Radiopaedia Blog

I recently wrote an email to our editorial board about upcoming changes to the site, most of which are behind the scenes. A number of them thought that this would be of general interest; a glimpse into some of the issues we face maintaining and improving the site. So, here is the email, only slightly edited. 

Peeking through the curtain

Hi everyone, 

Just wanted to let you know that the long and arduous journey to getting Radiopaedia running on Ruby on Rails 4, the coding environment that Radiopaedia is written in is hopefully nearly over. Rails 3 is no longer being supported and thus the upgrade is mandated. This new version is now passing all tests reliably and running on our staging servers and will be deployed to production next week (barring any surprises). 

This is an example of the sort of maintenance work that a site like Radiopaedia needs to undertake, just to keep going. How big a job is this? Well,  just this 'update' required 4195 individual additions to our code base, 3984 deletions, 190 commits, 786 files changes. It has taken us 3 months of work by various members of the team at Trikeapps and has naturally cost a great deal (think of 3 months of the salary of a full-time professional developer, and you start getting a feel for it).

And for all that effort, what will you see? Hopefully nothing. Nothing at all. Not a sausage. Except, almost certainly a few bugs which despite our best efforts won't have been noticed pre-release. *sigh*

What's worse is that Rails 5 was released in August and so, in the near future, we will embark upon the same process yet again. 

As far as our upcoming multiple choice question (MCQ) feature is concerned, that is another rabbit-hole of back-end change. To be able to write MCQs is all well and good (that work is pretty much finished, and will be released soon to the editors) but that is not very useful unless we keep track of who has answered what and how. So, what will be first released is just the tip of the MCQ-feature-iceberg. 

We want to be able to be clever about showing users the correct MCQs for their level of training. We want to be able to identify bad questions, and track a user's progress etc.. We want to keep stats on every question and work out which are questions suitable for medical students, and which are for fellows or consultants, and we want to do this all mechanically. Down the track, we want users to be able to ask our app questions like "how well am I going compared to other users at a similar place in their training?" and "show me questions that users of my level tend to get correct". We want to use spaced repetition to make sure users are learning from the questions, not just testing their knowledge. We want to be able to cluster questions intelligently by difficulty and topic. 

To achieve this is non-trivial. The very first thing that needs to be known and tracked is the 'who', and it turns out that unfortunately, both the 'country' and 'position' parts of our user profile are not up to the task, both because of how the data was collected, and because there has been no reason for anyone to update it. As a result, almost every registrar/resident who created a profile in 2010 is now a consultant, but almost none have updated their profile to reflect this. And so, with a heavy tangential heart, we have embarked upon rewriting that part of the database, and it gets more complicated because in the United States they call trainees residents, and in Australia, we call them registrars, and the number of years of training are different etc... In the process of doing this, we then also realized that there are a bunch of other changes we need to make to the user profile. We need to work out how to prompt users to periodically update / confirm their profile setting, and naturally need to keep track of when that 'time to update' is for each user. We also need to work on the design and user interface of that process etc... You get the picture. For every feature that reaches production, there is a large body of supporting work that is essentially invisible, but nonetheless crucial. 

So it may not be a surprise that we are going to have a 'become a supporter' campaign for the month of December; you will see a banner under the header. We have only done this once before, a few years back, but now aim to do this every year. This is merely a way of making folk aware that the possibility of supporting Radiopaedia exists, and to give them an opportunity to help financially if they so choose. It also helps us predict our income and reduce our reliance on advertising. 

For those of you who are already supporters, thank you very much. Every bit helps. For those of you that aren't, please don't feel pressure to become one. As a member of the editorial team, you are already contributing a great deal to the site, and I also realize that not all currencies or incomes are created equal. 

Anyway, I thought I would share this with you, A) to give you a small peek at what is required behind the curtain B) explain why we sometimes go months without releasing any significant user-facing new features/improvement C) make you aware of the changes, so that if there are bugs you can let me know and D) get you excited about MCQs which I think will be a tremendous addition to the site. 



Associate Professor Frank Gaillard is the Founder and Editor in Chief of He is also an academic neuroradiologist and Director of Research in the Radiology Department of the Royal Melbourne Hospital/University of Melbourne in Melbourne, Australia.


At this time of year, we ask those of you who use and love our website to consider becoming financial supporters. We do this because we want to continue to grow and improve what is already the best open access radiology resource available.

This is also a great opportunity to remind you all what an amazing resource Radiopaedia has become as a direct result of hundreds of people just like you who are willing to donate time, expertise and a few coins. Together we are proving that creating a comprehensive and reliable resource for all health professionals does not require expensive subscriptions and does not need to be hidden away behind a paywall, inaccessible to those who need it most.  

Radiopaedia is now read by over 2.5 million individuals every month, which we currently support largely by showing ads. We don’t like ads, and one day we may be free of them entirely if users like you decide to join the mission and contribute to a resource you use so very often. Meanwhile, not only does becoming a supporter mean that you are helping us, it also means that for you, ads will no longer be as visible; in fact, as a Roentgen level supporter, you will have a completely ad-free experience

Please take a moment to consider what Radiopaedia has meant to you over the years, and think of what it means to so many of your international colleagues who often use it as one of their only sources of reference.

If you think Radiopaedia is worth a few dollars a month, not just for you, but also for others, then please become a supporter — it only takes a few seconds and is the best way to help us. If you prefer you can also just make a one-off donation. If you are not in a position to contribute, then please don't feel bad. The site is for everyone. We'll gladly, however, accept your well-wishes — tweet a message @Radiopaedia telling us how the site has helped you. 

With your support, we will be able to continue to improve the site, create additional features to support your life-long learning, and ensure that we remain freely available to all.

Thank you so much,




Associate Professor Frank Gaillard is the Founder and Editor in Chief of He is also an academic neuroradiologist and Director of Research in the Radiology Department of the Royal Melbourne Hospital/University of Melbourne in Melbourne, Australia.


As part of a recent 5 part blog by Lincoln Berland MD titled You Don’t Need the Ultrasound Biopsy Guide!, we ran a survey to explore a few facets of use of guides. Specifically we sought to examine if use: 

  1. varies from region to region
  2. is related to when an individual learned to perform biopsies
  3. is related to number of biopsies performed

Before looking into these questions specifically, let's get an overview of respondents. 

We received 307 responses, with the majority of individuals not using a guide (72% never/almost never). Respondents reported performing a variable number of procedures a month, roughly evenly split between 2-10, 20-30 and >30. Most (80%) had been performing these procedures for less than 10 years. Of the 307 responses, 280 provided country information (from 70 different countries). 



Does use depend on the country or region you live in?

The fact that generally guides are not used, and that in many countries only 1 response was received, makes it difficult to be specific. Grouped into regions however there does seem to be a trend for greatest use in Europe and the Middle East, with the average response being somewhere between "not often" to "sometimes". The Americas (both north and south) and Asia reported guides used on average "not often", whereas Africa and Oceania (Australia and New Zealand) reported "never / almost never" (see below). 



Does use depend on when you trained?

The data was very skewed towards relatively junior radiologists with the vast majority being under 20 years experience, and most with fewer than 10 years. As such although the highest use was in the most experienced respondents, the number of responses was too low to infer any actual trend. 


Does use depend on how many biopsies you perform?

The strongest correlation seems to be with how often biopsies are performed. Radiologists performing on average more than 30 biopsies a month had the lowest average frequency of use (only 0.39; 0 = "never" and 1 = "rarely"). 




As a result of these relatively low numbers, anything other than simple descriptive statistics above are not really possible and statistical significance is unlikely to be met (even if one believed that the respondents were a truly random sample of radiologists across the globe, which clearly they are not). 

Having said that, I think that one can safely state that the use of ultrasound guides is not the default and that many (almost certainly most) radiologists rarely if ever use guides. It also feels that there is likely a strong influence on the number of procedures performed, with more experienced radiologists finding that the guides are unnecessary and perhaps hinder. 

Regional variation is probably more granular that we can assess, largely depending on what is the norm for the department in which you trained or are currently working. 

Thanks again to Lincoln Berland for his thought provoking series on the topic. 


  • part 1 - introduction
  • part 2 - planning and preparation
  • part 3 - approach and visualization
  • part 4 - the biopsy
  • part 5 - additional benefits & conclusion
  • survey results


A. Prof Frank Gaillard is a neuroradiologist at the Royal Melbourne Hospital, Melbourne, Australia, and is the Founder and Editor of 

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

Part 5 of a 5-part series on the advantages of a freehand technique over a needle-guide system for ultrasound-guided biopsies. If you haven't read the rest of this post, please start at part 1

Why “Do No Harm” is easier with a freehand technique

One of the observations that persuaded me not to use the guide is watching what happens to the needle when someone else is using the needle guide. If there is some difficulty seeing the needle or lesion, there is a strong tendency to want to move the transducer to see better while looking at the screen to find the needle. But the needle is already inside the patient! So if you are looking at the screen while you are moving the transducer, the needle may be bending and torquing while you aren’t watching. I have squirmed while seeing needles bend over 30-45 degrees! How could that not be traumatic to the tissues? It can even causing laceration at the organ surface or even internally, with significant lateral pressure on the end of the needle. That virtually can’t happen with a freehand technique. If you have to reposition with freehand, you partially withdraw and reinsert at a different angle, but I believe that is considerably less traumatic than the bending and angling that may occur with the needle guide.

Time and cost

All of the trickiness of setting up to use the guide takes time — sometimes a lot. I believe that I routinely have been able to perform procedures about 30-50% faster than someone using the guide (which is one big reason the technologists and nursers looked forward to my procedures days). The added cost of the device is obvious. However, there are additional costs of increased room time are real. I have also seen biopsies unnecessarily delayed because not all of the components needed were in stock or in the room or the device that attaches to the transducer actually broke and someone goes to find a replacement. Sometimes the device perforates the sheath and the user feels obligated to re-sterilize and start over… all totally avoidable problems if you don’t use this device.


If you believe that you cannot “walk” (biopsy) without a “crutch” (guide), then you don’t want to try to “walk” and do not develop and maintain the muscles and skills you need. I believe that no one would argue that doing biopsies requires fine eye-hand coordination and other visual and motor skills whether or not you use the guide. However, I believe that using the guide limits those skills from being thoroughly and frequently exercised, without you consciously realizing it. This may limit both your desire and ability to manage ultrasound-guided biopsies, particularly in challenging situations.

So, I recommend that if you have been accustomed to using the guide, try to toss the crutch aside from time to time, first in easier cases until you feel comfortable with your newly developing level of skill and I think that you, your technologists and patients will all be better off for the effort.


We have conducted a survey to get some insight into use of ultrasound biopsy guides and the results are now available! Read on... 


In this series: 

Lincoln L. Berland, MD is Professor Emeritus of the Abdominal Imaging Section of University of Alabama at Birmingham. 

Twitter: @linkberland

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


Part 4 of a 5-part series on the advantages of a freehand technique over a needle-guide system for ultrasound-guided biopsies. If you haven't read the rest of this post, please start at part 1


When planning the procedure, you need to visualize the geometry of the transducer and needle in your head and take care to view the true plane of the transducer. You must make sure that when you insert the needle, that it is in the plane of the transducer and that as you manipulate both the transducer and needle that you coordination the planes. The human eye is also remarkably good at estimating angles and you will be surprised how close you are to the proper angle when you start doing these. Yes, these are skills you may need to hone, but ones that help for other procedures and ones that virtually anyone who does procedures using needle guides can master…. really. 


First, positioning the patient and yourself is crucial, although many do not adequately account for their own positioning as well as they do the patient’s positioning. You need to be able to brace your scanning arm and sometimes the arm with which you are doing the biopsy, so you may need to elevate the table or move the patient. So, once the patient and you are properly positioned, you should brace yourself with your hand, arm and/or elbow resting on something immobile. I bring the lesion into optimal view, but before I actually insert the needle, I try to place my eyes directly within the plane of biopsy itself. If you are looking AT the plane rather than WITHIN the plane, you may not appreciate a subtle deflection of the needle from the viewing plane.

Finally — insert the needle

Once you see the lesion and you are properly braced, nothing is going to move (at least very much). If you are seeing the lesion and you know that you are inserting the needle in the plane of viewing, then you know that when you insert the needle, that it will be in the plane of viewing or very close. Here is the key that is nearly impossible for novices to accomplish psychologically: You should be looking at the needle and transducer as you insert, NOT the screen. Once you take your eyes off the needle and plane and turn your head (or even just your eyes) to look at the screen, you lose your eye-hand coordination and are likely to inadvertently incorrectly angle the needle or transducer. I have even sometimes stood in front of the screen or held my hand over it so the resident cannot see it as she/he inserts the needle. 

If you are looking at the needle while you insert it, it will be close to the right place. So, upon initial insertion, I don’t usually go all the way down to the lesion unless it is large and the orientation wouldn’t be a problem. I want to get it through the surface of the organ and within range of being able to see it. One other point, though, particularly for novices, is that you shouldn’t incrementally edge the needle into the patient millimeter by millimeter because you are scared to hurt something. If you have planned properly, you know that your route is safe and you will cause the patient considerably less discomfort if you insert swiftly through the sensitive peritoneum, liver capsule or other tissue plane rather than stretch and tent those surfaces as you insert slowly.


Once the needle is inserted, you can find it with subtle readjustments of the transducer and quickly figure out how to reposition, if necessary. You just need to appreciate that the screen and real geometry are nearly the same so that you intuitively know which way you need to re-angle the needle. So, yes, you may need to withdraw the tip to a more superficial position and reinsert. There are many different types of needles that you may use, so I won’t discuss actually acquiring or saving the specimens. Using the freehand technique is independent of these factors.

In the final 5th part of this series, I will discuss why the freehand technique is often less traumatic than using the needle guide and is cheaper and faster.

In this series: 

Lincoln L. Berland, MD is Professor Emeritus of the Abdominal Imaging Section of University of Alabama at Birmingham. 

Twitter: @linkberland

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


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