Monday, June 18, 2012

Small Bowel Aneurysmal Dilatation Differential Diagnosis

Small bowel aneurysmal dilatation is a common pattern of disease in the small bowel. It consists of a focal segment of dilated small bowel associated with a mass. The mass is typically circumferential. The mnemonic MALL can be used to recall the common diagnoses.

DiseaseNotes
MMalignant GISTLymphadenopathy absent; obstruction common
AAdenocarcinoma of small bowel
LLymphomaLymphadenopathy present; obstruction uncommon
LLeiomyosarcoma

Left Upper Quadrant Small Jejunal Aneurysmal Dilatation
Source: Radiology Assistant
Metastatic disease can also present with small bowel aneurysmal dilatation. The most common primary is melanoma, followed by lung, breast, and colon cancer. Metastases tend to be multifocal and necrotic.

Friday, June 15, 2012

Radiology Salary: Cautious Optimism?

The American Medical Group Association (AMGA) recently released their 24th annual survey of physician groups. The Annual Medical Group Compensation and Financial Survey was a mixed bag of results. Almost 70% of groups noted an increase in compensation, but the increase was quite small on average: 2.4%.

The question I bet you're wondering though: how did radiology salaries do? All told, not bad, but not spectacular either. The top five specialties were: cardiothoracic surgery ($532,567), interventional cardiology ($504,099), orthopedic surgery ($501,808), interventional radiology ($492,102), and diagnostic radiology ($354,917). However, of the five, interventional radiology had the second highest growth of 2.95%, just behind the interventional cardiologists' 4.13%. The cardiothoracic surgeons actually experienced a decline!

The main figure to watch though is the relative value unit, or RVU. An RVU is the primary measure of a physician's productivity for the majority of participating medical groups. Medicare decides that each procedure is worth a certain number of RVUs. That value is then adjusted by the geographic location / practice environment of the physician. The adjusted RVU is then multiplied by the a dollar conversion factor to arrive at the amount Medicare will re-imburse. Most HMOs in the U.S. use this value as a basis for their repayments. Many physician groups charge up to 300% of this value, and then recoup 60-80% of that amount. For example, take a procedure generally worth one RVU. In Manhattan, this might be adjusted to 2 RVUs. At a conversion factor of $50, Medicare would reimburse $100 for this procedure. The physician group may charge up to $300 to a private insurance company, and could expect to collect roughly $180 to $240 on average.

In radiology, RVUs have been falling, so radiologists have had to work harder (complete more RVUs) to maintain the same salary level. This trend is likely to continue, regardless of whether the Affordable Care Act ("Obamacare") passes in full or in part. Healthcare reform of some shape or another will occur. Radiologists will likely face even further decreases in compensation. The real question is: how will radiologists respond? No one is quite sure yet, other than there will certainly be change.

But going back to the title of the post - what cause is there for optimism about radiology salaries? Well, whatever optimism is there, it is indeed a cautious one. Looking further back in the data, salaries tend to stay flat for a few years, then advance, then flatten again, in a step-wise fashion. Radiology salaries have been fairly flat since 2008, so the field is due for a step up. Whether that happens in 2013 or 2015 though, is anyone's guess. Any future gains are contingent on the broader economy advancing. Til then, keep knocking out those RVUs!

Thursday, June 14, 2012

Gastric Bull's Eye Lesion Differential Diagnosis

While initially described on fluoroscopic studies, the gastric bull's eye lesion differential remains useful to know in the age of MDCT. A quick and dirty mnemonic for this appearance is KLM. 

DiseaseNotes
KKaposi's sarcoma
LLymphoma
MMelanoma / Metastases

Hematogenous metastasis from breast cancer
Source: Radiology
GIST and carcinoid tumor can also be included in the differential (but didn't fit the mnemonic so well). Rarely, a gastric lipoma can ulcerate and also give a targetoid appearance.

Wednesday, June 13, 2012

Vertebral Scalloping: Differential Diagnosis #26

Vertebral scalloping is typically caused by dural ectasia. The scalloping typically occurs posteriorly, but rarely may occur anteriorly as well. The mnemonic AMEN can be used to recall the common causes of this finding:

DiseaseNotes
AAcromegaly
Achondroplasia
Ankylosing spondylitis

scalloping in acromegaly secondary to hypertrophy
scalloping in achondroplasia due to small spinal canal 
MMasses
Mucopolysaccharidoses

e.g. Morquio's, Hurler's
EEhlers-Danlos syndrome
NNeurofibromatosis
Sagittal T2-weighted FSE MR Spine of a woman with achrondroplasia
Source: Radiology


Tuesday, June 12, 2012

Ivory Vertebra: Differential Diagnosis #25

Today's Daily Diff is for a homogeneously sclerosed vertebral body, also known as an ivory vertebra. Such sclerosis can occur due to benign or malignant processes. While neurologic involvement is not necessary, the mnemonic LIMP can be used to recall the most common causes:

DiseaseNotes
LLymphomausually Hodgkin's lymphoma
IInfection / idiopathic
MMetastatic disesaepeds: neuroblastoma, medulloblastoma; adults: breast, prostate
PPaget's diseaseblastic phase

Ivory vertebra in Hodgkin's Lymphoma
Source: Radiographics

Monday, June 11, 2012

Focal Liver Mass: Differential Diagnosis #24

A focal liver mass can represent a wide spectrum of pathology, from benign to highly malignant. Being able to distinguish between various diagnoses is critical for establishing an appropriate treatment plan. Unfortunately, there is no ideal modality for doing this - while one can use ultrasound, CT, MR, and nuclear medicine, each has its own limitations. However, knowing some basic features can help narrow the diagnosis.

This post will focus on the appearance of solid hepatic lesions (as opposed to cystic lesions),  as well as their appearance on CT. There's no good mnemonic for this, but try and stay CALM my Fine Happy Friend, if you see such a lesion:

DiseaseNotes
CCavernous hemangiomaMost common benign mass, second most common mass after mets; enhance peripherally first, delayed washout
AAdenomaTypically solitary; seen in women on OCP, men on steroids, or glycogen storage disorders; increased bleeding risk -> surgical removal
LLymphomaMultiple low density nodules; resemble microabscesses in Hodgkin's lymphoma; associated with splenic involvement
MMetastasesMost common malignancy (18:1 vs primary HCC)
hypovascular: colon ca
hypervascular: RCC, thyroid, melanoma, choriocarcinoma
calcified: mucinous adenocarcinoma, osteosarcoma, chondrosarcoma
cystic: mucinous colon ca, lung, carcinoid, melanoma



FFibrolamellar carcinomaLarge mass in a young, healthy person; slow growing; central scar, which may calcify (50%)
HHepatocellular carcinomaArterial hypervascularity; 25% calcify; portal/hepatic vein invasion common
FFocal nodular hyperplasiaCentral scar; contain all normal liver elements; take up sulfur colloid on nuclear scans

Hepatic Adenoma (Portal Venous Phase)
Source: Radiopaedia
To evaluate this lesions, a radiologist may perform a "multi-phase" or "four phase" CT. The phases are as follows:

  1. Non-contrast: prior to contrast injection
  2. Arterial phase: 30 seconds after contrast injection
  3. Portal venous phase:  70 - 90 seconds after injection. 
  4. Delayed phase: 5 - 10 minutes after contrast injection

The texts below have more detailed descriptions of how each lesions appears during each phase.

Wednesday, June 6, 2012

Cystic Hepatic Lesion: Differential Diagnosis #23

The Daily Diff for today relates to a common finding: a low density liver lesion representing a cyst. While the majority of these will be simple, benign cysts, being able to differentiate the other possible entities is worthwhile. Sorry, no mnemonic here, but here are the other possibilities:

DiseaseNotes

Simple hepatic cystmost common (up to 10% of population

Pyogenic cystthickened enhancing wall; gas present (20%); septic patient

Amebic cystsolitary; right lobe; enhancing thickened wall *and* surrounding parenchyma (double-rim target appearance)

Hydatid cystcaused by Echinococcus; thickened wall with calcifications; layering debris (hydatid sand); often multilocular with daughter cysts (spokewheel appearance)

Simple hepatic cyst (they can be huge!)
Source: Radiopaedia
References:

Tuesday, June 5, 2012

Diffuse Increased Liver Attenuation: Differential Diagnosis #22

Today's Daily Diff concerns the curious case of a diffuse hepatic enhancement on CT. Imagine opening a non-contrast CT of the abdomen and pelvis and seeing a chalk-white liver staring back at you. While not a common occurrence, it does occur frequently enough that the following differential is useful to keep in mind. For lack of a mnemonic, the following diagnoses are listed in alphabetical order:

DiseaseNotes

Amiodarone long-term; also causes lung and thyroid toxicity

Glycogen storage disorders

Gold

Hemochromatosis 

Hemosiderosisaka secondary hemochromatosis; often from long-term blood transfusions

Thorotrast administration (previous)Thorotrast is carcinogenic contrast agent that was used between 1928 and the 1950s, primarily for cerebral angiography; deposits in reticuloendothelial system and is associated with HCC and cholangiocarcinoma

In contrast (ha), diffuse decreased hepatic enhancement on CT is typically caused by diffuse fatty infiltration (hepatic steatosis), or diffuse metastatic involvement.

Diffuse hepatic enhancement on a noncontrast CT
Source: Fundamentals of Body CT


Monday, June 4, 2012

Radiologist Salary Trends In 2012

Many factors play into the ultimate salary that a radiologist earns. As we have discussed before, location, changes to Medicare, and specialization such as interventional radiology can have a significant impact on a radiologist's compensation. No two radiologists will face the same situation. Still, it is instructive to look at the overall trend in radiologist salaries to see where the field as a whole is headed.

To this end, Medscape has put together its Radiologist Compensation Report for 2012 (login required) after surveying over 20,000 practicing physicians in the U.S.. And frankly, the news is not good. Overall, physicians report a decrease of 26% in overall income! 26%! The number seems excessive, but the first paragraph of the report shows the gritty truth:
In 2011, radiologists were the highest-compensated of all specialties surveyed, tied with Orthopedists. Respondents earned a mean income of $315,000 – about 10% less than in Medscape's 2011 survey. Fully one third of radiologists earned $400,000 or more, although this proportion was down from the 2011 survey. Almost one half (48%) earned from $300,000 to about $500,000. About 16% of radiologists earned $100,000 or less -- typically, those working part-time -- up slightly from 1 year ago.
While a 10% drop is better than a 26% drop, that is still a huge drop. If the average radiologist is earning $315,000 this year, that implies a loss of thirty five thousand dollars in just one year. In general, wages show price stickiness, meaning that while they may go up slowly, they rarely go down (this is why in general, people discuss inflation in the economy, but not deflation). For radiologist salaries to be worse than merely 'flat' but to have actually decreased by a large amount is a significant adverse trend. So, what can a radiologist do about this?

Move to a different area of the country
There is significant variation in radiologist salary levels across the U.S. Regionally, the highest compensated area (Great Lakes - $345,000) makes nearly 25% more than the lowest compensated area (Northwest - $275,000). Additionally, within a given area, a radiologist in an underserved area who owns his or her own practice can make significantly more than the average value for the region. As Medscape notes:
For the second year in a row, radiologists in the Great Lakes region (Ohio, Michigan, Indiana, Illinois, Wisconsin, and Minnesota) earned the most, at a mean income of $345,000; however, this represents a decrease since last year. The next-highest earners were physicians in the Southeast, who earned $340,000, followed by physicians in the South Central region, at $337,000. Radiologists in the Northwest earned the least, at $275,000. In the overall physician survey, physicians in the North Central region earned the most.
Clearly though, such a move must factor in one's own preference for an urban vs. rural environment, climate tolerance, and family situation.

Get more training
The statistics cited here are for all radiologists. However, there is significant variation between subspecialties within radiology. An interventional radiologist stands to make 10-20% more than a body imager on average. Also, in general, the more years of experience one has, the more compensation they will receive, especially if they stay in one practice setting and become a partner within the practice.

Why not move here? Your higher salary will cover it.

Change your practice setting
It is a well-known fact that private practice radiologists make significantly more than academic or outpatient center radiologists. While there are some offsetting benefits of being in a practice setting with lower compensation (such as more flexible scheduling, or more vacation), if a radiologist's salary is your main concern, this is an area where you can make a huge impact. Medscape gives you the hard data:
Radiologists in office-based, single-specialty group practices earned the most, with a mean income of $373,000; this value has declined since Medscape's 2011 survey. Radiologists employed by healthcare organizations came in second, at $332,000, followed by those in solo practice, at $331,000. Radiologists working for outpatient clinics and in academic settings earned considerably less.
Overall, while the trend for radiologists and their salaries is adverse in 2012, radiologists still are quite well compensated and can make changes to their careers to help protect their income.

Friday, June 1, 2012

Cloud Considerations For Radiology Practices

The following is a guest post by Steve Deaton of Viztek LLC regarding how the shift to cloud computing will affect Radiology practices.

To better understand the benefits of a cloud-based solution for radiology, consider the ability to have instant access to exams, and the potential benefit of having a specialist always available.  One example would be a car accident that occurs during the early morning hours in a rural area. If the local hospital does not have a radiologist on site at all hours, the staff can call an off-site radiologist and give them access to their cloud-based PACS solution. This allows them to quickly gain information so they can either proceed with immediate treatment or call for transportation to a larger facility.  The diagnostic process can be shortened so that critical patient care can begin quicker.
Benefits
Cloud-based PACS systems enable practices to grant system access on-the-fly, allowing one physician to quickly communicate with a colleague in order to review time-sensitive images. In the car accident example, such speed and flexibility can quickly help the physician determine if the patient needs immediate treatment or not.
The right Cloud solution puts the practice’s entire workflow into the cloud. Geography and the time of day are removed as constraints, allowing patients to always receive the best level of care. This availability to multiple specialists who can access the system from any internet-enabled device does, of course, raise security concerns. For practices that choose a stand-alone EHR or PACS product that is bundled with a cloud service for web access, the security between the end user and the cloud hosting company needs to be thoroughly reviewed. IT and administrators at the practice should be wary of the partnering cloud provider, and ask detailed questions about security protections, breach responses, and who is ultimately responsible for the security of HIPAA information.

A cloud-based PACS solution means the practice no longer needs to connect to an onsite server or worry about complex setups such as VPNs.  This promotes better image sharing and personal care and also enables the practice to be closer to the longer-term goal of implementing a 100 percent electronic records practice. It’s also the perfect solution for multiple location practices, or those that read images for multiple institutions.
Cloud solutions are the ideal fit for practices that need to manage expenses and can benefit from a pay-per-usage plan that is dynamically scalable to meet growing or falling demand. Digital radiology images that need to be archived for years require a considerable amount of space, and the right cloud provider can offer any amount of needed space at the right price point. Cloud services can reduce capital investments in both ongoing maintenance and server equipment, and related IT staff needed to keep those systems running. Such savings can be substantial, especially over the longer term as the costs of cloud storage continue to decline.

Vendor Review
Truly web-based solutions will utilize an image viewer that is a web-written application and runs on any computer. There is not a need for high-powered diagnostic workstations, or the need for special in-system hardware that is running locally. Placing data on the cloud is not worthwhile if it comes with restrictions in terms of how staff actually access and use the data.
Careful review of prospective PACS, RIS, and EHR vendors is vital to understand the different levels of how solution providers can be “in the cloud.” Some providers who have been in existence for a decade or more often take pride in still running on their original platform. While this might sound like a smart decision that offers continuity and stability, it doesn’t take full advantage of technological progress. When these older heavy systems are put into the cloud, the users are, in essence, remote controlling a large workstation. Internet speeds and the rate of compression are not typically good enough for fluid image adjustment that is required for effective radiology viewing. This causes the familiar problem of image lag, making image manipulation a challenge.
These solutions with older coding might technically operate over the cloud, but they are available with limitations. If all of the tools and functionalities are not available to doctors when reading remotely, then the integration of a cloud system might not be worthwhile. These older solutions may not support mobile devices such as the iPad, which are transforming radiology practices and patient interactions. Practices should explore vendors that not only can meet the demands of today’s mobile and instant-access users, but also look to the future and proactively build systems that are in touch with the latest broader technology developments. Cloud-based PACS and EHR systems have not taken off as quickly as anticipated because it is being put in place on top of older systems that can’t harness all of its benefits. Vendors that offer a 100 percent web-based solution are poised to best take advantage of the cloud and gain widespread adoption among radiology practices.

So what is the solution? Top vendors will completely update their code every few years and start fresh, allowing them to build thin-coded systems that are cloud-friendly and enable all functionalities from any web-enabled PC. Utilizing the latest coding toolsets is the only way to ensure that a Cloud-based solution is a leap forward technologically over an in-house thick-client system.  Otherwise, legacy systems claiming to be on the Cloud do not provide all of the pieces needed to complete the workflow and ensure quality and consistent care. Steve Deaton is a VP of Sales at Viztek LLC, a leading cloud-technology provider.