Radiopaedia Blog

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

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. 

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. 

Frank

Associate Professor Frank Gaillard is the Founder and Editor in Chief of Radiopaedia.org. 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,

Frank

Associate Professor Frank Gaillard is the Founder and Editor in Chief of Radiopaedia.org. 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"). 

Conclusion

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

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.

Conclusion

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.

Survey

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: 

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

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 Radiopaedia.org.