Search Results

Flat Foot and Pain with Walking • Xray of the Week 2016 • Week #41 56 y/o female with chronic anterior talofibular ligament (ATFL) tear, flat foot, and pain with walking. What is the diagnosis? Fig. 1. Images show loss of fatty tissue, edema as well as scarring (arrows). Fig. 2 Normal appearance of the sinus tarsi with preserved fatty tissue – 3T Fig. 3 Note pes planus and mid foot arthrosis on sagittal image. Coronal Fat Sat image shows edema and scar. Fig. 4 Axial fat sat (left image) and T1 image shows loss of fatty tissue, edema as well as scarring (orange arrows). Fig. 5 Edema and scarring and reactive osseous edema (blue arrows) Fig. 6 Normal ligaments of the sinus tarsi. Discussion Sinus Tarsi Syndrome usually presents with lateral foot pain and tenderness. There may be subtalar micro-instability; however, frank ankle instability is usually not present. Pathologically there is scarring and degenerative changes of soft-tissue structures in the sinus tarsi. Seventy percent of patients have a history of inversion injury with lateral ligament complex tears, and it is frequently associated with posterior tibial tendon injury. On MRI, in the acute setting there is increased signal in fat on T2 weighted images due to edema. [Fig. 3-5] There may also be reactive osseous edema with high signal on PD and T2 weighted fat saturation images[Fig.5] Treatment of sinus tarsi syndrome is usually conservative, with initial immobilization and anti-inflammatory drugs, followed by physiotherapy. References: 1. Helgeson K. Examination and intervention for sinus tarsi syndrome. N Am J Sports Phys Ther. 2009;4 (1): 29-37. 2. Lee KB, Bai LB, Park JG et-al. Efficacy of MRI versus arthroscopy for evaluation of sinus tarsi syndrome. Foot Ankle Int. 2008;29 (11): 1111-6. 3. Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology. 1993;186 (1): 233-40. 4. Herrmann M, Pieper KS. [Sinus tarsi syndrome: what hurts?]. Unfallchirurg. 2008;111 (2): 132-6. 5. Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Refresher Courses. Radiological Society of North America. MR imaging of the ankle and foot. Radiographics. 2000;20 Spec No : S153-79. 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 All posts by Kevin Rice, MD

Headaches and confusion in 55F • Xray of the Week 2016 • Week #3 This 55 year old Hispanic female with past medical history of type 2 diabetes, hypertension, and hyperlipidemia, presented with 3 days of headaches and confusion. An MRI brain was performed, and due to the findings, genetic testing was performed. A mutation on chromosome 19q12 involving the Notch 3 gene was discovered. What is the diagnosis? Figure 1. CADASIL A: MRI- FLAIR axial image shows symmetric T2 hyperintensities in the anterior temporal lobes. B: MRI- DWI axial image shows no acute infarct. Figure 2. CADASIL Patient #2 A: MRI- FLAIR axial image shows symmetric T2 hyperintensities in the anterior temporal lobes in patient #2. B: MRI- FLAIR axial image shows confluent symmetric white matter T2 hyperintensity changes in patient #2. Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is an autosomal dominant condition which has an onset of symptoms between ages 30 to 50. [1,2] The gene mutation causes small vessel and arteriole stenosis as a result of fibrotic thickening of the basement membrane of the vessels. Symptoms are non-specific but may include weakness, dementia, focal neurological defects, and seizures due to recurrent transient ischemic attacks (TIA's). [1,2,3] On MRI, the anterior temporal lobes are affected up to 86% of the time [Fig. 1] and the external capsule is affected in up to 93% of cases at presentation. There are often confluent white matter regions of increased signal intensity on T2 weighted images, with a predilection for the anterior temporal lobe [Fig 2]. More circumscribed lesions may also be visualized in the basal ganglia, thalamus and pons; however, there is usually sparing of the cortex and subcortical U-fibers. [1,2] Treatment is supportive, and prognosis is poor as symptomatology is progressive. [1,3] References: 1. Yousry TA, Seelos K, Mayer M et-al. Characteristic MR lesion pattern and correlation of T1 and T2 lesion volume with neurologic and neuropsychological findings in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). AJNR Am J Neuroradiol. 1999;20 (1): 91-100. 2. Auer DP, Pütz B, Gössl C et-al. Differential lesion patterns in CADASIL and sporadic subcortical arteriosclerotic encephalopathy: MR imaging study with statistical parametric group comparison. Radiology. 2001;218 (2): 443-51. 3. Bohlega S, Al Shubili A, Edris A et-al. CADASIL in Arabs: clinical and genetic findings. BMC Med. Genet. 2007;8 : 67. 4. Lotz PR, Ballinger WE, Quisling RG. Subcortical arteriosclerotic encephalopathy: CT spectrum and pathologic correlation. AJR Am J Roentgenol. 1986;147 (6): 1209-14. Danielle Rice, MD is a neurohospitalist at Gottlieb Memorial Hospital, a part of Loyola University Health System. Dr. Rice graduated cum laude from Kent State University and earned her medical degree from Northeastern Ohio Universities College of Medicine. Dr. Rice completed a residency in adult neurology from Rush University Medical center and a fellowship in multiple sclerosis from the University of Chicago. Dr. Rice is board certified in Neurology and is an assistant professor in the Department of Neurology of Loyola University Chicago Stritch School of Medicine. Kevin Rice, MD is president of Global Radiology CME. Follow Dr. Kevin Rice on Twitter @KevinRiceMD All Posts by Kevin M Rice, MD All Posts by Danielle Rice, MD

27 year old Female with Palpable Right Breast Mass • Xray of the Week 2016 • Week #30 A 27-year-old, African American female presented with a right breast mass, palpable for one year. Given the patient’s age, an ultrasound was performed. The findings prompted a mammogram. What is the diagnosis? Left: Medial lateral oblique (MLO) mammogram of right breast. Mammogram revealed two irregular, spiculated masses with pleomorphic calcifications involving the entire upper, outer quadrant of the right breast, corresponding to this patient’s region of palpable lesion. Right: Breast ultrasound showing an irregular, hypoechoic mass with posterior shadowing. There are also bright internal echoes consistent with microcalcifications. Mild increased flow is present with color Doppler sonography. Fig.2 Spot magnification views of right breast demonstrate pleomorphic calcifications and irregular, spiculated masses Fig.3 Ultrasound demonstrating dilated ducts with internal echos in the periareolar breast adjacent to the mass. DIAGNOSIS: An ultrasound core biopsy was performed. Pathology was invasive ductal (IDC), grade 2 and ductal carcinoma in situ (DCIS), comedo type with high nuclear grade, Estrogen and Progesterone Receptor Positivity (ER/PR +), and HER2/neu 2+ (equivocal). DISCUSSION: In younger women, palpable masses are often benign and related to hormonal influences, commonly fibroadenomas, and cysts, or galactoceles in pregnant or breastfeeding females. Fibroadenomas are the most common benign breast tumor, especially in African American women and women under the age of 30. However, ultrasound imaging of a fibroadenoma will typically reveal a circumscribed, hypoechoic mass which often has posterior acoustic enhancement. A cyst would demonstrate circumscribed margins, be anechoic, and have posterior acoustic enhancement. This patient’s mass did not demonstrate benign characteristics, thus prompting mammographic evaluation. The features of this patient’s mass, including the irregular margins, suspicious calcifications, hyperemia and associated dilated ducts with internal echos are all common appearances for IDC and DCIS on mammogram and ultrasound. The incidence of breast cancer is very low in young females. For women under the age of 40, the risk of developing breast cancer within 10 years is less than 2%. However, African American women have higher rates of premenopausal breast cancer in comparison to other groups. It is important to closely evaluate the ultrasound appearance of masses in women under the age of 30. Characteristics associated with malignancy include: spiculation, taller than wide, microlobulations, angular margins, markedly hypoechoic nodule, posterior acoustic shadowing, punctate calcifications, or duct extension. If there are any of these suspicious findings, further imaging with mammography is required. References: 1. American Cancer Society. Cancer Facts & Figures for African Americans: 2013-2014, 2013 2. Dogan BE, Ceyhan K, Tukel S, Saylisoy S, Whitman GJ. Ductal dilatation as the manifesting sign of invasive ductal carcinoma. J Ultrasound Med. 2005 Oct;24(10):1413-7. Available at: http://www.jultrasoundmed.org/content/24/10/1413.full#ref-1 doi:10.1148/radiol.2423051631 3. Jokich PM, Monicciolo DL, Adler YT: Breast ultrasonography. Radiol Clin North Am 30:993-1009, 1992. 4. Kaur, K. (2014, July 2). Breast Lumps in Young Women: Diagnostic Approaches. Retrieved July 9, 2016, from http://reference.medscape.com/features/slideshow/breastlumps#9 Dr. Anjali Malik received her B.A. in Public Health from The Johns Hopkins University and her MD from Tulane University. She completed her residency in Diagnostic Radiology at the University of Texas - Southwestern with Dr. Neil Rofsky. In 2013, Dr. Malik commenced a Breast Imaging Fellowship with Dr. Rachel Brem at George Washington University. Currently, she is a Breast Imaging and Intervention Specialist at Eastern Radiologists, Inc in Greenville, NC. She is passionate about breast imaging, women’s health issues, and preventive medicine. Follow Dr. Malik on Twitter @AnjaliMalikMD Shannon Maree Osborne is in the Class of 2019 at The Brody School of Medicine at East Carolina University Related Cases: Phyllodes Tumor Medullary Carcinoma of the Breast

Enlarging Painless Right Upper Thigh Mass • Xray of the Week This 26 y/o male presented with a right upper inner thigh mass for over a year. The mass was painless and growing. What is the differential diagnosis? (Left) T2 weighted coronal image demonstrating a high signal intensity lobulated medial right thigh mass. (Right) FSE PD weighted axial image with fat saturation demonstrating the markedly hyperintense mass. (yellow arrows) Above: T1 weighted coronal image demonstrating a low signal intensity lobulated subcutaneous right thigh mass. Discussion Biopsy of this mass demonstrated a schwannoma. The appearance of the mass is non-specific. However, there are multiple ring-like hypointense structures, consistent with the fascicular sign (1, 2,4). Although this mass is not located along the anatomic course of a peripheral nerve, the appearance is suspicious for peripheral nerve sheath tumor due to the presence of the fascicular sign. The fascicular sign is characterized by multiple small ring-like structures with peripheral hyperintensity on T2 weighted images representing the fascicular bundles within the nerves. Other signs of Schwannoma or neurofibroma include the tail, target, bag-of-worms, and split-fat signs. (4) The target sign is characterized by peripheral high T2 signal and central low signal on T2 weighted images. The split-fat sign is visualized as a thin peripheral rim of fat best seen on planes along long axis of the lesion in non-fat-suppressed images. The vast majority (approx 90%) of schwannomas are solitary. Multiple schwannomas are virtually diagnostic of Neurofibromatosis 2 (NF2). However up to 20% of solitary schwannomas are seen with NF2. Clinical presentation is usually a painless mass; however, there may be symptoms related to local mass effect or dysfunction of the nerve from which the tumor arises. Differential diagnosis for soft tissue masses is broad (1): Mesenchymal Tumors: Dermatofibrosarcoma protuberans, Lipoma, Angiomas (hemangioma, lymphangioma), Peripheral nerve sheath tumor (schwannoma, neurofibroma), Malignant fibrous histiocytoma, Liposarcoma, Leiomyosarcoma, Fibromatosis Skin Appendage Lesions: Epidermal inclusion cyst, Pilomatricoma, Cystadenoma Metastatic Tumors: Carcinoma, Melanoma, Myeloma Other Tumors and Tumor-like Lesions: Myxoma, Lymphoma Inflammatory Lesions: Cellulitis, Fasciitis, Adenitis, Abscess References: 1. F D Beaman, M J Kransdorf, et al. Superficial Soft-Tissue Masses: Analysis, Diagnosis, and Differential Considerations. RadioGraphics 2007; 27:509 –523 2. F D Beaman, MD, M J Kransdorf, MD. Schwannoma: Radiologic-Pathologic Correlation. RadioGraphics 2004; 24:1477–1481 3. A Chhabra and T Soldatos. Soft-Tissue Lesions: When Can We Exclude Sarcoma? AJR 2012; 199:1345–1357 4. Chandan Kakkar, et al. Telltale signs of peripheral neurogenic tumors on magnetic resonance imaging. Indian Journal of Radiology and Imaging. 2015, Volume 25 Page: 453-458 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 M. 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 and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin Rice, MD

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