Radiopaedia Blog

Stroke is the leading cause of disability in adults around the world. One of the major causes is atrial fibrillation (AF) and our aging population is contributing to an epidemic of AF. Anticoagulation therapy is highly effective stroke prevention for AF patients and there have been major changes to the therapeutics options available with the introduction of novel oral anticoagulants "NOACs".

In some ways the novel anticoagulants are simpler than warfarin - no regular INR monitoring, fixed dose, less food and drug interactions etc. However, like any new drugs there are unfamiliar issues. Despite the lack of INR monitoring, regular clinical monitoring and assessment of creatinine clearance is critical as they all have significant renal excretion. There are p-glycoprotein and other interactions to watch out for. Management of these anticoagulants around the time of invasive procedures is clearly an important area and the "safe" time off drug varies with renal function and the risk level of the procedure. Even recognizing that a patient is taking one of these new drugs can be an issue as most hospital protocols ask about warfarin but not dabigatran/Pradaxa, rivaroxaban/Xarelto and apixaban/Eliquis!

The management of bleeding complications remains a challenging area as no specific antidote is yet on the market and traditional factor replacement therapies have not been proven to work. The side effect profile does vary across the agents (eg dyspepsia with dabigatran) and there are drug-specific issues around the use of dosing aids and crushing tablets. AnticoagAF provides detailed information on the use of each of these novel anticoagulants with specific guidance on perioperative and bleeding management based on currently available guidelines and will be regularly updated as new information comes to light.

AnticoagAF, a simple but comprehensive  iOS app developed by the Royal Melbourne Hospital Neuroscience Foundation is the prefect reference for clinicians who are considering what and when to prescribe and how to manage specific situations like surgery, bleeding and stroke thrombolysis. 

AnticoagAF app is now available on iTunes for $1.99

Currently the app is only avialble on iOS, although an Android version may be available in future. Profits form the sale of this app go to the RMH Neuroscience Foundation supporting continuing stroke research.

This is a guest post from Dr Bruce Campbell, who authored the app, and who is a collegue and friend at Royal Melboure Hospital. 

 

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3rd Dec 2013 23:55 UTC

Body-packer

This man was caught body packing 500g of cocaine while entering Switzerland. The street value of his rectum, sigmoid and descending colon was around US$40,000.  

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Each month I will collate some of the feedback we get from our users and post it on our blog. It is always rewarding to hear that what we are building is important and appreciated. If you have feedback or a story of how Radiopaedia.org helps you, please send it to general@radiopaedia.org

 

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After having trialed a new text editor in a number of places in the site, we have finally released it site-wide. 

This is a huge improvement from our previous editor which is no longer being developed and it should make the process of editing articles and case easier. 

All the same funcitons are there. 

Please let us know if you run into any problems, by writting to general@radiopaedia.org or leaving us a comment via the feeback tab on the right. 

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Deciding what to include in the conclusion of a report is one of the most difficult but important challenges faced by a radiologist. It will come as no surprise to you that clinicians love a conclusion, so much so that it is often the first and only thing they read. And so here's my list of the...

1. Not having a conclusion

If your report is longer than three or four sentences then it really should have a conclusion. In my experience, radiologists most often omit a conclusion when they are unsure how to interpret the findings. Unfortunately this is precisely when a conclusion is most valuable, as it's likely the clinician will find the case difficult too.

Solution: Don’t be afraid to admit when you are uncertain.  Write your conclusion as if you are talking face to face to the referring clinician.

e.g. The parenchymal appearances in the lung bases are of uncertain significance and not clearly pathological. Comparison with previous imaging or a follow-up study may be helpful.

 

2. Repetition

Repeating your findings and descriptions such that the conclusion is almost as long as the body of the report defeats the whole purpose!  Often I find it is the radiologists who are insecure about the significance of their many findings that are most tempted to repeat them all in the conclusion.

Solution: Restrict your conclusion to short relevant descriptions only and never have a whole sentence without an interpretation.

e.g. Right anterior cranial fossa mass with appearances characteristic of a meningioma.

 

3. Not answering the question

Good clinicians almost always ask one or more specific questions in their referral. Ignoring or failing to address a question is a sure-fire way to alienate a referrer and may stop them ever sending a patient to you again!

Solution: Explicitly address the clinician's question in your conclusion.

​e.g. Normal study, with no evidence of appendicitis.

4. Irrelevant incidental findings

Including irrelevant incidental findings in a conclusion makes the important points harder to find. When the study is otherwise normal then it might be permissible to add one irrelevant incidental finding to the conclusion but even this is a questionable practice.

Solution: Only include an incidental finding in the conclusion if it warrants its own follow-up or management (e.g. Bosniak 2F renal cyst) or if it impacts the management of the primary condition (e.g. deviated nasal septum in a patient undergoing transsphenoidal surgery).

 

5. Guess what I am thinking

Many conclusions I read never actually state what the author thinks is going on. A statement of facts can mean nothing to a clinician without an encompassing impression.  For example, “Gallstones. Dilated common bile duct.” is nowhere near as useful as “Gallstones. Although choledocholithiasis is not definitely seen, given the common bile duct is dilated, a small distal stone is suspected.”

Solution: Always assume the clinician reading your report is tired, rushed and not familiar with the condition. Don't hide your diagnosis or the patient may be managed incorrectly.  

 

So that rounds out the top 5 mistakes made in radiology report conclusions. Hopefully now you can successfully avoid these pitfalls in your next reporting session. If you think of other important ones to add to these five then please leave a comment below.

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