T h e P r a c t i c e o f R a d i o l o g y • Pe r s p e c t i ve Romano Radiology in Italy
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The Practice of Radiology Perspective
Radiology in Italy: What Is Happening? Stefania Romano1 Romano S
Keywords: Italy, radiology DOI:10.2214/AJR.09.2801 Received March 24, 2009; accepted without revision March 27, 2009. S. Romano was named the 2007 Lee F. Rogers International Fellow by the American Roentgen Ray Society. 1 Department of Diagnostic Imaging, “A. Cardarelli” Hospital, Viale Cardarelli 9, 80131 Naples, Italy. Address correspondence to S. Romano (
[email protected]).
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AJR:193, October 2009
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he Italian physicist Augusto Righi was one of the first scientists who considered the importance of Roentgen’s discovery, reporting on the relevance of x-rays at the Royal Academy of Bologna in February 1896 [1]. He published more than 60 articles about radiology from 1896 to 1919 [1]. In 1896 and 1897, several experimental medical and diagnostic research studies on x-rays were performed in Italy [1]. However, the very first Italian radiologist was probably Domenico D’Arman [1]. In December 1895, he attempted an initial experiment in diagnostic radiology in his private laboratory [1]. Radiology as “art” and “science” was born in the public hospitals, then in the Italian academic world [1]. The first independent department of diagnostic radiology was founded in Trieste Hospital in November 1904, directed by Massimiliano Gortan [1]. Four years later in Lucca, the first board competition for the nomination of chief of the department of radiology took place [1]. The first university schools of medicine to officially start to teach diagnostic radiology as a discipline were in Rome, Genoa, and Naples [1]. In 1910, Aristide Busi started to develop the seriographic technique, and in 1913, the first seriography instrument was built [2]. Alessandro Vallebona (1899–1987) introduced the tomographic technique in 1930 and the axial tomography method in 1947 [3]. In 1938, the final model of the stratigraphic machine was presented at the 13th Italian Congress of Radiology [4]. Pietro Cignolini (1897–1993) was an internationally known pioneer of cardiovascular diagnostic radiology. He invented the instrumentation to perform chimography, the so-called Cignolini’s polykymograph [5]. From its origins to today, technology development of diagnostic radiology techniques in Italy followed the worldwide attempt to explore new
imaging fields and methods, such as CT, ultrasound, and MRI, with numerous scientists deeply involved in the diagnostic and therapeutic applications, in both academic and nonacademic institutions. As testimony of the history of radiology, inside the “Pietro Cignolini” Institute of Radiology of the University of Palermo, Italy, there is a museum, conceived by Adelfio Elio Cardinale and directed by Marcello De Maria. This institution, which contains different sections with huge collections of historical devices, pictures, books, and journals, was inaugurated in 1995 during the celebrations of the centennial of the discovery of the x-ray by Wilhelm Conrad Roentgen (http://www. unipa.it/~radpa/museo/museo.html) (Figs. 1–9). Italian Society of Medical Radiology At the beginning of 1913, the Italian Society of Medical Radiology (SIRM) was founded, and in the same year the first meeting was held in Milan on October 12–14 [6]. SIRM is currently the largest medical society in Italy, with more than 9,200 members, including full members and junior and senior radiologists. The national meeting is held every 2 years. More than 5,000 participants attended the last national meeting, held in Rome in June 2008. SIRM offers a large variety of courses for continuing medical education for each radiologic subspecialty. SIRM also provides the main framework for presenting and exchanging the scientific experience of different hospital- and university-based working groups. SIRM is currently the national member of the European Society of Radiology with the largest number of both institutional and individual affiliated radiologists. The official journal of SIRM, La Radiologia Medica, was founded in 1913. Felice Perussia was the first promoter and editor in chief. The journal, a monthly publication distributed
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Romano free of charge to all SIRM members, has been published by Springer in both Italian and English since 2006. It is directed by Roberto Pozzi Mucelli, a professor at Verona University. The ISI Web of Knowledge (Thompson) calculated the first impact factor for 2006–2007, released in June 2008, to be 0.967. The SIRM president, with a term of 2 years, is elected by all the SIRM members, as are the board of councilors, who have a term of 4 years. The real scientific and professional core of the society is represented by the subspecialty sections as well as the regional groups, the latter having a prominent professional mission. The subspecialty sections are focused on clinics (abdominal and gastrointestinal, breast, cardiovascular, dental and head and neck, emergency, musculoskeletal, neuro, pediatrics, thoracic, urogenital, and
vascular and interventional radiology), a particular imaging technique (CT, contrast materials, MRI, or ultrasound), or other issues (ethics and legal issues, informatics, management and economics, radiobiology, and radioprotection). All these sections provide sharing of radiologic culture and advancement, thus increasing the skill and expertise of Italian radiologists. Each section has a president, with a term of 2 or 4 years, and a board of councilors, with a term of 4 years, elected by all the section members. Each section organizes a biannual meeting. These subspecialty meetings, as well as many others meetings organized by SIRM and its regional groups every year, are attended by a constantly increasing number of radiologists. These meetings are included in the continuing medical education annual
program, which is effective and mandatory for all Italian physicians. In Italy there are some other national scientific radiologic societies correlated to the diagnostic field: the Italian Association of Oncologic Radiotherapy (AIRO), the Italian Association of Nuclear Medicine and Molecular Imaging (AIMN), and the Italian Association of Neuroradiology (AINR). The Neuroradiology Journal is the official journal of AINR and of several scientific societies from all round the world (http://www.centauro. it/theneuroradiologyjournal/editorial.htm). The official journal of the AIMN is The Quarterly Journal of Nuclear Medicine and Molecular Imaging, which is also the official publication of several other scientific socie ties, including the International Association of Radiopharmacology (IAR), Section of the
Fig. 1—Portrait of Pietro Cignolini (left) and his polykymograph machine (arrow) in Museum of Radiology, Palermo, Italy.
Fig. 2—Several old devices to regulate kilovoltage, milliamperage, and exposure time are shown in main corridor of Museum of Radiology, Palermo, Italy.
Fig. 3—Metalix high-tension generator for orthoscopy (from 1930) in Museum of Radiology, Palermo, Italy.
Fig. 4—Main control console for orthoscopy device (from 1915) in Museum of Radiology, Palermo, Italy.
Fig. 5— Detail of main control console designed by Augusto Righi (from 1930) in Museum of Radiology, Palermo, Italy.
Fig. 6—Room in Museum of Radiology, Palermo, Italy, with collection of old radiologic apparel; among them are anti-x-ray leaded rubber apron and radiographic cassette.
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Radiology in Italy
A
B
Fig. 7—A and B, Cathode ray tubes from 19th century in Museum of Radiology, Palermo, Italy.
Fig. 8—Pneumatic apparatus to create void inside cathode ray tube (foreground) in Museum of Radiology, Palermo, Italy.
Fig. 9—Generator for Wimshurst’s electrostatic machine (foreground) in Museum of Radiology, Palermo, Italy.
Society of Radiopharmaceutical Chemistry and Biology, and the International Research Group in Immuno-Scintigraphy (IRIST). In addition, the journal Il Radiologo is an official publication of SIRM and the National Union of Radiologists (SNR) as well as the quarterly information journal of AIRO, AIMN, and AINR. In 2007, SIRM, AIRO, AIMN, and ANR organized more than 270 courses, most of them promoted by SIRM.
to introduce a ready-to-use, nonionic, lowosmolar iodinated contrast agent, iopamidol (Iopamiro and Isovue). Even after nearly 30 years of market presence, iopamidol is still one of the best known and most widely used iodinated contrast agents for all radiographic, CT, and angiographic applications because of its unsurpassed safety and efficacy [7–9]. In the field of low-osmolar contrast agents, Bracco also developed Iomeron (iomeprol), with a viscosity so low that an iodine concentration of 400 mg I/mL is possible, the highest approved so far. Iomeprol has an excellent safety profile [10], and the high iodine concentration of the iomeprol 400 formulation more readily permits increased iodine delivery rates and thus greater contrast enhancement for numerous applications [11, 12]. In the field of MRI, one of the most successful and innovative contrast agents to emerge from Bracco in the late 1990s is Mul-
Discoveries With World Impact: Contrast Media in Diagnostic Radiology Despite having remained a family-owned private Italian company since its inception in 1927, Bracco is today a world leader in discovery, development, manufacturing, and marketing of safe, effective, and highly innovative contrast agents for all areas of diagnostic imaging. The Italian company was the first
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tiHance (gadobenate dimeglumine). Compared with other available gadolinium-based agents, MultiHance has two particularly distinguishing features. On the one hand, it has markedly increased R1 and R2 relaxivity in vivo because of weak, transient interaction with serum albumin [13], and on the other hand, it undergoes elimination through both the renal and hepatobiliary pathways [14]. Whereas the former feature leads to markedly increased signal intensity enhancement and diagnostic image quality for all routine applications when compared directly with other agents at equivalent doses [15, 16], the latter enables diagnostic imaging of the liver during both the dynamic and delayed hepatobiliary phases of contrast enhancement [17]. Finally, Bracco has developed SonoVue (aqueous suspension of phospholipid-stabilized microbubbles filled with sulfur hexafluoride) for ultrasound applications, a secondgeneration contrast agent that has proven highly valuable for real-time imaging in both radiology and cardiology [18, 19]. Current Practice of Radiology in Italy The main task of the Italian national health system, organized on a regional basis, is to guarantee public assistance following criteria that are based on efficiency, competition, and cost reduction. In Italy, there are different institutions for diagnostic radiology: academic, public hospital, and ambulatory as well as private structures with or without a relationship of accreditation with a regional public health system. All radiologists working in public institutions receive a salary, depending on the role (chief of department, responsible for radiologic section, attending radiologist, and so on) and regulated by a national collective contract of work, with renewal every 4 years. In private practice, in which radiologists may stipulate a personal contract of work with the administration of one or more private institutions, the estimate of a mean salary is not possible to predict because it is correlated not only to national directives but also to characteristics of the same structure in terms of workflow, equipment, and imaging techniques performed. No official data are known regarding the total number of Italian radiologists operating in public, academic, or private institutions; however from SIRM data it is possible to assess that, in 2008, 53.6% of the members were radiologists working in public, 21.5% in academic, and 23.8% in private (with or without accreditation with the public health system) institutions.
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Romano In 2000, a survey [20] on the public and private diagnostic imaging structures present in Italy was conducted by the Ministry of Health. The survey estimated that 44 million diagnostic imaging examinations were performed in hospitals in 2000, with a mean of 0.8 examination per citizen, whereas 20% of all procedures were performed in other ambulatory structures. There were differences in distribution of the percentage of the examinations performed in public hospitals with respect to those in ambulatory structures, varying from region to region, from north to south. Moreover, it was also estimated that more than one third of all radiologic procedures were frequently done in an emergency setting. Regarding the workflow, the survey showed that in 2000 1.423 examinations for each employee (administrative role) were performed, whereas the work-charge for each technologist resulted in about 2,800 diagnostic imaging examinations (ultrasound excluded, in Italy exclusively performed by physicians), with differences varying from region to region. Regarding the estimated number of workers for each public unit of diagnostic imaging, that same survey [20] assessed that in Italy in 2000 the total units were 25.717, among them 5,354 radiologists, 1,041 chiefs of department, and 10,687 technologists. It was also estimated that in Italy, for a mean of 20 units of workers for each radiology department located in a public institution, there were seven units of workers for each radiology department located in private structures having an accreditation relationship with the public health system. Diagnostic Radiology Training Program After medical school graduation and board certification for medical practice, the access of physicians to the residency program in diagnostic radiology is regulated every year by a preliminary main examination and a national directive issued by the Ministry of University and Research and the Ministry of Health to define the number of residents in view of the future work perspectives and possibilities. In Italy, the residency program in diagnostic radiology is the same for all universities and is based on a 4-year program. It is expected to be changed to a 5-year program next year. The current educational program does not provide a final official subspecialization, but during the training period specific interest in one particular radiologic field can be developed.
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The need for simultaneously providing education and clinical radiologic practice requires intense cooperation between university and nonacademic institutions. As a result, part of the residency program has been devoted recently to daily activity in public hospitals. Similarly, there has been a growing interest in learning about radiology abroad (mainly in Europe and the United States), either with stages during the residency program or through postresidency fellowships. International Affairs The opening of the international scenario for Italian radiologists has been effective for many years. This process has involved a large, active attendance of Italian researchers and practitioners to the foreign meetings. The effect of this internationalization skill can be also noted by the increased number of Italian speakers at the annual meetings of well-recognized international radiologic societies, among which are the Radiological Society of North America (RSNA), the American Roentgen Ray Society (ARRS), the European Congress of Radiology (ECR), the International Congress of Radiology (ICR), the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) as well as awards and events such as the Integrated Science and Practice Session on the Multicenter Trials on Screening and Research during the 2007 RSNA meeting in Chicago, IL, performed in conjunction with SIRM (rsna2007. rsna.org/rsna2007/v2007/conference/event_ display.cfm?id=66601&em_i=6002298). In fact, promotion of and participation in multicenter trials has been a SIRM initiative: a large number of radiologic academic and nonacademic institutions have already published results [21–23]. On the other hand, scientific research has been promoted by SIRM for many years. In 2002, the society started to organize focused courses on research methodology in radiology. These courses are held every year in different cities: radiologists and statisticians teach how to develop a study design, a sample size estimate, or data analysis and statistical testing. From 2002 to 2008, a total of 566 SIRM members attended these courses. The international scientific activity of Italian radiologists can be appreciated on the basis of the number of original research articles published from 2002 to 2007 in Radiology (59), AJR (48), European Radiology (81), and Eu-
ropean Journal of Radiology (36). According to a survey performed by SIRM in 2006, more than 100 Italian radiologists served as reviewers of manuscripts for peer-reviewed journals. At present, a number of Italian radiologists serve as reviewers for the European Journal of Radiology (76), European Radiology (71), AJR (29), and Radiology (23) [24–27]. Italian radiology is in continuous evolution: active, ready for creative comparison of experience, and open to the international scene, without losing its national culture and the lessons learned from the pioneers of Italian radiology. Acknowledgments Thank you to Alfredo Siani, SIRM president; Roberto Grassi; Miles A. Kirchin; Massimo Midiri; Francesco Sardanelli; Luigi Solbiati; and Franco Vimercati for their support and suggestions. References 1. Cignolini P, Cardinale AE. L’epoca dei pionieri in Italia. In: Cardinale AE, ed. Immagini e Segni dell’Uomo: Storia della Radiologia Italiana. Naples, Italy: Idelson-Gnocchi, 1995:131–162 2. Bernabeo RA, Pontieri GM. Elementi di Storia della Medicina. Padova, Italy: Piccin, 1993 3. Cittadini G, Cittadini G Jr, Sardanelli F. Diagnostica per Immagini e Radioterapia, 6th ed. Genova, Italy: ECIG, 2008:32–34 4. Pace GM. Rapporti tra radiologia e industria: dalla rivoluzione industriale alle multinazionali. In: Cardinale AE, ed. Immagini e Segni dell’Uomo. Storia della Radiologia Italiana. Naples, Italy: Idelson-Gnocchi, 1995:221–237 5. Cardinale AE. Sicilia. In: Cardinale AE, ed. Immagini e Segni dell’Uomo. Storia della Radiologia Italiana. Naples, Italy: Idelson-Gnocchi, 1995:871–895 6. Di Guglielmo L. La SIRM Associazione Italiana di Radiologia Medica e la sua rivista societaria “La Radiologia Medica.” In: Cardinale AE, ed. Immagini e Segni dell’Uomo. Storia della Radiologia Italiana. Naples, Italy: Idelson-Gnocchi, 1995:163–207 7. Solomon RJ, Natarajan MK, Doucet S, et al. Cardiac Angiography in Renally Impaired Patients (CARE) study: a randomized double-blind trial of contrast-induced nephropathy in patients with chronic kidney disease. Circulation 2007; 115: 3189–3196 8. Barrett BJ, Katzberg RW, Thomsen HS, et al. Contrast-induced nephropathy in patients with chronic kidney disease undergoing computed tomography: a double-blind comparison of iodixanol and iopamidol. Invest Radiol 2006; 41:815–
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Radiology in Italy 821; erratum Invest Radiol 2007; 42:94 9. Sahani DV, Soulez G, Chen KM, et al. A comparison of the efficacy and safety of iopamidol-370 and iodixanol-320 in patients undergoing multidetector-row computed tomography. Invest Radiol 2007; 42:856–861 10. Thomsen HS, Morcos SK, Erley CM, et al. The ACTIVE Trial: comparison of the effects on renal function of iomeprol-400 and iodixanol-320 in patients with chronic kidney disease undergoing abdominal computed tomography. Invest Radiol 2008; 43:170–178 11. Cademartiri F, de Monye C, Pugliese F, et al. High iodine concentration contrast material for noninvasive multislice computed tomography coronary angiography: iopromide 370 versus iomeprol 400. Invest Radiol 2006; 41:349–353 12. Romano L, Grazioli L, Bonomo L, et al. Enhancement and safety of iomeprol-400 and iodixanol-320 in patients undergoing abdominal multidetector computed tomography. Br J Radiol 2009; 82:204–211 13. Giesel FL, von Tengg-Kobligk H, Wilkinson ID, et al. Influence of human serum albumin on longitudinal and transverse relaxation rates (R1 and R2) of magnetic resonance contrast agents. Invest Radiol 2006; 41:222–228 14. Spinazzi A, Lorusso V, Pirovano G, Kirchin M. Safety, tolerance, biodistribution and MR imag-
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ing enhancement of the liver with gadobenate dimeglumine. Acad Radiol 1999; 6:282–291 15. Prokop M, Schneider G, Vanzulli A, et al. Contrast-enhanced MR angiography of the renal arteries: blinded multicenter crossover comparison of gadobenate dimeglumine and gadopentetate dimeglumine. Radiology 2005; 234:399–408 16. Pediconi F, Catalano C, Padula S, et al. Contrastenhanced MR mammography: improved lesion detection and differentiation with gadobenate dimeglumine. AJR 2008; 191:1339–1346 17. Grazioli L, Morana G, Kirchin MA, Schneider G. Accurate differentiation of focal nodular hyperplasia from hepatic adenoma at gadobenate dimeglumine–enhanced MR imaging: prospective study. Radiology 2005; 236:166–177 18. Quaia E, Bertolotto M, Cioffi V, et al. Comparison of contrast-enhanced sonography with unenhanced sonography and contrast-enhanced CT in the diagnosis of malignancy in complex cystic renal masses. AJR 2008; 191:1239–1249 19. Aggeli C, Giannopoulos G, Roussakis G, et al. Safety of myocardial flash-contrast echocardiography in combination with dobutamine stress testing for detection of ischemia in 5,250 studies. Heart 2008; 94:1571–1577 20. Italian Ministry of Health Website. Public and private diagnostic imaging structures in Italy.
www.ministerosalute.it/imgs/C_17_pubblicazioni_362_allegato.doc. Accessed July 7, 2009 21. Sardanelli F, Podo F, D’Agnolo G, et al. Multicenter comparative multimodality surveillance of women at genetic-familial high risk for breast cancer (HIBCRIT study): interim results. Radiology 2007; 242:698–715 22. Sardanelli F, Giuseppetti GM, Panizza P, et al.; Italian Trial for Breast MR in Multifocal/Multicentric Cancer. Sensitivity of MRI versus mammography for detecting foci of multifocal, multicentric breast cancer in fatty and dense breasts using the whole-breast pathologic examination as a gold standard. AJR 2004; 183:1149–1157 23. Bazzocchi M, Zuiani C, Panizza P, et al.; Italian Trial for Breast MR in Multifocal/Multicentric Cancer. Contrast-enhanced breast MRI in patients with suspicious microcalcifications on mammog raphy: results of a multicenter trial. AJR 2006; 186:1723–1732 24. [No authors listed]. Announcement to our reviewers. Eur J Radiol 2008; 65:v–viii 25. [No authors listed]. Acknowledgement to reviewers. Eur Radiol 2008; 18:423–428 26. Berquist TH. To the 2008 AJR manuscript and book reviewers. AJR 2009; 192:302–306 27. Mc Loud TC, Kressel H. Manuscript reviewers: a note of thanks. Radiology 2008; 249:731–737
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