Radiopaedia Blog

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The Diagnostic Imaging Pathways App is an offline decision-support tool designed to help clinicians make appropriate medical imaging choices. This free resource is based upon the popular website of the same name. It's currently available for iOS, with an android version expected soon.

The App is divided into 12 subspecialty categories under which specific clinical pathways can be accessed to guide the user towards the most appropriate imaging test. An overview button allows each pathway to be visualized in its entirety at any time.

There are many things to like about this App, particularly the fact that it is a free resource made available globally. Trying to cover every single clinical scenario is however an impossible task and keeping pathways up to date and evidence based is going to prove a constant challenge. 

In order to get an idea of the current status of this App and its potential for the future, we invited a group of radiologists on Twitter to take a look for us. We'd love to get your feedback too, which you can send to us through the comments section or via social media. 

@DrAndrewDixon


Erik Ranschaert

Review: 
This mobile application is a very useful tool which every hospital-based physician should have at hand in order to help them choose the most appropriate diagnostic approach. The form is very attractive but some of the content runs a bit behind, which is a little disappointing. The information in some pathways would benefit from more detailed and updated information.

The prostate pathway in particular seems very old fashioned. The initial recommended imaging modality is TRUS biopsy although many cancers are being missed using this technique. MRI is really of great added value in case of negative TRUS biopsies as tumors in the transition zone are easily missed, and this is not reflected in the pathway. And who is still performing endorectal MRI? The most appropriate pathway is normal (transabdominal) prostate MRI (preferably 3T).

Rating: 

 

Jeremy Jones

Review:
The app covers a broad selection of presentations across a number of pediatric specialties. The topics covered are representative of the majority of the presentations I see on a daily basis and the suggestions for imaging are relevant for the UK as well as Australia & New Zealand. The ability to see an overview of the guidance as well as having a pathway that requires interaction is helpful to gain an understanding of the whole pathway as well as the arm that you are using. Overall, I think that this will be a helpful resource for any healthcare professional who uses radiological services.

Rating:

 

Jenny Hoang

Review:
A good start, but there’s a lot more work to do! The app was easy to use and graphics were cute. Overview of pathways was great to have. I do worry that this app could be perceived as evidence-based guidelines when there are actually major deficiencies. I found many of the head and neck pathways to be incomplete, too simplified or out of date. 

I particularly disagree with the incidental thyroid nodule pathway which recommends either US or thyroid scintigraphy for all nodules depending on TSH. This approach is not cost-effective and can lead to harm from over-investigation and overdiagnosis. The approach in the ACR White Paper on Incidental Thyroid Findings should be used instead. There is also no mention of the use of 4D-CT in the hyperparathyroidism pathway and the radiation dose from parathyroid scintigraphy is much more than the 1-5mSv listed. 

Rating:

 

Vikas Shah

Review:
The Diagnostic Imaging Pathways (DIP) app is visually pleasing and easy to navigate, with the pathway overview in particular being a handy feature. Some key guidelines are missing (e.g. anal cancer staging) and some take a path quite different to that in most UK centers (e.g. recommending both abdominal AXR and CT if acute diverticulitis is suspected, or contrast enhanced CT in renal colic if the patient is aged over 50). However, the concept is sound, and the app is technically well designed so I can see this being "spun off" in different countries to suit local needs. 

Rating:

 

Nikhil Mehta

Review:
The diagnostic imaging pathways app has a very user friendly, easy and fast on the go interface. I tried various clinical scenarios, which I come across in day to day radiology practice. Some pathways work along the same line as we use India. Some of the pathways need updating, like the criteria for multiple sclerosis. The stroke pathway matches our evaluation steps. We use the ASPECTS score for MCA infarction and CT perfusion most often in the proper clinical scenario followed by extracranial carotid angiography. Overall I think the pathways are useful but further additions and updating are required.

Rating:

 

Alexandra Stanislavski

Review:
The DIP website and smartphone app are designed assist clinicians with a) choosing the best imaging tests for their patient, and b) adjusting patient management depending of the test result.  Among the sixteen pathways in the O&G section, there are some that achieve this very well. For example,  “Adnexal masses” and “Bleeding in early pregnancy” are excellent, detailed and current pathways. Several others however are less satisfying because they’re either too brief, or do not clearly define the role of imaging.  Interestingly, the website flags many of these as “due for review October 2015”. I am looking forward to seeing the updates.
 
The transition from website to app is a great idea, and the app menu interface is nicely presented. I would have liked to see more focus on the “Pathway Overview”, rather than multi-page decision making tool, which is a little clumsy. The best bits on the website are the pearls of wisdom in the hover boxes on the pathway overview page, and these are lost in the app version. Overall – great concepts, impressive breadth – with room for improvement for content and app usability.

Rating:

 

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This week we have released a bunch of small improvements to the site, some of which represent significant improvements to the back end of the site. 

Case view

The largest release is that we have replaced the case viewing engine to one similar to that used in presentation mode. This now means:

  1. stacks will start loading from the key image (or middle image if a key image has not been selected); this means that you will get to the important part of the stack straight away rather than having to start at the very top (often blank) image. 
  2. scrolling will be touch responsive on mobile devices (phones / tablets); this will be a huge improvement as previously scrolling was impractical. 

rID

We have instituted a unique radiopaedia ID (rID) for all cases and exposed this in our case information box (to the right of the case images). 

The box is now collapsed by default, as we plan to put all sorts of additional info in there which is not needed for general browsing. Keeps things nice and neat. 

The rID is an excellent way to keep track of where you got images from in a presentation. 

To make this even easier we have also included rID in the 'download image' attribution links. 

 

 

 

 

Presentation mode

Presentation mode has had a couple of minor tweaks. Firstly the size of the text has been increased (1) and will scale according to your screen size. This will be easier on the eye and much better when presenting cases on projectors. 

Secondly we have changed the attribution at the bottom right corner. The contributing user's name (2) is now a blue clickable link to the contributor's profile, their supporter status is indicated (3) and the rID is exposed (4). Clicking the rID takes you to the case in view mode. 

There is much more to come, so stay tuned for an every bigger and better radiopaedia.org

Thanks for your continued support. 

Frank. 

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Everyone knows that radiology is a discipline of images. Perfectly penetrated chest radiographs, speckled T2 hyperintensities in the liver parenchyma, subtle fat stranding around the appendix on a noncontrast CT... these images are the domain of the radiologist.

But there is another domain of radiology that doesn't always receive enough attention: the words of imaging. One could even think of the duties of the radiologist as threefold:

  1. to obtain a high quality image
  2. to medically interpret the image
  3. to express the image and interpretation in words

Each is important.

When I listed the imaging findings above, your mind probably pictured them immediately. The words were a mediator between your mind and the image. Although the language of radiology is highly mimetic (representational of an "objective" reality, rather than creative), it is inevitable that the way in which we structure a report will change the way our reader looks at an image. A report is not a shadow of an image (a shadow of a shadow), but a lens through which an image is read. The way a report is structured can either obscure an image or shed light on it.  

Since this is the case, attention to the language of radiology is not optional. Words must be used carefully and deliberately in order to achieve the effect we want.

Active vs. passive voice

One effect that should be deliberately chosen is when to use the active voice and when to use the passive voice when writing a report.

The active voice is the more common way of constructing an English sentence:

  • "I dictated the report" (subject - verb - object)

The passive voice often implies the subject:

  • "The report was dictated" ("object" - verb)

This passive construction raises the question: "by whom"?  The report was dictated... by whom?

The passive construction is endemic to much scientific writing and by extension, to radiology reports. Take these common radiology phrases as examples:

  • ... was seen / can be seen (by whom?)
  • ... is/was noted (by whom?)
  • ... is shown  (by whom?)

Passive constructions often contain a form of "to be": is, was, been, were, etc. But the way to determine if a sentence is passive is to see what part of the sentence is being acted upon. If the subject is acting ("I am reading a study"), then the sentence is active. If the object of the action is the important part of the sentence ("The study is being read by me"), then the sentence is passive. For example, a report I read today contained the sentence:

  • "No discrete parenchymal mass delineated."

This is a passive construction (and an incomplete sentence).

So why do radiologists use passive forms so often?

It probably partly arises from good intentions. In medical writing, we try to remove the "I" as much as possible to achieve a (somewhat illusory) semblance of objectivity. There's probably some humility involved as well, not wishing to grandstand one's interpreting self to the reader again and again and again.

Probably the most important reason it's so pervasive is because it's unconscious. Most of us were trained that way. We absorb it by reading other reports. It's now a habit.

So why is there anything wrong with the passive voice?

The problem is that it gently tortures the English language. Sentences containing passive constructions are more grammatically complex and constant repetition of the passive tense becomes difficult for a reader to wade through. 

The passive voice also connotes a lack of confidence and adds "hedginess" to a report by artificially disassociating oneself from it.

Furthermore, some may subconsciously use this awkward construction to promote an illusion of complexity and academic erudition.

Compare these two examples:

  • "a 1.8 cm para-aortic lymph node is seen" (passive)

vs.

  • "there is a 1.8 cm para-aortic lymph node"

 

  • "in the ascending colon, a fat-containing submucosal lesion is noted" (passive)

vs.

  • "there is a fat-containing submucosal lesion in the ascending colon"

The first construction (the passive construction) is unnecessarily complex. Seen by whom? Even though the sentences contain the same number of words, one has to read the first sentence more slowly... the grammar is implying something, leaving behind some faint residue of mystery. The second sentence (the more active existential "There is..." construction) is simple and declarative. One can read it at top speed. There is no grammatical mystery.

There is no situation in which a passive voice is more clear and concise than an active voice.

So, active voice vs. passive voice... why should you as radiologist care?

You should care because over the remainder of your career you will probably craft thousands (or tens of thousands) of these important little text objects we call radiology reports.

If you're going to spend a good part of your life putting these things together, it's important to be conscious in your choice of voice. The active voice is easier on the reader. The active voice is often shorter, saving you valuable time over thousands of reports. The passive voice may seem nobly objective, but it's a strain on grammar and it could be abused as a subtle (and eventually habitual) way to avoid committing to the second duty of the radiologist, to medically interpret the image. 

Try experimenting with your reports by eliminating the passive voice (for instance, see the next blog post "Staying active: an exercise in reporting").  Your readers will thank you ("you will be thanked by your readers"?). You may even find that you prefer it, too.

-----

Thanks to Tim Luijkx and Eric A. Blair.

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With the launch of Radiopaedia Courses and our (very) successful first course, we have now added the ability for all registered users to keep track of the courses they have attended and from now on print-out attendance certificates. 

Just click on your name (top right) when logged in and select "courses" 

 

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