2.

Cohen

3.

Shellock FG. Monitoring during MRI: an evaluation of the effect of high-field MRI on various patient monitors. Med Electronics September 1986: 93-97. Edelman RR, Shellock FG, Ahladis J. Practical MRI for the technologist and imaging specialist. In: Edelman RR, Hesselink J, eds. Clinical magnetic resonance imaging. Philadelphia: Saunders, 1990.

4.

5.

MD.

Pediatric

Shellock

FG.

onance

imaging.

Patient

U

sedation.

Biological

effects

Magn

and

Q

Reson

Harvard

Medical

Francis

1990;

safety

1989;

Confidentiality

175:611-612.

aspects

of magnetic

res-

5:243-261.

Brigham

and

Women’s

Hospital,

Boston,

MA

radiologists

02115

sponsibility not typically

to respect have the

have patient same

both

a legal

and

an

ethical

While

confidentiality (1). depth of doctor-patient

re-

we do

relation-

ship that the primary physician has, there is still the implied promise by all physicians not to disclose information about patients without their consent. The radiologist’s relationship with a patient ranges from interpreting a radiograph, in which case there is usually no direct contact, to performing a diagnostic or interventional study, where one does have some degree of direct contact with the patient. The patient’s right to confidentiality is the same, no matter what the depth of the doctor-patient relationship. A patient’s right to confidentiality takes many forms. The flagrant, intentional disclosure of confidential patient information is rare. Unauthorized disclosure to third parties and discussion

of a patient’s

disease

in public

areas

of the

hospital

are breaches of confidentiality against which all physicians must constantly be on guard. There is another, perhaps less obvious area of concern, which is the reason for this letter. Disclosure of clinical information, whether for research or teaching purposes, at society meetings and continuing education courses is a breach of confidentiality if a particular patient can be identified. It is conceivable that a patient would

give

explicit

permission

to be identified,

but this would

occurrence,

since

the

overwhelming

majority

phy,

or

tient’s opposed which

magnetic

resonance

images,

name is relatively large with to traditional radiographs. the patient can be identified

dentiality,

but

Radiologists

this

seems

should

be

where

the

size

of the

pa-

respect to image size, as Publication of images in is also a breach of confi-

to be an

even

grateful

to patients

more

rare for

occurrence. providing

material to use for research and educational purposes. Let us, at the least, respect their right to confidentiality. Whoever photographs images that will be used for a presentation should be aware that patient names should be removed from final

image.

The

ultimate

responsibility,

however,

lies

with the physician who presents the image. Despite its rare occurrence, the presentation of images in which the patient can be identified is something that all presenters should strive to prevent. Awareness of this responsibility should help prevent such a breach of patient confidentiality.

writing

Manage

Volume

BD.

The

patient’s

right

1989; 4:204-209.

177 #{149} Number

2

to confidentiality.

that

information

this

we

point

find

the

article,

we

on that

same

true

increase

of our

screening

Division

have

continued

group to be

We have

mammograms

for

developed

to gather

of patients,

the possibility

sensitivity.

that time, 1 1 of 208 total cancers er but were picked up by virtue We

have

sensitivity

mentioned

might

and

that double

been the

double past

reading

reading

3 years.

for independent

all

During

first read-

were missed by the of double reading.

a system

at

86.5%.

double

read-

ing (with the use of automated multiviewers) that is quite ficient and results in very little increase in total radiologist time. We have not increased the cost to the patient because double reading.

The authors efit

are certainly

of a medical

audit.

correct

We have

about

learned

The authors are also correct takes to perform an ongoing is streamlined

tine,

as they

considerably

I hope raphy

that all

will

heed

its

take

radiologists

the

and

time engaged

time

to read

and effort it if the procedure

will

part

of the

rou-

be required.

in screening

this

benre-

and false-negative

it becomes

additional

of

by careful

about the time audit. However,

suggest

less

ef-

the educational more

view of our true-positive, false-positive, cases than we have by any other means.

mammog-

important

article

and

message.

References 1

.

Murphy assurance

WA Jr. Destouet for mammography

JM, Monsees screening

BS. Professional quality programs. Radiology 1990;

175:319-320. 2.

Bind RE. Low-cost screening mammography: report on finances and review of 21,716 consecutive cases. Radiology 1989; 171:87-90.

U

Comparison

J Med

Pract

of Digital and Radiography: Study

Musculoskeletal Performance

Conventional Observer

From: John

M. Bramble,

MD,

Department Medical

of Diagnostic Center

39th

and

Street

and

Mark

D. Murphey,

Radiology,

Rainbow

MD

University

Boulevard,

Kansas

of Kansas

City,

KS 66103

Editor:

In the April well-designed

ventional

1990 issue and

radiography

of Radiology,

executed

study

Wegryn comparing

(1). The results

et al presented digital

do not agree

a

and

with

con-

the

findings quirements

in our studies of digital image spatial resolution refor nondisplaced fractures and subperiosteal resorption (2,3). Wegryn et al reach the conclusion that a matrix size of 1,024 X 840 X 12 bits (1.5 line pairs per millimeter [lp/ mm]) is sufficient for identification of many musculoskeletal abnormalities and that 2,048 X 1,680 X 12 bits (2.5 lp/mm) is needed

Reference 1. Hirsh

Radiology NC 28204

of pre-

senters do not show such an image. It almost certainly is not intentional and probably occurs as an oversight or perhaps from lack of awareness that this is a breach of confidentiality. It is more likely to occur with ultrasound, computed tomogra-

the

Since

follow-up

be

the exception and not the rule. The statistical presentation of data certainly poses no threat to patient confidentiality (1). I have been dismayed at times, however, to see images presented where the patient’s name can be read. Such a presentation is a rare

for

Editor:

The authors

physicians,

Assurance Programs

Richard E. Bird, MD Charlotte Radiology, Providence 1611 East Third Street, Charlotte,

Editor: As

Quality Screening

From:

91.5%.

School

Street,

U Professional Mammography

The article by Drs Murphy, Destouet, and Monsees (1), which appeared in the May 1990 issue of Radiology, was excellent and made several very important points. The authors mentioned the likelihood of underestimating the magnitude of false-negative mammographic interpretations on an initial medical audit. We reported the results of the medical audit of our screening program in the April 1989 issue of Radiology (2). At that time we reported sensitivity of

in Radiology

From: Douglas L. Brown, MD Department of Radiology, 75

Radiology

for

visualization

of some

abnormalities.

of nondisplaced fractures, we concluded resolution less than 2.88 lp/mm could nostic performance. There are important

In

the

study

that using a spatial adversely affect diagpoints that we would

Radiology

#{149} 587

like to emphasize olution

in comparing

requirements

The design

the two studies musculoskeletal

in digital

of the two

studies

affects

the

results. The primary differences between by Wegryn et al are in case selection monitors versus laser-printed films. ed cases of subperiosteal resorption tures, as well as normal controls. We cifically because they were small or

interpretation

subtle

because

of the

studies and the study and use of computer

For our studies, we selectand nondisplaced fracchose these lesions spethin, and decreasing spa-

acteristic analysis that better represents work. As noted by Wegryn et al, some

of overlapping

spatial

the task of everyday of their selected lesions

It is reasonable

to speculate that lesions may be subtle for a variety of causes, including small size, overlapping shadows, and faint difference in contrast from the background (4). Mild decreases in spatial resolution with some subtle lesions (due to overlapped structures

or

detect

them.

faint

contrast)

The

differences

do

not

necessarily

in case

selection

affect

ability

could

account

to

for the discrepancy in results. On the basis of the results of Wegryn et al, it would be reasonable to use digital images of lower spatial resolution for the usual case mix of skeletal radiology.

The

lows

design

of the

this conclusion.

sion. Our is important

study

(using

a mixture

We do not disagree

selection points

of subtle cases out exceptions

incidence

their

a!-

conclu-

for which spatial resolution to the general rule support-

ed by the findings of Wegryn et al. In clinical practice, it is easy to identify a higher

of cases)

with

of subperiosteal

cases

resorption

that

will

(and

have

thereby

need a high-resolution study). Those patients with a history of chronic renal failure are known by clinical evaluation. A greater problem in clinical practice is to identify patients at risk for nondisplaced fractures. However, the delay in diagnosis

of many

the

nondisplaced

morbidity

and

fractures

mortality,

does

provided

not

usually

increase

the injured part is propatients who will re-

tected with a splint. Usually these are turn for follow-up assessment with repeat bone scintigraphy. There are some clinical

examinations or settings in which

delay

increase

in diagnosis

of even

a few

days

may

a

morbidity

and mortality. One such clinical setting is nonaccidental trauma. Our data suggest that higher-spatial-resolution images are necessary for adequate detection of metaphysea! corner fractures

in infants.

There

also be considered, ficiency

have

fractures

data

Using server

are other

such in

on those computer

(as used detection

that

osteoporotic

monitors measures

is a double-edged

the image film with

sword.

information a full 12-bit

in our studies). The improved contrast of subtle abnormalities. Furthermore,

zooming capabilities of computer-controlled displays the observer to take advantage of viewing techniques have been shown to improve performance. However, gryn et a! suggest, the radiologist must be willing to time to manipulate zoom and contrast. In other words, diologist

may

the computer

be either

display

should

spine fractures and insufhips. However, we do not fractures. versus laser-printed film for ob-

computer monitor can display greater contrast than a printed width cilitate

settings

as cervical

particular

performance

clinical

more

compared

accurate

with

or less

reading

accurate

The

with window can fathe

allow that as Wetake

the

the rausing

laser-printed

film. The radiologist can be more accurate with computer displays if more time is taken with manipulating the windows. It can also be argued that use of laser-printed films with a full 12-bit contrast range reduces the ability to detect the subtle findings. However, subjectively, all fractures were just as easy to see on the laser-printed films as on the conventional films in our studies. Therefore, we propose that case selection contributed more to the difference in results than did reading from computer monitors or laser-printed films. Reading from computer monitors may have contributed to interobserver variance There

in

the

study

are three

588 #{149} Radiology

by

points

Wegryn

et al.

that we would

like to add about

both

diagnostic

importance

of contrast

range,

contrast

resolution.

A 1,024

X 840

image

matrix

may

less

have

than 1-lp/mm resolution, while a 128 X 128 image matrix may have greater than 3-lp/mm resolution. Wegryn et al acknowledge this by reporting the measured spatial resolution in line pairs per millimeter. We wish to emphasize to the general audience that matrix size is not equivalent to spatial resolution. The third point is that the arguments about spatial resolution requirements for skeletal radiology have concentrated on the issue of what is necessary for diagnostic-quality digital images. The term “diagnostic quality” refers to the issue of replacing conventional studies with digital studies. With few exceptions, teleradiology equipment is not of diagnostic quality when used for conventional plain radiography. Most studies that are transmitted to an on-call radiologist are read twice, once with the teleradiology setup and subsequently from the film hard copy. When studies are read twice, the issue of the significance of delay of diagnosis is more important than diagnostic quality is. In summary, we suggest the following interpretation based on the multiple experiments at the Cleveland Clinic Foundation and the University of Kansas. For most examinations in skeletal radiology, a spatial resolution of 1.25 lp/mm is sufficient for diagnostic digital images and teleradiology, but 2.5 lp/mm is preferable. For certain examinations, higher spatial resolution is recommended, such as for subperiosteal resorption and nonaccidental trauma of infants. Continued research is likely to identify other clinical settings in which higherspatial-resolution images are required in skeletal and chest radiography.

lesions. Wegryn operating char-

structures.

The

resolution, and signal-to-noise ratio has not been studied in digital skeletal radiology. In some situations, the contrast resolution may be more important than the spatial resolution. In teleradiology systems based on video digitizers, contrast dynamic range is often more of a problem than spatial resolution. The second point is that matrix size is not equivalent to

our

tial resolution increases the subtlety of these et al chose a mixture of cases for free receiver

were

studies.

of spatial-resradiology.

References 1. Wegryn SA, Piraino DW, Richmond BJ, et al. Comparison of digital and conventional musculoskeletal radiography: an observer performance study. Radiology 1990; 175:225-228. 2. Murphey MD, Bramble MD, Cook LT, Martin NL, Dwyer SJ. Nondisplaced fractures: spatial resolution requirements for detection with digital skeletal imaging. Radiology 1990; 174:865-870. 3. Murphey MD. Digital skeletal radiography: spatial resolution requirements for detection of subpeniosteal resorption. AJR 1989; 152:541-546. 4. Kundel HL, Revesz G. Lesion conspicuity, structured noise, and film reader error. AJR 1976; 126:1233-1238.

Di

and

Wegryn

Piraino

respond:

We appreciate the comments of Drs Bramble and Murphey, as well as their interest in resolution requirements for digital musculoskeletal radiology. As mentioned by Drs Bramble and Murphey, the case selection in our study emphasized a variety of musculoskeletal pathologic lesions, both subtle and nonsubtie. Although the lesions chosen represented a wide spectrum of disease, it would be misleading to classify the subtle cases as representing the “usual mix” in skeletal radiology. For example, of the 17 fracture cases classified as subtle, 10 (59%) were nondisplaced fractures. All of our subtle nondisplaced fractures could

be identified

on the monitor Subjectively,

at the

with some

2.5-lp/mm

resolution

appropriate fractures

window

appeared

when

viewed

and center

more

settings. to

conspicuous

readers when viewed on the digital system when window and level settings were optimized. Our purpose in evaluating images on an interactive video monitor was to maximize contrast

resolution.

fers from digitally

Whether

interpretations generated

testing. A disadvantage itor is the increased

lesion

conspicuity

on the video laser-printed

of interpretation reading time

films

significantly

display will

dif-

monitor require

versus

further

from a video display incurred. In our study, November

monthere 1990

like to emphasize olution

in comparing

requirements

The design

the two studies musculoskeletal

in digital

of the two

studies

affects

the

results. The primary differences between by Wegryn et al are in case selection monitors versus laser-printed films. ed cases of subperiosteal resorption tures, as well as normal controls. We cifically because they were small or

interpretation

subtle

because

of the

studies and the study and use of computer

For our studies, we selectand nondisplaced fracchose these lesions spethin, and decreasing spa-

acteristic analysis that better represents work. As noted by Wegryn et al, some

of overlapping

spatial

the task of everyday of their selected lesions

It is reasonable

to speculate that lesions may be subtle for a variety of causes, including small size, overlapping shadows, and faint difference in contrast from the background (4). Mild decreases in spatial resolution with some subtle lesions (due to overlapped structures

or

detect

them.

faint

contrast)

The

differences

do

not

necessarily

in case

selection

affect

ability

could

account

to

for the discrepancy in results. On the basis of the results of Wegryn et al, it would be reasonable to use digital images of lower spatial resolution for the usual case mix of skeletal radiology.

The

lows

design

of the

this conclusion.

sion. Our is important

study

(using

a mixture

We do not disagree

selection points

of subtle cases out exceptions

incidence

their

a!-

conclu-

for which spatial resolution to the general rule support-

ed by the findings of Wegryn et al. In clinical practice, it is easy to identify a higher

of cases)

with

of subperiosteal

cases

resorption

that

will

(and

have

thereby

need a high-resolution study). Those patients with a history of chronic renal failure are known by clinical evaluation. A greater problem in clinical practice is to identify patients at risk for nondisplaced fractures. However, the delay in diagnosis

of many

the

nondisplaced

morbidity

and

fractures

mortality,

does

provided

not

usually

increase

the injured part is propatients who will re-

tected with a splint. Usually these are turn for follow-up assessment with repeat bone scintigraphy. There are some clinical

examinations or settings in which

delay

increase

in diagnosis

of even

a few

days

may

a

morbidity

and mortality. One such clinical setting is nonaccidental trauma. Our data suggest that higher-spatial-resolution images are necessary for adequate detection of metaphysea! corner fractures

in infants.

There

also be considered, ficiency

have

fractures

data

Using server

are other

such in

on those computer

(as used detection

that

osteoporotic

monitors measures

is a double-edged

the image film with

sword.

information a full 12-bit

in our studies). The improved contrast of subtle abnormalities. Furthermore,

zooming capabilities of computer-controlled displays the observer to take advantage of viewing techniques have been shown to improve performance. However, gryn et a! suggest, the radiologist must be willing to time to manipulate zoom and contrast. In other words, diologist

may

the computer

be either

display

should

spine fractures and insufhips. However, we do not fractures. versus laser-printed film for ob-

computer monitor can display greater contrast than a printed width cilitate

settings

as cervical

particular

performance

clinical

more

compared

accurate

with

or less

reading

accurate

The

with window can fathe

allow that as Wetake

the

the rausing

laser-printed

film. The radiologist can be more accurate with computer displays if more time is taken with manipulating the windows. It can also be argued that use of laser-printed films with a full 12-bit contrast range reduces the ability to detect the subtle findings. However, subjectively, all fractures were just as easy to see on the laser-printed films as on the conventional films in our studies. Therefore, we propose that case selection contributed more to the difference in results than did reading from computer monitors or laser-printed films. Reading from computer monitors may have contributed to interobserver variance There

in

the

study

are three

588 #{149} Radiology

by

points

Wegryn

et al.

that we would

like to add about

both

diagnostic

importance

of contrast

range,

contrast

resolution.

A 1,024

X 840

image

matrix

may

less

have

than 1-lp/mm resolution, while a 128 X 128 image matrix may have greater than 3-lp/mm resolution. Wegryn et al acknowledge this by reporting the measured spatial resolution in line pairs per millimeter. We wish to emphasize to the general audience that matrix size is not equivalent to spatial resolution. The third point is that the arguments about spatial resolution requirements for skeletal radiology have concentrated on the issue of what is necessary for diagnostic-quality digital images. The term “diagnostic quality” refers to the issue of replacing conventional studies with digital studies. With few exceptions, teleradiology equipment is not of diagnostic quality when used for conventional plain radiography. Most studies that are transmitted to an on-call radiologist are read twice, once with the teleradiology setup and subsequently from the film hard copy. When studies are read twice, the issue of the significance of delay of diagnosis is more important than diagnostic quality is. In summary, we suggest the following interpretation based on the multiple experiments at the Cleveland Clinic Foundation and the University of Kansas. For most examinations in skeletal radiology, a spatial resolution of 1.25 lp/mm is sufficient for diagnostic digital images and teleradiology, but 2.5 lp/mm is preferable. For certain examinations, higher spatial resolution is recommended, such as for subperiosteal resorption and nonaccidental trauma of infants. Continued research is likely to identify other clinical settings in which higherspatial-resolution images are required in skeletal and chest radiography.

lesions. Wegryn operating char-

structures.

The

resolution, and signal-to-noise ratio has not been studied in digital skeletal radiology. In some situations, the contrast resolution may be more important than the spatial resolution. In teleradiology systems based on video digitizers, contrast dynamic range is often more of a problem than spatial resolution. The second point is that matrix size is not equivalent to

our

tial resolution increases the subtlety of these et al chose a mixture of cases for free receiver

were

studies.

of spatial-resradiology.

References 1. Wegryn SA, Piraino DW, Richmond BJ, et al. Comparison of digital and conventional musculoskeletal radiography: an observer performance study. Radiology 1990; 175:225-228. 2. Murphey MD, Bramble MD, Cook LT, Martin NL, Dwyer SJ. Nondisplaced fractures: spatial resolution requirements for detection with digital skeletal imaging. Radiology 1990; 174:865-870. 3. Murphey MD. Digital skeletal radiography: spatial resolution requirements for detection of subpeniosteal resorption. AJR 1989; 152:541-546. 4. Kundel HL, Revesz G. Lesion conspicuity, structured noise, and film reader error. AJR 1976; 126:1233-1238.

Di

and

Wegryn

Piraino

respond:

We appreciate the comments of Drs Bramble and Murphey, as well as their interest in resolution requirements for digital musculoskeletal radiology. As mentioned by Drs Bramble and Murphey, the case selection in our study emphasized a variety of musculoskeletal pathologic lesions, both subtle and nonsubtie. Although the lesions chosen represented a wide spectrum of disease, it would be misleading to classify the subtle cases as representing the “usual mix” in skeletal radiology. For example, of the 17 fracture cases classified as subtle, 10 (59%) were nondisplaced fractures. All of our subtle nondisplaced fractures could

be identified

on the monitor Subjectively,

at the

with some

2.5-lp/mm

resolution

appropriate fractures

window

appeared

when

viewed

and center

more

settings. to

conspicuous

readers when viewed on the digital system when window and level settings were optimized. Our purpose in evaluating images on an interactive video monitor was to maximize contrast

resolution.

fers from digitally

Whether

interpretations generated

testing. A disadvantage itor is the increased

lesion

conspicuity

on the video laser-printed

of interpretation reading time

films

significantly

display will

dif-

monitor require

versus

further

from a video display incurred. In our study, November

monthere 1990

was a 40% increase

in reading

time

when

images

were

read

from the video display monitor compared with the original radiograph. We believe that most radiologists analyze images for an appropriate length of time to ensure their satisfaction, so that use of the video monitor itself would not cause a reading to be more or less accurate. We agree with Dna Bramble and Murphey that certain clinical settings dictate the need for a higher-resolution radiographic study. A spatial resolution greater than 2.5 lp/mm is likely to be necessary for those special circumstances in which one would normally obtain a high-resolution or magnification image. Scott

A. Wegryn,

Department

MD,

and

David

of Diagnostic

Foundation 9500 Euclid

W. Piraino,

Radiology,

not

This letter to adopt

controlled

Clinic

who

Cleveland,

OH

Tube

1.

2. 3.

5.

Recanalization

for

6.

7.

From:

and

R#{246}schreport

the

data

on

100

it is difficult to alization procedure.

attribute

with

patency.

subsequent

Obviously,

consecutive

unilateral

tubal ococclusion,

to the recando occur to acknowledge can

The authors

and

seem this point because they also present a much smaller retroactively selected patient population with bilateral occlusion. While pregnancy rates in that group appear comparable to those in the larger patient population, this patient population included only 20 women, a rather small number on which to

base statistical

conclusions.

Thurmond and R#{246}schkindly refer in their concluding paragraph to our experience (3). The quoted data from our pilot study are by now outdated. Since 1988 we have been perform-

ing balloon

catheterization

tuboplasty

[TBT])

procedures

under

a protocol

(transcervical approved

Administration (FDA), which coast to coast in a multicenter experience of this trial was presented

of the American

Infertile

patients,

in

ing victims of abuse ious new technologies

clusions

approach should

like to suggest ed under procedure

an

be

Society

recently

nonsurgical.

that their

FDA-approved is introduced

At

catheterization multicenter to a broader

and (though the

often

introduction reproduction

to the attention

as Thurmond toward many

U.S.

the

(5). are quite

desperation,

(6). The uncontrolled involving assisted

even brought this issue (7). We are as convinced therapeutic

Fertility their

balloon Food

involves six teaching trial. The prelimiat the 45th Annual

and Drug institutions

nary Meeting

by

same

willof varhas

of Congress

R#{246}sch that the not all) tubal octime,

procedure

we

would

be evaluat-

protocol before public. While we

the have

no doubt that their center is exceptionally qualified to perform the procedure, we have seen no evidence that this skill can easily be transferred to others. This is exactly the reason why the FDA requires that new instrumentation be evaluated more

Volume

than

one

institution.

177 #{149} Number

2

this

benefit

therapeutic

un-

neither

area

nor

ratheir

for

treatment

of infertility.

Radiology

1990;

174:371-374.

before

the

Subcommittee

on

Regulation,

Business

Oppon-

and Energy of the Committee on Small Business, House Representatives, 101st Congress, 1st session, Washington, DC, March 9, 1989. Serial no. 101-5. Washington, DC: U.S. Government Printing Office, 1989.

pregnancies

pregnancies

to enter

will

tunities

Editor: We have followed with great interest the nonsurgical approach of fallopian tube recanalization developed by Thurmond and R#{246}sch(1) from its inception, since we have been pursuing a similar method for approximately the same time period (2,3). We would like to take the opportunity of the publication of their recent article (4), which appeared in the February 1990 issue of Radiology, to congratulate them on the accumulation of an impressive experience. At the same time, a few important points need to be made. with either unilateral or bilateral proximal (4). In the presence of only unilateral tubal

approach

Confino E, DeCherney A, Corfman R, et al. Transcervical balloon tuboplasty: a multicenten study. Presented at the 45th Annual Meeting of the American Fertility Society, San Francisco, Novemben 13, 1989. Blackweli RE, Cam BR, Chang RJ, et al. Are we exploiting the infertile couple? Fertil Stenil 1987; 48:735-737. Consumer protection issues involving in vitro fertilization clinics: hearing

Thurmond

wish

an

Thurmond AS, Novy M, Uchida BT, Roach J. Fallopian tube obstruction: selective salpingography and recanalization. Radiology 1987; 163:511-514. Confino E, Friberg J, Gleicher N. Tnanscenvical balloon tuboplasty (TBT). Fertil Stenil 1986; 46:963-966. Confino E, Fniberg J, Gleicher N. Preliminary experience with transcenvical balloon tuboplasty. Am J Obstet Gynecol 1988; 159:370-375. Thunmond AS, Roach J. Nonsungical fallopian tube necanaliza-

Norbert Gleicher, MD, and Edmond Confino, MD Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center California Avenue at 15th Street, Chicago, IL 60608

patients clusion

Such

to the radiology community in an indiscriminate and

References

4.

44195-5001

as a plea procedure

patients.

tion

Avenue,

U Nonsurgical Fallopian Treatment of Infertility

in

fashion.

diologists

MD

Cleveland

is meant this new

Dr Thurmond

of

responds:

Selective salpingography and fallopian tube recanalization has been proved to improve diagnosis of fallopian tube disease (1). The procedure is a simple extension of conventional hysterosalpingography and involves the use of catheters and guide wires found in most radiology departments. Because the technique is the same as that used for angiography, it is within the capabilities of any residency-trained radiologist. Is this procedure a treatment for infertility caused by proximal

tubal

obstruction?

Is it a technique

that

can

be easily

to others with the same success rates? These questions are more difficult to answer. A multicenter trial is a method of obtaining data, and one method we considered. transferred

Another

nique

option,

and

and

equipment

the

one

to our

we

chose,

is to improve

satisfaction,

publish

the

the

tech-

results,

allow others to confirm our results. The advantage of this approach is that others are free to applaud or criticize our technique and results; there is no pressure to obtain uniform data or to conform to the opinions of the multicenter trial and the single manuscript. Independent confirmation may therefore be obtained. Other investigators using the same technique and equipment are confirming our results and have had the same high technical success rates and pregnancy rates and

(2-5).

Our research Board of Oregon

was

approved by the Institutional Health Sciences University and

by the Medical

Research

Foundation

of Oregon

Review was funded and

the

Ra-

Society of North America (1). Our research was not funded by a private company seeking profit. More important, patients are referred to us by gynecologists who independently decide that our procedure may benefit their patients. These diological

gynecologists situation

do

not

is inherently

gain

less

financially

prone

from

to abuse

their

than

referral.

one

This

in which

there is self-referral. As we have discussed in the past, our procedures and results are more similar than they are different. I believe that our goal is also the same-improved management for the unfortunate women who are suffering from infertility. References 1. 2.

Thurmond AS, Roach J. Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology 1990; 174:371-374. Platia MP, Chang R, Loniaux DL, Doppman J. Therapeutic potential of transvaginai recanalization for proximal fallopian tube obstruction. Presented at the American Fertility Society Meeting,

Radiology

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