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Nearly half of all radiologists have been sued at least once, according to an article published in the October 2012 issue of the Journal of the American College of Radiology. Having been on the credentials committee at several hospitals for the last 15 years, I have seen many errors which could have been easily prevented. Here are the top seven Do's and Don'ts if you have the misfortune of getting into a medical-legal matter. 1. DO NOT discuss the case with anyone except your attorney. 2. DO NOT alter the medical record. 3. Although tempting, DO NOT review the medical record or the images without your attorney present. If you look at any of the medical record or images, it is arguably discoverable in deposition and the courtroom and may be used against you. Reviewing the images with your attorney is likely protected by the attorney-client privilege and not discoverable by the attorney suing you. 4. If you get a 90 day letter with intent to sue, DO contact your insurance provider immediately. Often, they can obtain radiology or other experts and get their legal team to have the case dropped before it ever gets filed in court. 5. If a case does get filed in court, DO inform all the hospitals' medical staff services offices where you have privileges. It varies at different hospitals, but in general if you inform them within 30 days you will be safe. DO NOT wait until reappointment time to inform the hospitals. Most hospitals have an obligation to report any pending suits, settlements, or judgments in their bylaws. ____________________________ Although tempting, DO NOT review the images without your attorney present. ___________________________ 6. If you are applying for new hospital privileges, or are up for reappointment, make sure you answer the question about any pending suits, settlements, or judgments correctly. DO NOT just blindly sign the form without checking it carefully, especially if someone else has filled it out for you. A false statement on the application is your responsibility and has very serious consequences such as revocation of privileges or inability to obtain privileges. These events may also be reportable to the Medical Board of your state. 7. If you have a settlement or judgment against you, DO inform all the hospitals where you have privileges within 30 days. Again, don't wait until reappointment time to inform the hospitals. The good news is up to 80% of medical malpractice suits are dropped or dismissed without payment. Only approximately 15% are settled, and of the 5% that make it to court, the defendant prevails 80-90% of the time. Make it easier to defend yourself and carry the day by following the common sense tips in this article. Kevin Rice, MD is the Chief of Staff and the Chair of the Radiology at Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD Disclaimer: Kevin Rice, MD is not an attorney and the above should not be construed as legal advice. Check with your own attorney and insurance provider if you have any legal matters. Courtroom gavel photo courtesy of: https://www.flickr.com/photos/joegratz/117048243/ Creative Commons 01.0 Universal (CC0 1.0)

44 y/o Female with intermittent knee pain and swelling for several years • Xray of the Week Figure 1.a. T1 weighted sagittal image demonstrating a low signal intensity lobulated intra-articular mass. Figure 1.b. FSE PD weighted sagittal image with fat saturation demonstrating the markedly hyper-intense mass with characteristic low-signal-intensity linear structures, due to fibrous septa. Figure 2. Axial FSE PD weighted image with fat saturation demonstrating the markedly hyper-intense mass with characteristic low-signal-intensity linear structures, due to fibrous septa. Discussion: Synovial haemangiomas are rare benign vascular malformations that occur in synovial joints. They may be a form of soft tissue hemangioma and occasionally synovial haemangiomas may present with a hemarthrosis. However, symptoms are usually non-specific, consisting of pain, swelling and limited range of motion of the affected joint. Most synovial haemangiomas are seen in the knee. Phleboliths seen on plain radiographs may be diagnostic if present. As in this case, MRI typically shows a lobulated intra-articular mass which is usually low or intermediate signal intensity on T1 weighted images and markedly hyper-intense on T2 weighted images. In addition, the T2 weighted images characteristically demonstrate low-signal-intensity linear structures in the mass, due to fibrous septa or vascular channels. Since MRI demonstrates the precise location and extent of the tumor, it is essential for preoperative planning. Pedunculated and well-circumscribed lesions usually are resected arthroscopically. Diffuse hemangiomas require open wide excision and recurrence is common in cases of diffuse lesions. References: 1. Arslan H, Islamoglu N, Akdemir Z, et al. Synovial Hemangioma in the Knee: MRI Findings. J Clin Imaging Sci. 2015; 5: 23. Published online 2015 Apr 30. 2. Barakat MJ, Hirehal K, Hopkins JR et-al. Synovial hemangioma of the knee. J Knee Surg. 2007;20 (4): 296-8. 3. Sheldon PJ, Forrester DM, Learch TJ. Imaging of intraarticular masses. Radiographics. 25 (1): 105-19 4. Watanabe S, Takahashi T, Fujibuchi T et-al. Synovial hemangioma of the knee joint in a 3-year-old girl. 2010. Journal of Pediatric Orthopaedics B. 19(6):515-520, NOV 2010. 5. Rajni, Khanna G, Gupta A, Gupta V. Synovial hemangioma: A rare benign synovial lesion. Indian J Pathol Microbiol [serial online] 2008 [cited 2018 Feb 11];51:257-8. Available from: http://www.ijpmonline.org/text.asp?2008/51/2/257/41676 Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All posts by Phillip Tirman Kevin Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter @KevinRiceMD

Foot pain • Xray of the Week 54 year old male with pain and soft tissue masses of both feet. (Left) T1 weighted axial image demonstrating low signal intensity tophi adjacent to the first and second metatarsal phalangeal joints with associated bone erosions. Note the typical overhanging edges and sclerotic margins of the erosions. (Right) Sagittal FSE PD weighted image with fat saturation showing a large intermediate signal intensity tophus posterior to the tibio-talar joint. There is also synovial proliferation, erosions and tibialis anterior tendon tophus formation. T1 weighted sagittal image demonstrating low signal intensity tophi adjacent to the first metatarsal phalangeal joint. Axial FSE PD weighted image with fat saturation showing a large intermediate signal intensity tophus posterior to the tibio-talar joint. There is also synovial proliferation, erosions and tibialis anterior tendon tophus formation. A vitamin E capsule is at the site of the patient’s pain. T1 weighted sagittal image demonstrating low signal intensity tophi adjacent to the tibiotalar joint with associated bone erosions. Note the typical overhanging bone and sclerotic margins of the erosions. 1. Girish G, Glazebrook KN, Jacobson JA. Advanced Imaging in Gout. AJR Am J Roentgenol. 2013;201: 515-525. 2. Barnes CL and Helms CA. MRI of gout: a pictorial review. Int. J. Clin. Rheumatol. (2012) 7(3), 281–285. 3. Oaks J, Quarfordt SD, Metcalfe JK. MR features of vertebral tophaceous gout. AJR Am J Roentgenol. 2006;187 (6): W658-9. 4. Yu JS, Chung C, Recht M et-al. MR imaging of tophaceous gout. AJR Am J Roentgenol. 1997;168 (2): 523-7. 5. Perez-Ruiz F, Dalbeth N, Urresola A, et-al. Imaging of gout: findings and utility. Arthritis Res. Ther. 2009;11 (3): 232. 6. de Ávila Fernandes E, Kubota ES, Sandim GB, et-al. Ultrasound features of tophi in chronic tophaceous gout. Skeletal Radiol. 2011;40 (3): 309-15. Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including MRI of the Shoulder and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All Posts by Phillip Tirman, MD Kevin Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. All posts by Kevin Rice, MD Follow Dr. Rice on Twitter @KevinRiceMD

This how I do Clario zVision Peer Review: Above. Step 1. In "My Reading Queue", click on "Peer Review" (blue arrow), then click on "Peer Review Assigned to Me" (red arrow). Above. Step 2. Then this list of cases should pop up. Click on the arrow down for places you do not have privileges to remove the case from the list (orange box). Next, click on the first case in the list. Above. Step 3. Then the patient report will pop up. Click on the magnifying glass icon in the top right (red arrow), and that will open the images for that case. Step 4. Click on your Rating, Category and make a note if there is a discrepancy (blue arrow). Then click "Submit and Next" on the bottom right (orange box). This will automatically load the next case. Repeat Step 4 until you run out of cases, and you are done! More Clario zVision tips: Clario zVision Auto-Next Mode Tips How to Re-assign a Case While in Auto-Next Mode in Clario zVision Clario zVision Communication Notes Tips Clario zVision • How to Change Reading Queue Sorting Clario zVision • How to Not Enter Patient View All posts by Kevin M. Rice, MD

It is possible to speed up loading of Clario so that it doesn’t load the patient view screen each time you open a case. Entering the patient view with each case takes quite a bit of time. If this isn't necessary for each case, turn this functionality off. If you need to enter the patient view screen to leave a Clario note, you can do this manually by clicking on the patient name on the worklist. Unfortunately due to a quirk in Clario, going back to seeing the worklist quits Autonext mode, but it’s easy to start it up again. Although it does take time to load, the patient view screen is extremely helpful in identifying comparison exams. So be careful when using this technique as it may result in lack of display of prior cases. This Clario zVision tip submitted by Tomer, Roth, MD Emergency Radiologist / Neuroradiologist at Renaissance Imaging Medical Associates. Above: Click name in top right corner. Above: Click Profile Management. Above: Note which profile you are on. You will need to change this for each profile you have. To change which profile you are changing, click the dropdown and select another profile. Above: Click the dropdown menu beside “Enter Patient View”, and uncheck “Launch Viewer”, and “Launch Dictation”. Once finished, click save. More Clario Tips: Clario zVision Auto-Next Mode Tips How to Re-assign a Case While in Auto-Next Mode in Clario zVision Clario zVision Peer Review Made Easy Clario zVision Communication Notes Tips Clario zVision • How to Change Reading Queue Sorting All posts by Kevin M. Rice, MD

Communication notes are used for two purposes: To communicate to operations if there is an issue with the study. To document a communication to the care provider. There are two different buttons to use for each of these notes: Use the communication note to indicate a problem with the exam, such as missing images. Use the communication log to document a call report. Above: On the worklist, you’ll see a communication note icon in the indicators column to show which exams have notes. The red/pink icon will indicate that the note is not complete. The gray note indicates the note is complete and the case is ready to read. More Clario zVision tips: Clario zVision Auto-Next Mode Tips How to Re-assign a Case While in Auto-Next Mode in Clario zVision Clario zVision Peer Review Made Easy Clario zVision • How to Change Reading Queue Sorting Clario zVision • How to Not Enter Patient View All posts by Kevin M. Rice, MD

Working in Auto-next mode is the most efficient way to use Clario zVision. But what if you are interrupted and need to read a specific case? You don't need to exit auto-next mode if you have someone call about a stat case. Just click on the straight arrow to the left of the patient name in the auto-next list and it will load that as the next case. In the above example, I am in auto-next mode. The case with the straight pink arrow pointing right on patient CLA... for Dr. Wang is a case that I clicked on the formerly white arrow to the left of the name. This case will be loaded next, rather than loading the next case on the auto-next worklist. The curved pink arrows are the cases where I clicked the curved white arrow next to the patient names Co... and Ko.... The arrow turned pink after I clicked it, and those cases will be skipped. They are MRI's which I don't read. What if someone calls for a stat read and you don't see the case on the Auto-next worklist? Here is what to do, so you do not have to leave auto-next mode: As seen on the above screenshot, click the + sign (red circle). This has opened the Quick Search box. Type in (or copy and paste from a Chat) the ACC# or MR# (open red arrow), and press enter on your keyboard. The case will appear, as in this instance pt GO.... Next, click the pink arrow pointing right (big white closed arrow). Then close the window and it will load to your auto-next list, making it the next case to read. More Clario zVision tips: Clario zVision Communication Notes Tips How to Re-assign a Case While in Auto-Next Mode in Clario zVision Clario zVision Peer Review Made Easy Clario zVision • How to Change Reading Queue Sorting Clario zVision • How to Not Enter Patient View All posts by Kevin M. Rice, MD

If you order cases by "Time Remaining" it will make for a more efficient radiology group. Clario zVision does not always load the oldest case at the top of the list. Make this change in Clario to ensure you are always reading the oldest case. This Clario zVision tip submitted by Tomer, Roth, MD Emergency Radiologist / Neuroradiologist at Renaissance Imaging Medical Associates. Above: Right click “My Reading Queue” and click “Properties”. Above: A box will appear that allows you to change the sorting orders. Make sure all are "Ascending". More Clario Tips: Clario zVision Auto-Next Mode Tips How to Re-assign a Case While in Auto-Next Mode in Clario zVision Clario zVision Peer Review Made Easy Clario zVision Communication Notes Tips Clario zVision • How to Not Enter Patient View All posts by Kevin M. Rice, MD

In order to efficiently get through the cases, you need to work in auto-next mode. But, what if a case that needs to be assigned to someone else pops up? Here is a great hack from Sara Larsen at Clario Medical on how to re-assign it. It will require a few steps for now, but Clario is working to make this a one step process. This is an actual case that came up for me to read, but another radiologist did the thoracentesis. This is how I re-assigned it to Lucas Payor, MD. 1. Above. Open the exam as above. Right click on the date in patient view (Red arrow). 2. Above. Choose "Change Status" (Red arrow). 3. Above. Change to Unread (Red arrow.) 4. Above. Click the 'Assign/Lock Exam icon. (orange square) 5. Above. Choose a radiologist (red arrow) or group (blue arrow) to assign the exam to and select "Assign". 6. Dismiss the case in PACS. (Click the red X in Carestream) It will load the next case. More Clario zVision Tips: Clario zVision Auto-Next Mode Tips Clario zVision Communication Notes Tips Clario zVision Peer Review Made Easy Clario zVision • How to Change Reading Queue Sorting Clario zVision • How to Not Enter Patient View All posts by Kevin M. Rice, MD

39M with history of intravenous drug abuse found down • Xray of the Week Figure 1: Initial MRI of the Brain with and without contrast (hospital day 6) Gyriform increased DWI signal with corresponding decreased ADC signal involving the cortical gray matter of the bilateral hippocampal gyri, compatible with restricted diffusion. Figure 2: Initial MRI of the Brain with and without contrast (hospital day 6)Within the left globus pallidus is an additional tiny focus of restricted diffusion, representing a lacunar injury. Figure 3: Initial MRI of the Brain with and without contrast (hospital day 6)Diffuse increased IR/T2 signal involving this region of the bilateral hippocampal gyri, consistent with edema. No involvement of the uncus or other areas of the temporal lobe. Figure 4: Initial MRI of the Brain with and without contrast (hospital day 6)After administrations of contrast, no significant enhancement is appreciated in either hippocampal region. Subtle tiny focus of enhancement involving the left globus pallidus, corresponding with focus of restricted diffusion. Figure 5: Follow-up MRI of the Brain with and without contrast (hospital day 16)The hippocampal gyri have diminished volume in the interval and no longer restrict diffusion. There is now bilateral linear peripheral T1 shortening involving the cortical gray matter bilaterally (in the regions of the alveus and fimbria). After administration of gadolinium, subtle patchy areas of enhancement is seen within the hippocampal gyri bilaterally. The previously described punctate focus of restricted diffusion in the left basal ganglia has resolved. Figure 6: 10-day Interval change between MRI's performed on day 6 to day 16. The hippocampal gyri have diminished volume in the interval and no longer restrict diffusion. There is now bilateral linear peripheral T1 shortening involving the cortical gray matter bilaterally (in the regions of the alveus and fimbria). After administration of gadolinium, subtle patchy areas of enhancement is seen within the hippocampal gyri bilaterally. The previously described punctate focus of restricted diffusion in the left basal ganglia has resolved. Introduction Isolated bilateral hippocampi injury is a known complication of opioid abuse that is a rare cause of memory impairment or amnesia. The imaging findings, however, overlap with other disease processes and therefore require good clinical history and clinical care to rule out other temporal lobe pathology. This case report aims at discussing the imaging findings of toxic encephalopathy related to hippocampal ischemia. Case Report Patient is a 39 year-old male, with a past medical history only significant for intravenous drug abuse and recent incarceration, who presented to the ED after being found down on the ground for an unknown amount of time. At presentation, the patient was ill-appearing, in acute distress, hypotensive, and somnolent with GSC of 15. On initial questioning, he reported a recent use of heroin “yesterday” but was otherwise a poor historian with uncertainty of last day of drug use before then.Laboratory analysis was remarkable for a white blood cell count of 30.6 (3.5-10.1 bil/L), C-reactive protein of 39.1 (0.0-7.9 mg/L), creatine kinase of 302,793 (40-230 U/L), potassium of 9.1 (3.5-5.2 mmol/L), and troponins were elevated to 1.19 (0.00-0.03 ng/mL. Initial imaging (CT scans of the head, chest, abdomen, and pelvis) were negative. On hospital day 6 and 16, MRI exams of the brain were performed, which demonstrated isolated bilateral hippocampal infarcts (Figs. 1-6). No evidence of infection was found on a lumbar puncture and blood cultures were negative over the course of his hospital stay. Discussion The etiologies of hippocampal injury include: ischemia, infection, toxic/metabolic, paraneoplastic syndrome, and seizures. Toxic exposure secondary to heroin resulting in ischemia has been described in the medical literature (1). Interestingly, bilateral hippocampal infarction has also been described with acute cocaine intoxication (3). Ischemia is the most common neurovascular complication from opioid abuse (1). A pathologic study on chronic heroin addicts demonstrated gliosis preferentially within the Sommer sector of the hippocampus (CA1 region) (1). It is important to decipher if restricted diffusion in the hippocampus is in an arterial distribution (vascular etiology) vs non-vascular distribution. The hippocampus is located within an end arterial vascular territory and supplied by the anterior, middle, and posterior hippocampal arteries. These arteries create an anastomotic network but during ischemic conditions may lead to infarction. All the remaining etiologies, when seen with bilateral changes, can cause hippocampal dysfunctions such as anterograde amnesia syndromes, but have distinctly different imaging patterns. Limbic encephalitis may present with hippocampal edema with typically no restricted diffusion. A case report by Marinkovic et al. discussed that sudden memory loss, with prolonged cognitive impairment beyond 10 days was seen with hippocampal stroke in their patient (4). In a case series performed by Bhattacharyya et al. 16 patients with restricted diffusion or bilateral hippocampal lesions were studied. Of the 8 patients with presumed hypoxia, 5 presented with symptoms including confusion and amnesia. All the patients who survived the study had persistent anterograde amnesia ranging from a few days to 20 months, which suggest that the imaging findings regarding the bilateral hippocampal restricted diffusion are significant (2). An additional case series performed by Small et all. concluded that a common link of toxic exposure/substance abuse was present in their 4 patients with acute hippocampal gyriform ischemia. They also believe that these cases may be underestimated due to the nature of treating those with substance abuse and relating the patient’s neurological symptoms (confusion, memory loss) to general acute intoxication. The authors also note that bilateral symmetrical lesions, such as with this entity, may not be readily identified by radiologists which also leads to fewer accurate diagnoses (1). Conclusion Our case illustrates acute ischemia of the bilateral hippocampi as a complication of opioid abuse and as a rare cause for amnesia. The initial MRI of the brain demonstrated acute bilateral hippocampal ischemia. An additional small lacunar injury was seen in the left basal ganglia, further suggesting parenchymal ischemia. Over the course of his hospital stay, no clinical evidence was found for other differential diagnoses. The patients age and negative CT scans of the head, chest, abdomen, and pelvis made paraneoplastic syndrome (limbic encephalitis) unlikely. Negative blood cultures and lumbar punctures excluded underlying infectious process (like herpes simplex virus). The 10-day follow-up MRI of the brain demonstrated laminar necrosis and interval enhancement, evidence of evolving changes related to infarction. References: 1. Small, J. E., Butler, P. M., Zabar, Y., & Barash, J. A. (2016). Complete, bilateral hippocampal ischemia: a case series. Neurocase, 22(5), 411–415. doi:10.1080/13554794.2016.1213299 2. Bhattacharyya, S., Gholipour, T., Colorado, R. A., & Klein, J. P. (2017). Bilateral Hippocampal Restricted Diffusion: Same Picture Many Causes. Journal of Neuroimaging, 27(3), 300–305. doi:10.1111/jon.12420 3. Connelly, K.L, Chen, X. , Kwan, P.F. (2015). Bilateral hippocampal stroke secondary to acute cocaine intoxication. Oxford Medical Case Reports, March 2015 (issue 3), 215–217. doi:10.1093/omcr/omv016 4. Marinkovic I., Lyytinen J., Valanne L., Niinikuru R., Pekkonen E. Bilateral Hippocampal Infarction as Etiology of Sudden and Prolonged Memory Loss. Case Rep Neurol, 2012(4), 207–211. doi:10.1159/000345564 Vernon F. Williams DO is Diagnostic Radiology resident at Beaumont Hospital, Farmington Hills Campus in Michigan. Prior to residency, he completed undergraduate training at the University of Texas at Austin and Medical school at The University of North Texas Health Science Center, Texas College of Osteopathic Medicine. Dr. Williams will be starting an abdominal imaging fellowship at Vanderbilt University in Tennessee for the academic year of 2020-21. He is a case contributor for the recently published Top 3 Differentials in GI Radiology in 2019. Colby J. Jones DO is currently a Diagnostic Radiology resident at Beaumont Farmington Hills located in Farmington, MI. Prior to residency, he completed his undergraduate training at Morehead State University, majoring in Biomedical Science. He then completed his 4 years of medical school at the Kentucky College of Osteopathic Medicine. Over the course of his training, he has continued to realize the importance of diagnostic imaging and the direct effect it has on providing care to patients. After completion of his training, Dr. Jones plans to provide quality diagnostic care and support radiological growth in rural and underserved areas. Rocky Saenz DO FAOCR is currently a practicing Radiologist in Michigan at Beaumont, Farmington Hills, formerly Botsford Hospital. He is the Chairman of the Department of Radiology since 2019. He was Program Director for the Diagnostic Radiology Residency from 2009-2019 at Beaumont Farmington Hills, Botsford Campus, an affiliate of Michigan State University. He completed his first book in 2011, CT for the Non-Radiologist. He was awarded the title of “Fellow” by the American Osteopathic College of Radiology in 2015 (after 10 years of service). He then co-authored a 2nd book in 2015 Neuroradiology Case Review and completed the 2nd edition of CT for the Non-Radiologist in 2016. Dr. Saenz published his latest book in 2019 Top 3 Differentials in GI Radiology. He has published multiple articles in the following journals: American Journal of Roentgenology, Radiology, and Journal of the American Osteopathic College of Radiology and published on-line articles for European Society of Radiology, American College of Radiology, Resident and fellow Section of ACR, and American Journal of Orthopedics. He was awarded, faculty teacher/professor of the year 2019-2020 in the department of Radiology at Botsford Campus.

Global Radiology wishes to congratulate Dr. Grace Rubin on the publication of the paper: Imaging and clinical features of breast tuberculosis: a review series of 62 cases in Clinical Radiology. Dr. Rubin first presented her E-Poster for the paper at Global Radiology's Imaging in Prague 2019 congress and was awarded Best Poster in the category of Body Imaging. Dr. Rubin and her team at Helen Joseph Hospital in Johannesburg (University of Witwatersrand) performed a retrospective analysis of data from three academic teaching hospitals. Data was from pathologic sampling of all breast biopsies on patients over an 18-month period. Their research demonstrated the varied clinical and radiological features of breast tuberculosis. They concluded that there should be a high index of suspicion for TB in any young HIV positive woman with unilateral breast abnormalities which especially include: abscess, lymphadenopathy, and diffuse edema or skin thickening(1). They also state that core needle biopsy is preferred over fine-needle aspiration as it yields a better tissue sample and better yield for diagnostic purposes. The work is based on the masters thesis of lead author of the paper, Dr. Denny Matthew. Dr. Rubin is Clinical Head of Radiology, at Helen Joseph Hospital in Johannesburg, a University of Witwatersrand affiliated academic hospital. She was presented with the Award by Dr. Neil Rofsky, Body Imaging Faculty at Imaging in Prague 2019. Grace Rubin - Breast Tuberculosis - A review of 62 cases. E-Poster presented at Global Radiology's Imaging in Prague 2019 congress. Reference: 1. Mathew D, Rubin G, Mahomeda N, Rayne S. Imaging and clinical features of breast tuberculosis: a review series of 62 cases. Clinical Radiology. Article in Press. Accepted 10 March 2020. Published online. DOI: https://doi.org/10.1016/j.crad.2020.03.017

59 y/o female patient with pain in left groin following fracture of the left superior and inferior pubic ramus 12 months ago. Images demonstrate progression over a 10 month period. What is the diagnosis? Figure 1. Plain radiographs (A, C, E) and coronal CT (B,D, F) images of the left hip. Figure 2: Plain radiographs (A, C, E) and coronal CT (B,D, F) images of the left hip. A&B from July 2018 demonstrate evidence of focal hydroxyapatite deposition (HAD) at the left greater trochanter (red arrow). C&D from August 2018 and March 2019 demonstrate the start of a bony erosion (yellow arrow) and resorption of the calcium deposit (red arrow). E&F dated April and May 2019 show progression of the bony erosion (yellow arrow) and complete resorption of the calcium deposit (red arrow). Discussion Hydroxyapatite crystal deposition disease (HADD) is a condition of uncertain etiology characterized by periarticular and intra-articular deposition of hydroxyapatite crystals. Deposits of calcium hydroxyapatite crystals in the periarticular connective tissue and in other soft tissues can produce painful inflammatory reactions, but symptomatic deposits within the joints are rare. As seen in this case, occasionally crystal deposits result in cortical erosion and osseous invasion. Intraarticular deposits are rarely seen but can lead to rapid joint destruction, and when in the shoulder it is known as Milwaukee shoulder. In HADD, the majority of the patients are between the ages of 40 and 70 and the clinical picture is nonspecific with acute joint swelling, warmth, stiffness, and pain that may last for days to weeks and resolve spontaneously. The inflammation may lead to loss of range of motion and function of the involved joint. Symptomatic deposits may be seen in the soft tissues, secondary to generalized hypercalcemia or hyperphosphatemia. The most frequent and often asymptomatic form of HADD is seen in a periarticular distribution due to trauma and overuse. Most often affecting the shoulder it is known as calcific tendinitis or peritendinitis calcarea. Less frequently, intra-articular deposition of calcium hydroxyapatite may be secondary to generalized hypercalcemia or hyperphosphatemia or as part of a congenital metabolic disorder. Acute calcific periarthritis is an arthropathy with juxta-articular deposition of calcium hydroxyapatite crystals and local inflammation leading to acute pain usually involving a single finger or toe. The majority of calcium and phosphate in the body is stored in the skeleton as calcium hydroxyapatite. However, deposition of calcium hydroxyapatite in the soft tissues results in necrosis and disintegration of the tissue with associated surrounding inflammatory reaction. On radiographs, the calcifications are periarticular, round or oval shaped with well-defined borders (Fig. 2A, B). As in this case, there may be spontaneous resorption of the calcific bodies (Fig. 2E, F). The differential diagnosis includes calcium pyrophosphate dihydrate crystal deposition disease (CPPD), dystrophic calcification, renal osteodystrophy, hyperparathyroidism, hypoparathyroidism, tumoral calcinosis, collagen vascular disease, sarcoidosis, ochronosis, milk-alkali syndrome and gout. Treatment is usually conservative with analgesia and physiotherapy. Ultrasound barbotage (needling and lavage) or extracorporeal shockwave therapy has been used with some success in refractory cases. References: 1. Bohndorf K, Jobke B et al. Imaging of Bones and Joints - A Concise, Multimodality Approach; Thieme 2016: 458-465 https://www.thieme.com/books-main/orthopaedic-surgery/product/3594-imaging-of-bones-and-joints 2. Hottat N, Fumiere E, Declour C. Calcific tendonitis of the gluteus maximus tendon: CT findings. Eur Radiol 1999; 9:1104–1106. 3. Buckens CF, Terra MP, Maas M. Computed Tomography and MR Imaging in Crystalline-Induced Arthropathies. Radiol Clin North Am. 2017 Sep;55(5):1023-1034. Epub 2017 Jun 12. Review. doi: 10.1016/j.rcl.2017.04.008. 4. Freire, V., Moser, T.P. & Lepage-Saucier, M. Radiological identification and analysis of soft tissue musculoskeletal calcifications. Insights Imaging 9, 477–492 (2018). https://doi.org/10.1007/s13244-018-0619-0 5. Hongsmatip P, Cheng KY, Kim C, et. al. Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies. Eur J Radiol. 2019 Nov;120:108653. Epub 2019 Sep 8. Review. https://doi.org/10.1016/j.ejrad.2019.108653 6. Yang I, Hayes CW, Bierman JS. Calcific tendonitis of the gluteus medius tendon with bone marrow oedema mimicking metastatic disease. Skeletal Radiol 2002; 31:358–361. 7. Thornton MJ, Harries SR, Hughes PM, et. al. Calcific tendinitis of the gluteus maximus tendon with abnormalities of cortical bone. Clin Radiol 1998; 53:296–301. 8. Resnick D. Calcium hydroxyapatite crystal deposition disease. In: Diagnosis of bone and joint disorders. Philadelphia: Saunders, 2002: 1619–1657. Amazon 9. Flemming DJ, Murphey MD, Shkitka KM, et. al. Osseous involvement in calcific tendonitis: a retrospective review of 50 cases. AJR 2003; 181:965–972. 10. Chow H, Recht M, Schils J, Calabrese L. Acute calcific tendinitis of the hip. Arthritis Rheum 1997; 40:974–977. DOI: 10.1002/art.1780400528 11. Kraemer EJ, El-Khoury GY. Atypical calcific tendinitis with cortical bone erosion. Skeletal Radiol 2000; 29:690–996. DOI: 10.1007/s002560000278 12. de Witte PB, Kolk A, Overes F, et. al. Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids: Five-Year Outcomes of a Randomized Controlled Trial. Am J Sports Med. 2017 Dec;45(14):3305-3314. doi: 10.1177/0363546517721686. Björn Jobke, MD, is a practicing MSK radiologist, Senior Clinical Artificial Intelligence Advisor for Radiology, and sarcoma expert at Telemedicine Clinic (TMC)/Unilabs. Before entering radiology, he undertook a research doctorate at the Institute of Bone Pathology in Hamburg Germany, investigating sarcomas and metabolic bone diseases. He performed an MSK research post-doctorate at UCSF and a clinical MSK fellowship in Leiden, Holland. Later, he was the lead radiologist in several German sarcoma centers.Dr. Jobke has published numerous articles and co-authored several book chapters, including on sarcomas in a popular MSK reference book. He was a lecturer at several MSK meetings including ISS, ESSR and TMC Academy meetings. Radiological-pathological synopsis was the fundamental basis of his early training and which he continues to be passionate about and eager to pass on his knowledge. Since 2016 Dr. Jobke has worked for TMC’s musculoskeletal section and is based in San Francisco. https://www.linkedin.com/in/bj%C3%B6rn-jobke-679b8497/ https://www.doximity.com/pub/bjorn-jobke-md https://academy.telemedicineclinic.com/image-reporting-simulator/2858/soft-tissue-tumour-basics-i/