to an album) to keep track of those you have uploaded

Splitting a single study into two

Sometimes a single DICOM study may contain multiple series that are best divided into two studies on Radiopaedia. For example, you may wish to separate the non-contrast and contrast enhanced components of a single CT Brain study into two studies. There are several ways to do this (including on Radiopaedia itself) but with the plugin you can achieve this by highlighting the non-contrast series to upload that as a new case. Then copy the rID number of that new case, highlight the contrast enhanced series and upload that to the existing case.    

Simultaneous case uploads

If you are keen to upload multiple cases at the same time (not supported directly by the current plugin), then you can do this using Terminal to open multiple instances of Horos / Osirix by typing the command: open -n -a "APPLICATION NAME"

Feedback & Updates

If you have any feedback about the plugin you can add a comment below this post, or alternatively contact Dr Andrew Dixon via his profile page or via twitter. The download link on this page automatically updates with the latest version of the plugin. 

The code for this plugin is open source on GitHub and can be accessed here. Feel free to build upon it and let us know if you come up with any improvements that we should add.  

Plugin by Jarrel Seah, Jennifer Tang and Andrew Dixon

A recent article by Caleb Garling from the San Francisco Chronicle about Radiopaedia.org raised a few interesting questions, and it made me sit back and think about what exactly Radiopaedia.org is about, along with some of the areas we we will be focusing on in the coming years.

Radiopaedia.org started with a dual purpose. The first is to create a platform to enable radiologists from all over the world to share their cases and their collective expertise. The second is to create a resource available to all health professionals independent of their personal, institutional or regional wealth.

Almost a decade into this project we have come a very long way in achieving a degree of success on both fronts.

We have created a bespoke web app which can display radiology cases on any modern browser in a way that is intuitive to most radiologists, and have amassed almost 15,000 cases covering an enormous variety of conditions. Thousands of contributors have also collaborated in writing over 6,500 articles and slowly we are getting to the point that most conditions have at least some content, and in very many instances the articles are comprehensive with many illustrative cases. We have done this all without charging a single dollar to any user to access our site or any of our content (NB the cases featured in our various iOS apps are available for free on the site).

Currently (Feb 2014) we are visited by well over 1 million unique individuals each month, who read over 4.5 million pages each month. 

Caleb Garling in his article asked: “But Radiopaedia does invite more questions. The [cases] are crowdsourced — are the diagnoses accurate? Do people have to worry about their X-rays being posted online without their knowledge? And perhaps most importantly, is this actually useful for doctors?”

These are good questions.

I have tried as best I can to answer the middle question  in a separate blog post (patient privacy and cases on Radiopaedia.org), but what about the other two questions? 

Is radiopaedia.org useful?

As far as usefulness for our intended audience (radiologists and other health professionals) I can only go on anecdotal experience and the hundreds of feedback emails and comments we receive each year (recently we have started to publish these here - we love to hear from you, and if you want to let us know how you find Radiopaedia.org useful leave a comment or send us an email). I personally think we are useful, and over the years I have been approached by hundreds of residents/registrars, fellows and consultants, both in radiology or other specialties who have told me how much they rely on Radiopaedia.org for study and as a references. Not only that, but I find myself referring to the site frequently.

Accuracy and quality

That brings us to the big question, and the one what will be one of the main focuses of our attention over the coming years: accuracy / quality of new content as well as of the content we already have.

Being a collaborative resource, contributed to by thousands of individuals from a wide range of backgrounds and bringing to the project a wide range of knowledge, the cases contributed are unavoidably of variable quality, despite fairly explicit guidelines outlining what constitutes a good quality case. 

Although all new cases undergo moderation by our section editors there is still variation in quality not just of the images themselves, but also in how solidly the diagnosis has been established. To give contributors the option of holding on to a case until they are able to ‘polish it’ prior to publishing it, we have recently released draft mode for cases and it has resulted in an improvement in the overall quality of cases. Additionally, we will soon also be allowing moderators to push a sub-standard or incomplete published case back to draft mode, at which time the contributing authors will be asked to improve the case. Perhaps even more importantly for future case uploads, we will be improving the edit mode for cases and adding incentives to fully document how a diagnosis has been established.

The other focus is in creating better search tools, which can float the better cases to the top of the results. The challenge is in how to mechanically identify these cases as with the number of cases we have a manual approach is impractical. We have been thinking hard about this and have a number of avenues to explore. As with everything we do, we will take an iterative approach, gradually improving each feature.

All of this is however not going to be enough without the support of our amazing community of dedicated volunteers. A huge advantage we have over traditional resources, an advantage which I think eventually will be shown to be decisive, is that any error can be corrected immediately. With good referencing we can create content that is of excellent quality, trustworthy and up to date. Most importantly we can continue to make all this content available to every single individual on the planet for free. By doing so we can help them become better doctors and thus help patients.

I look forward to seeing Radiopaedia.org grow into an even more comprehensive and mature resource and I hope that you will help us in our endeavor. 

Dr Frank Gaillard is a neuroradiologist at the Royal Melbourne Hospital, Melbourne, Australia, and is the Founder and Editor of Radiopaedia.org.

NB: Opinions expressed are those of the author alone, and are not those of his employer, or of Radiopaedia.org. 

A frequent question I am asked revolves around privacy issues for cases submitted to Radiopaedia.org. Understandably this issue is of concern to many both within the health industry and from the general public. The main worry, I think, is the possibility of a third party recognizing an individual from their images and thus become privy to information that would normally only be available to the patient and their treating physicians.

Before discussing Radiopaedia.org's approach, the first thing to mention is that every hospital and practice I have worked at has a privacy policy and it behooves each contributor to ensure that they contribute cases in line with their local guidelines. However, there is considerable variation when it comes to local policy and thus Radiopaedia.org has its own strict policy guidelines which are incorporated by reference into our terms of use. This policy is based on HIPAA (Health Insurance Portability and Accountability Act) which precludes any cases containing individually identifiable health information.

The US department of Health & Human services website on HIPPA defines it as follows:  

Individually identifiable health information” is information, including demographic data, that relates to:

• the individual’s past, present or future physical or mental health or condition,
• the provision of health care to the individual, or
• the past, present, or future payment for the provision of health care to the individual,

and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.

What does that mean in practice? Well, our case publication guidelines go into a fair bit of detail but the key points are that:

A) cases should be devoid of all patient identifiers and preferably have no text overlay on the images whatsoever (this can be difficult to achieve in some instances).

B) the supporting text (e.g. presenting complaint, case discussion etc..) should not include any other information which could be used to specifically identify an individual to a third party. 

C) if a case is for one reason or another unique in a way that could lead to identification of an individual then it should also not be uploaded. This means that a case which is has been featured in the media is usually inappropriate. 

We take this very seriously, and failure to abide by these rules is a breach of our privacy policy and terms of use.  All our cases are moderated by our dedicated volunteer section editors and any case found to have patient information is immediately deleted and the contributor sent a warning email.

Should a user repeatedly upload cases with patient details their account will be suspended; this has not occurred. 

Should you find information which could identify a patient please write to us immediately at [email protected] and we will remove the content. 

At the end of the day we accept cases to help us build an amazing resource which is shared without charge with every health professional on the globe, in the hope that this will lead to better diagnosis, treatment and outcome for patients. 

Provided we do so with a sensible approach to privacy, I think this is something we can all be proud of. 

Dr Frank Gaillard is a neuroradiologist at the Royal Melbourne Hospital, Melbourne, Australia, and is the Founder and Editor of Radiopaedia.org.

NB: Opinions expressed are those of the author alone, and are not those of his employer, or of Radiopaedia.org.