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Relative value units (RVUs) are utilized to evaluate physician productivity in many fields, including radiology. The goal of this paper is to use the electronic medical record (EMR) to evaluate whether the current RVU system allows for fair comparison between radiologists' time effort.The study was approved by the local Institutional Review Board (IRB). Over 600,000 radiology studies with unique current procedural terminology (CPT) codes were evaluated, and after exclusion of studies interpreted in conjunction with trainees or interpreted using other software systems, a total of 241,627 studies remained. The median 25%ile, 50%ile, 65%ile, 75%ile and modal study ascribable times (SATs) for each CPT code was calculated across all radiologists. To evaluate the potential bias incurred using the current RVU system, the number of days required to achieve the Association of Administrators in Academic Radiology AAARAD 65%ile were calculated.RVU values were positively correlated with SATs (r = 0.69-0.71, p 0.001). The variability in the radiologists' time to achieve the AAARAD 65%ile benchmark was highest for musculoskeletal imaging, and lowest for thoracic imaging. The discrepancy in the number of days of work required to achieve the AAARAD 65%ile benchmark was 141.1% (197.7 days) for musculoskeletal imaging, 107.5% (161.9 days) for neuroimaging, 89.6% (185.9 days) for body imaging, and 72.2% (84.0 days) for thoracic imaging.The current RVU system is not strongly correlated with radiologist effort measured by radiologists' time. A time-based metric is more representative of radiologist work. However, there is no perfect method to measure radiologists' work.

This expert consensus document represents an initiative by the European Neuroendocrine Tumor Society (ENETS) to provide guidance for synoptic reporting of radiological examinations critical to the diagnosis, grading, staging and treatment of neuroendocrine neoplasms (NENs). Template drafts for initial tumor staging and follow-up by computed tomography (CT) and magnetic resonance imaging (MRI) were established, based on existing institutional and organisational reporting templates relevant for NEN imaging, and applying the RadLex lexicon of radiological information (Radiological Society of North America), for consistency regarding the radiological terms. During the ENETS Scientific Advisory Board meeting 2018, the template drafts were subject to iterative interdisciplinary discussions among experts in imaging, surgery, gastroenterology, oncology and pathology. Members of the imaging group stated a strong preference for a combination of limited and standardised options by way of drop-down menus. Separate templates were produced for the initial work-up and for follow-up, respectively. To provide a detailed description of the radiological findings of the primary tumor and its local extension and spread, different templates were developed for bronchial, pancreatic and gastrointestinal NENs for CT and MRI, respectively. Each template was structured in 10 sections: clinical details, comparative imaging modality, acquisition technique, primary tumor findings, regional lymph node metastases, distant metastases, TNM classification, reference lesions according to RECIST 1.1, additional findings and conclusion. Two templates were developed for follow-up, for CT and MRI, respectively, and were specifically focused on assessment of therapy response. These included a qualitative response assessment, such as decrease of vascularisation and presence of necrosis, and a quantitative assessment according to RECIST 1.1 and the modified RECIST (mRECIST) for assessing tumor response following transarterial chemoembolisation.

The role of Radiology is fundamental to the ruling in or ruling out of the disease hypothesis. Physicians order diagnostic imaging studies, technologists perform the image capture process, and radiologists analyze the images and clinical information and generate a report of their findings. The radiology report is used by the requesting physician in establishing the patient’s diagnosis and planning the path of treatment. In the radiology department each of these steps involves the use of complex integrated medical software systems to manage clinical information and images. The performance and usability of these systems is critical to the timely treatment of patients. This paper focuses on reducing radiology report turnaround times by integrating advanced algorithms and automation in the information systems responsible for managing radiology workflows.

Assess whether introducing order priorities with defined performance expectations in the electronic health record (EHR) reduces immediate inpatient radiology orders.This Institutional Review Board-approved, retrospective study was performed at a 776-bed academic hospital conducting 164,000+ inpatient radiology examinations annually. Study period was January 2, 2017, to July 23, 2017; 14 weeks pre- and postimplementation of an education-only intervention including replacing urgent and as soon as possible priorities with imaging within next 6, 12, or 24 hours; imaging in the morning; and required for discharge priorities. STAT routine, timed, today order priorities remained unchanged. Institution-wide training immediately pre- and postimplementation was provided through two waves of e-mail and electronic tip sheets. Primary outcome measure was total STAT studies ordered of total radiology studies ordered per week (STAT rate). Secondary outcomes were non-STAT, non-routine (non-SR) order rate, and routine order rate. Paired t test and statistical process control (SPC) analysis were performed.STAT rate pre- (22.5%, 7,150 STAT of 31,765 total; weeks 1-14) and postintervention (23.4%, 7,481 STAT of 32,034 total; weeks 16-29) remained unchanged (P = .37). SPC demonstrated no special cause variation. Postintervention non-SR rate increased 3-fold (2.7%, 859 non-SR of 31,765 total pre-intervention versus 8.2%, 2,615 non-SR of 32,034 total postintervention; 8.2%/2.7% = 3.0; P.0001). There was an 8.8% relative reduction in routine rate postintervention (73.9%, 23,471 routine of 31,765 total pre-intervention; 67.4%, 21,579 routine of 32,034 total postintervention; (73.9% - 67.4%)/73.9% × 100 = 8.8%; P.0001).Implementing ordering priorities with defined performance expectations in the EHR reduced routine but did not reduce STAT inpatient radiology orders. More stringent interventions may be needed to reduce unnecessary STAT inpatient radiology ordering to improve use of limited imaging resources.

Cesarean section scar pregnancy is the rarest form of ectopic pregnancy. Cesarean scar ectopic pregnancy poses a diagnostic and management challenge, and if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity or mortality. We describe the presentation, workup including radiology studies, and subsequent management plan of a cesarean scar ectopic pregnancy in a 34-year-old female with a history of four previous cesarean sections. We were successful in treating this rare form of ectopic pregnancy without any maternal morbidity with a combination of medical and surgical management.

Rationale and Objectives This study seeks to quantify the financial impact of COVID-19 on radiology departments, and to describe the structure of both volume and revenue recovery. Materials and Methods Radiology studies from a large academic health system were retrospectively studied from the first 33 weeks of 2020. Volume and work relative value unit (wRVU) data were aggregated on a weekly basis for three periods: Presurge (weeks 1–9), surge (10–19), and recovery (20–33), and analyzed compared to the pre-COVID baseline stratified by modality, specialty, patient service location, and facility type. Mean and median wRVU per study were used as a surrogate for case complexity. Results During the pandemic surge, case volumes fell 57%, while wRVUs fell by 69% relative to the pre-COVID-19 baseline. Mean wRVU per study was 1.13 in the presurge period, 1.03 during the surge, and 1.19 in the recovery. Categories with the greatest mean complexity declines were radiography (−14.7%), cardiothoracic imaging (−16.2%), and community hospitals overall (−15.9%). Breast imaging (+6.5%), interventional (+5.5%), and outpatient (+12.1%) complexity increased. During the recovery, significant increases in complexity were seen in cardiothoracic (0.46 to 0.49), abdominal (1.80 to 1.91), and neuroradiology (2.46 to 2.56) at stand-alone outpatient centers with similar changes at community hospitals. At academic hospitals, only breast imaging complexity remained elevated (1.32 from 1.17) during the recovery. Conclusion Reliance on volume alone underestimates the financial impact of the COVID-19 pandemic as there was a disproportionate loss in high-RVU studies. However, increased complexity of outpatient cases has stabilized overall losses during the recovery.

Artificial intelligence (AI) in radiology has gained wide interest due to the development of neural network architectures with high performance in computer vision related tasks. As AI based software programs become more integrated into the clinical workflow, radiologists can benefit from better understanding the principles of artificial intelligence. This series aims to explain basic concepts of AI and its applications in medical imaging. In this article, we will review the background of neural network architecture and its application in imaging analysis.

Background: Diagnostic radiology studies in children harbor more radiation hazards than in adults due to their small size and higher cellular proliferation rate. Therefore, reducing the radiation burden to children should be top priority. Measurement of radiation dose is the first step to this goal. Nevertheless, we do not know whether the radiation of portable radiographs at our hospital meets the standards or not. Objectives: This study aims at measuring the primary and scattered radiation at different distances from patients. This eventually would help us to keep the radiation to minimum. Methods: This study was conducted on 84 patients from 4 different wards (U1-U2) in our hospital in 2017. After obtaining ethical approval from ethical committee and also written consent from parents, all patients who needed portable X-ray were included in our study. A thermo-luminescent dosimeter was placed on the patient’s chest to measure the entrance surface dose (ESD), while Geiger-Muller dosimeters located at one and two-meter distances from the X-ray tube used to scale the scattered radiation. Then, data were analyzed in SPSS 16. Results: The average ESD was 0.3873, 0.3867, 0.3700, and 0.4033 millisievert (mSv) in U1 to U4 respectively, whereas the scattered radiation doses measured as 0.00986, 0.00750, 0.01250, 0.1014 at one-meter and 0.00250, 0.00220, 0.00238, 0.00314 mSv at two-meter distances. There was no significant difference in radiation dose between those units (P > 0.05). Conclusions: Radiation received by patients in this study was three to four times higher than the standard dose. Significant scattered radiation was also detected at one and two-meter distances. To reduce radiation, improvement of exposure protocols such as reducing mAs and using proper shielding is emphasized.

Artificial intelligence (AI) is a broad umbrella term used to encompass a wide variety of subfields dedicated to creating algorithms to perform tasks that mimic human intelligence. As AI development grows closer to clinical integration, radiologists will need to become familiar with the principles of artificial intelligence to properly evaluate and use this powerful tool. This series aims to explain certain basic concepts of artificial intelligence, and their applications in medical imaging starting with a concept of overfitting.

The appropriate communication and management of incidental findings on emergency department (ED) radiology studies is an important component of patient safety. Guidelines have been issued by the ACR and other medical associations that best define incidental findings across various modalities and imaging studies. However, there are few examples of health care facilities designing ways to manage incidental findings. Our institution aimed to improve communication and follow-up of incidental radiology findings in ED patients through the collaborative development and implementation of system-level process changes including a standardized loop-closure method. We assembled a multidisciplinary team to address the nature of these incidental findings and designed new workflows and operational pathways for both radiology and ED staff to properly communicate incidental findings. Our results are based on all incidental findings received and acknowledged between November 1, 2016, and May 30, 2017. The total number of incidental findings discovered was 1,409. Our systematic compliance fluctuated between 45% and 95% initially after implementation. However, after overcoming various challenges through optimization, our system reached a compliance rate of 93% to 95%. Through the implementation of our new, standardized communication system, a high degree of compliance with loop closure for ED incidental radiology findings was achieved at our institution.

The purpose of the study was to assess the doses of personnel and the population at the expense of all the main activities and sources of radiation in the territory of the Voronezh region. The data of the forms of state statistical supervision No. 1-DOZ “Information on the doses of personnel from persons under normal use of technogenic sources of ionizing radiation”, No. 3-DOZ “Information on radiation doses of patients during X-ray radiology studies”), No. 4-DOZ “Information on radiation doses of the population due to natural and technogenically altered background” for 2010-2016 and the radiation and hygienic passport of the territory of the Voronezh Region. Based on the results of monitoring the radiation situation, the situation associated with the impact of ionizing radiation sources in the Voronezh Region has been characterized as safe for the past 7 years. The average annual effective dose per 1 inhabitant due to all ionizing radiation remains stable with a slight upward trend and lies in the range from 2.925 (2010) to 3.399 mSv (2016). In the structure of the collective dose of the population of the Voronezh region, the dose from natural sources is 83.65%, from medical sources – 16.06%, from technogenically changed background radiation, including global fallout and accident at the Chernobyl nuclear power plant – 0.18%, from the activities of enterprises using Sources of ionizing radiation – 0.11%. The average annual effective dose of natural exposure to humans varies from 0.660 to 0.704 mSv / year, natural radiation from radon from 0.832 to 1.465 mSv / year. The average effective dose from medical research for the procedure for the study period was 0.27-0.40 mSv and tends to decrease due to the introduction of modern low-dose medical diagnostic equipment. On the territory of the Voronezh region, there were no population groups with an effective radiation dose exceeding 5 mSv / year. Gamma-background in the region in 2010-2016. Did not exceed the natural level and amounted to 0.08 – 0.16 μSv / h. The excess of hygienic standards for the effects of ionizing radiation sources on humans has not been recorded.

The duodenum is a short segment of the bowel that is frequently overlooked on radiologic examination. This unique portion occupies both intraperitoneal and extraperitoneal locations, with proximity to many visceral organs, including pancreas, stomach, aorta, and liver. This close proximity creates a differentiation challenge for the radiologist. Duodenal pathologies are categorized into neoplastic and nonneoplastic conditions. Majority of radiologists are familiar with duodenal neoplasm. However, duodenal involvement by a multitude of nonneoplastic conditions can be encountered. The majority of related radiology studies have concentrated on neoplasms of the duodenum—either primary or secondary. However, a broad range of nonneoplastic conditions merit discussion. In this review, multimodality imaging features of nonneoplastic duodenal diseases are discussed and emphasized. Objective To conduct a systematic review of the frequent imaging features of nonneoplastic diseases of the duodenum, with an emphasis on accurate diagnosis so that the patient who will benefit from treatment can be identified.

Distinguishing retrohepatic end-to-side portocaval shunts (ES-PCS) and side-to-side portocaval shunts (SS-PCS) can be difficult, but it is essential for determining the treatment strategy. Our experience with retrohepatic PCS is analyzed.Since 2007, 9 children (5/9 ES-PCS and 4/9 SS-PCS) were surgically treated. Radiology studies included Doppler-ultrasound, CT/MRI and angiography/occlusion test (8/9).CT in 5/5 ES-PCS revealed the portal vein (PV) entering the left side of the vena cava with a uniform shape. 4/4 SS-PCS showed aneurysmal PV containing the origin of the main intrahepatic portal branches (IHPB) entering the cava anterior aspect or slightly to the right with a variable length (from long to short/wide). ES-PCS anatomy showed caudate lobe absence with the fistula entering the left cava aspect free of parenchyma, but anterior through the caudate lobe in SS-PCS. With the angiography/occlusion test, the IHPB was undeveloped in ES-PCS (portal pressure 38 mmHg) and hypoplasic in SS-PCS (portal pressure 25 mmHg). ES-PCS treatment included: 1/5 hepatectomy and 4/5 definitive banding (one by laparoscopy); while in SS-PCS: 1/4 liver transplantation, 2/4 1-step closure (one by laparoscopy), and 1/4 definitive banding.Fistula shape, cava relationship, IHPB and portal pressures differ between the two shunt types. A question arises regarding the need for secondary complete closure after banding.Level IV.

Major changes in the management and funding of healthcare are underway that will markedly change the way radiology studies will be reimbursed. The result will be the need to deliver radiology services in a highly efficient manner while maintaining quality. The science of process improvement provides a practical approach to improve the processes utilized in radiology. This article will address in a step-by-step manner how to implement process improvement techniques to improve workflow in abdominal imaging.

Emergency Department crowding is an increasing problem, leading to treatment delays and higher risk of mortality. Our institution recently implemented a telemedicine physician intake ("tele-intake") process as a mitigating front-end strategy. Previous studies have focused on ED throughput metrics such as door to disposition; our work aimed to specifically assess the tele-intake model for clinical accuracy.We retrospectively reviewed ED visits at a high acuity, tertiary care academic hospital before and after tele-intake implementation. We defined the primary outcome as the degree of additional laboratory, imaging, and medication orders placed by the subsequent ED provider. Our secondary outcomes were the cancellation rate of intake orders and the percentage of encounters where no additional second provider orders were necessary.For in-person and tele-intake physician encounters between September 2015 and February 2017, most labs and diagnostic radiology studies, and approximately half of CT, ultrasound, and pharmacy orders were initiated by the intake physician. We found no significant difference for our primary outcome (p = 0.2449). For both tele-intake and in-person encounters,1% of orders were cancelled by the second provider. Additionally, 30.8% of in-person and 31.5% of telemedicine patient encounters required no additional orders to make a disposition decision.This novel analysis of an innovative patient care model suggests that the benefits of tele-intake as a replacement for in-person physician directed intake are not at the cost of over or under utilization of diagnostic testing or interventions.

Your first emergency case as an attending surgeon will be a very exciting and stressful experience no matter how many years of training that you have under your belt between residency and fellowship. Your first goal is to stay calm and composed, remembering that you have been trained well and are capable of handling the situation. Make sure that YOU explain all of the risk and benefits of the surgery with the patient and family. Reviewing any labs and radiology studies and having a plan before you walk into the operating room will be very helpful. There is no fault in calling a mentor for questions or asking one of your partners to come into the operating room to help.

Electrocardiographic gating, multidetector computed tomography (CT), dual-energy CT, parallel magnetic resonance imaging techniques, and advanced postprocessing methods are some of the many recent advancements that have revolutionized cross-sectional imaging of thoracic aorta. Imaging appearances of aortic disease can be complex and variable. Normal findings may simulate abnormalities, and many abnormalities may be asymptomatic. Knowledge and understanding of the imaging techniques, imaging findings of acute thoracic aortic syndromes, natural history of aortic diseases, and aortic surgical techniques may help to appropriately perform and interpret aorta-specific radiology studies.

Rationale and Objectives Radiation exposure from medical imaging has received increasing attention in recent years. Ongoing calls to report radiation doses received during radiology studies as a means of recording cumulative exposure and identifying rare over-exposures have culminated in the State of California passing a mandatory reporting requirement effective July 1, 2012. Herein we describe a radiology housestaff-led quality improvement project to track radiation dose reporting a full year prior to state reporting mandates using a template-driven reporting system and our results over the first 12 months of its implementation. Materials and Methods Effective July 2011, all radiology trainees were instructed to use a standard computed tomography (CT) report template that included a CT dose measurement derived from dose information routinely displayed on our picture archiving and communication system. Consecutive reports from July 1, 2011, to June 30, 2012, of patients who underwent CT examinations at our institution were then retrospectively reviewed. Compliance of each study with the reporting requirement was assessed based on the presence or absence of a radiation dose statement within the finalized report. Results A total of 36,217 eligible consecutive CT reports were identified within the review period. Of these, 91.9% reported the radiation dose for the examination, greatly exceeding the initial goal of 80% compliance with the dose reporting requirement. Conclusion Successful reporting of CT radiation doses resulted from template-driven reporting, readily accessible calculation tools to facilitate dose calculation, and minimization of reporting burden on the radiologist a full year prior to state regulatory mandates.

Rationale and Objectives Postgraduate year (PGY)-1 residents are frequently required to order imaging studies and make preliminary interpretations on them. This study determines whether PGY-1 residents feel their radiology education in medical school sufficiently trained them for the clinical responsibilities of internship. Materials and Methods This multicenter, institutional review board–approved survey asked PGY-1 trainees three categories of questions: 1) extent of medical school training for ordering and interpreting imaging studies, 2) confidence levels in ordering appropriate imaging studies and making common/emergent diagnoses, and 3) rating the importance of radiologic interpretation by interns. Respondents also submitted ideas for medical school teaching topics deemed most useful for interns. Results A total of 175 questionnaires were returned with good representation across specialties. Although 63.7% of interns were frequently asked to independently preview radiology studies, 12.6% received no formal radiology training in medical school. Participants rated chest radiographs as the most important study for interns to competently interpret (93.4% reporting very or extremely important). However, only 60.2% of interns reported high confidence in recognizing common/emergent pulmonary findings, and 56.3% for evaluating line and tube position. With regard to ordering imaging studies, 81.0% had never used or never heard of the American College of Radiology Appropriateness Criteria®. Only 33.1% had high confidence in knowing when to order oral/intravenous contrast. Similar low percentages had high confidence identifying and premedicating contrast allergies (36.4%) and knowing risk factors of nephrogenic systemic fibrosis (13.2%). Conclusions PGY-1 residents feel that medical school curriculum emphasizing interpretation of chest radiographs and ordering appropriate imaging studies would better prepare students for the responsibilities of internship.

We quantitated how often review of recent radiology studies provides information useful to the densitometrist. While preparing bone mineral density (BMD) reports on 1012 consecutive patients, radiology reports in electronic medical records (EMRs) for the previous 5 years at potentially relevant sites (lumbar spine X-rays, abdominal computed tomography (CT) scans, and so forth) were reviewed. When a study was found, it received a grade according to how relevant findings were to the BMD report: "1" for studies that were irrelevant, "2" for those that confirmed the impression formed from review of the BMD images, "3" for those that clarified the impression that was unclear after reviewing the BMD images, and "4" for those that revealed new relevant data when no abnormality was noted on review of the BMD images. A total of 562 patients (55.5%) had a radiologic study at a site of potential interest within the past 5 years. Fifty-three patients (5.2% of all patients) had a grade 4 study, 88 patients (8.7% of all patients) had a grade 3 study, and 185 patients (18.3% of all patients) had a grade 2 study. Two hundred sixty-four patients (25.8%) had a grade 2 or 3 study, and 299 (29.5%) had a grade 2–4 study. The radiographic study that was most likely to be found in patients' EMR was chest X-ray (34.7% of all patients), but it was also the one that was least likely to have any relevance to the reader; only 10.5% of the total chest X-rays were graded 2–4. The next most likely studies to be found in patients' EMR were abdominal CT scans (18.0% of all patients) and lumbar spine X-rays (14.4% of all patients), but these studies were much more likely to be useful to the reader, as 62.6% of abdominal CT scans and 78.1% of lumbar spine X-rays were graded 2–4. The likelihood of a patient having radiologic examinations in the EMR at sites potentially relevant to the BMD reader is high, but the likelihood that these clarify abnormalities noted on BMD is only moderate. Review of the EMR is unlikely to be relevant when the dual-energy X-ray absorptiometry images are normal.

Although radiological evaluation plays an integral role in the management of oncology patients, little is known about which elements of such evaluation are most important or about how satisfied clinicians are with the quality of radiology services in cancer patients. We have developed a 36-item anonymous survey evaluating availability of and satisfaction with radiology services to medical oncologists. The survey was distributed to members of the Medical Oncology Group of Australia resident in Australia. We received 124 responses (51%). Most respondents (76.9%) were satisfied with their radiology services. Satisfaction correlated closely with the availability of standardized reporting and promptness of reporting (P < 0.001). Oncologists in private practise were more likely to receive prompt reports (P < 0.0001). Oncologists in public practice were more concerned about availability of CT scanning (P = 0.02). Services that were reported as less frequently available, despite being ranked as very important, included measurements of key lesions and comparison to previous studies. Standardized reporting was considered helpful by 91% of respondents. Only 32.5% of respondents reported receiving such a summary in more than 50% of cases and 21% never received such a summary. Our findings highlight the need for closer collaboration between oncologists and radiologists in order to address specific needs and develop optimal patterns of practise. Consideration should be given to standardization of reporting of radiology studies in oncology.

Pragmatism, as a philosophical option, is concerned with end results and argues that “all our thought-distinctions, however subtle, demand a possible difference of practice.”1 Physicians calculate daily the best plan of action for each patient, following some pragmatic rules: only taking into account different strategies when they lead to different results, the personal effort and moral risks are considered, and if of equal outcome and cost, the strategy that best preserves clinical safety and moral values. The purpose of this study is not to clarify the content of philosophical pragmatism, but to observe how it is applied in clinical decisions and what difficulties arise. We propose a paediatric case to illustrate this process: Dr Seel has just been visited by a 3 year old boy affected by earache. Dr Seel thinks the boy has otitis, because the eardrum was bulging and slightly red, and Dr Seel is aware of current evidence-based recommendations2 which suggest that it is often not necessary to treat otitis with antibiotics. However the mother requests such treatment: “A few months ago he also had ear pain and non steroidal anti-inflammatory medicine didn’t work.” Dr Seel reconsiders her decisions, recalling the eardrum appearance, and prescribing antibiotics as a safer option. We can distinguish several aspects in this vignette: 1. Calculation of efficiency : What must I do to achieve a diagnosis or therapeutic goal, and how time-consuming would it be? For this calculation, the doctor has four sources of information: (1) her own experience; (2) evidence-based clinical guidelines; (3) deliberation with colleagues or her team3 and (4) any assistance available from laboratory or radiology studies. The result of this process is an action plan.4 Pragmatic calculus integrates all four elements, being physicians—in general—unable to specify the assigned weight to each one. The result of …

Clinically oriented material is being incorporated increasingly early into medical school curricula. Traditional models of incorporating radiology early on, mainly as an adjunct to pathology or anatomy instruction, are not focused on learning important aspects of clinical radiology. Medical students can be better served by an integrated curriculum that focuses on appropriate ordering of radiology studies, an intuitive understanding of imaging modalities, and understanding the patient experience. © 2014 American College of Radiology.

Objective: To determine whether senior surgical residents can independently interpret radiologic studies for the trauma patients under their care. Method: Five senior surgical residents (PGY-4 and -5) participated in this prospective study. The residents independently read trauma films as part of the emergency assessment, documenting their interpretations to be compared with the reports by nighthawk radiologists. Results: During a period of 4 months, 426 films of 124 trauma patients admitted to a Level II trauma center were read by one of the five senior surgical residents, and by nighthawk radiologists. Approximately 22% of these were penetrating injuries and the remainder blunt trauma. Residents identified 127 injuries versus 128 injuries indentified by the radiologists, with 99.2% agreement. The residents missed two injuries, while the radiologists missed one. Conclusions: Senior surgical residents can independently and accurately interpret the trauma radiology studies, a skill essential for time-critical decision making.

Mobile devices, wireless networks and software have significantly evolved since the late 1990s and are now available with sufficient computing power, speed and complexity to allow real-time interpretation of radiology studies. Emergency radiology (ER)'s time-sensitive nature would seem to be an excellent match for study interpretation using mobile devices, allowing the radiologist to read studies anywhere, at any time. While suitable for use by the radiologist outside of the hospital, or clinicians and surgeons at the bedside or in the operating room, these devices do have limitations, and regulatory approval for in-hospital diagnostic use is limited. In the ER setting, we suggest that the best use of mobile devices is to be available to consult directly with patients about their imaging findings and to the clinical team during rounds and at handover. This will bring the radiologist to the clinician and patient, helping us to better understand the patient's presentation, educate both the physician and patient and increase the visibility and value of the radiologist as a member of the clinical care team.

Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors' center is also presented.

Study objective As use of radiology studies increases, there is a concurrent increase in incidental findings (eg, lung nodules) for which the radiologist issues recommendations for additional imaging for follow-up. Busy emergency physicians may be challenged to carefully communicate recommendations for additional imaging not relevant to the patient's primary evaluation. The emergence of electronic health records and natural language processing algorithms may help address this quality gap. We seek to describe recommendations for additional imaging from our institution and develop and validate an automated natural language processing algorithm to reliably identify recommendations for additional imaging. Methods We developed a natural language processing algorithm to detect recommendations for additional imaging, using 3 iterative cycles of training and validation. The third cycle used 3,235 radiology reports (1,600 for algorithm training and 1,635 for validation) of discharged emergency department (ED) patients from which we determined the incidence of discharge-relevant recommendations for additional imaging and the frequency of appropriate discharge documentation. The test characteristics of the 3 natural language processing algorithm iterations were compared, using blinded chart review as the criterion standard. Results Discharge-relevant recommendations for additional imaging were found in 4.5% (95% confidence interval [CI] 3.5% to 5.5%) of ED radiology reports, but 51% (95% CI 43% to 59%) of discharge instructions failed to note those findings. The final natural language processing algorithm had 89% (95% CI 82% to 94%) sensitivity and 98% (95% CI 97% to 98%) specificity for detecting recommendations for additional imaging. For discharge-relevant recommendations for additional imaging, sensitivity improved to 97% (95% CI 89% to 100%). Conclusion Recommendations for additional imaging are common, and failure to document relevant recommendations for additional imaging in ED discharge instructions occurs frequently. The natural language processing algorithm's performance improved with each iteration and offers a promising error-prevention tool.

Authors Reply: We agree with Drs. Pincavage, Ratner, and Arora that resident patients are indeed often at higher risk for missing appointments. We did not in our study look at the issue of prior behavior with respect to missed appointments, but in a sample of ten patients in our study population, six of the ten had missed several appointments in the years preceding their resident PCP’s graduation. In our practice in general, resident patients are more likely to miss scheduled appointments than faculty patients; indeed, resident patients missed 17% of appointments as compared to 7% missed appointments for faculty patients in the past year. We suspect that residents were particularly concerned about patients who missed appointments and may have explicitly listed these patients as high risk for that reason. We agree that handoffs in these patients are likely to be more risky than in patients who generally keep appointments and that special outreach efforts should be made to these patients. This is particularly problematic since the graduated residents most familiar with these at-risk patients and their medical problems are no longer available to detect missed opportunities for care such as overdue radiology studies or blood tests. We analyzed visits to our own emergency room for this sample of ten patients and found that only a single patient had an ER visit within the year after their resident’s graduation. We are unable to capture ER visits and admissions to other hospitals and agree that ER utilization would indeed be a useful variable to examine in future studies of this phenomenon. We agree that a year is a longer than desired interval for follow-up of many patients and that many of these patients should have had multiple visits during this study year. We set the year as an intentionally long period. We agree that a future study of diabetics in which there are clear guidelines for intervals of visits might indeed look at shorter intervals between visits. Finally, we were similarly intrigued with the study by Young and colleagues in which case loads were rebalanced, though note that the number of trainees in that program was much smaller. Young described 16 graduating residents having a mean of only 18–22 patients in each psychiatry resident’s case load compared to our population of 46 residents. These investigators did not report on patient retention, so it is not clear that rebalancing loads will indeed improve patient follow-up. We have attempted rebalancing of case loads to a small degree for certain target diagnoses for educational reasons, but many of our patients who do follow up return to see a different resident PCP than our assignment due to a variety of factors. We are skeptical as to whether rebalancing will improve retention unless it is coupled with early intensive outreach from a new provider.

Clinical imaging plays an essential role in cancer care and research for diagnosis, prognosis, and treatment response assessment. Major advances in imaging informatics to support medical imaging have been made during the last several decades. More recent informatics advances focus on the special needs of oncologic imaging, yet gaps still remain. We review the current state, limitations, and future trends in imaging informatics for oncology care including clinical and clinical research systems. We review information systems to support cancer clinical workflows including oncologist ordering of radiology studies, radiologist review and reporting of image findings, and oncologist review and integration of imaging information for clinical decision making. We discuss informatics approaches to oncologic imaging including, but not limited to, controlled terminologies, image annotation, and image-processing algorithms. With the ongoing development of novel imaging modalities and imaging biomarkers, we expect these systems will continue to evolve and mature.

The hemodynamics and fluid mechanical forces in blood vessels have long been implicated in the deposition and growth of atherosclerotic plaque. Detailed information about the hemodynamics in vessels affected by significant plaque deposits can also provide insight into the mechanisms and likelihood of plaque weakening and rupture. In the current study, the governing equations are solved in their finite volume formulation in several patient-specific stenotic geometries. Of specific interest are the flow patterns and forces near ulcerations in the plaque. The flow patterns and forces in vessels with ulcerated plaques are compared with those in stenotic vessels without evidence of ulceration and to the hemodynamics in the same vessels as they likely appeared prior to ulceration. Hemodynamics “before” and “after” hemorrhage may suggest fluid mechanical and morphological factors of diagnostic and predictive value. Recirculation zones, vortex shedding, and secondary flows are captured by both laminar and turbulent solutions. The forces on vessel walls are shown to correlate with unstable plaque deposits. Performing before and after studies of vessels in long-term radiology studies may illuminate mechanisms of hemorrhage and other vessel remodeling.

To assess the effect of short-term corticosteroid premedication on serum glucose in hospitalized patients.Serum glucose in adult inpatients receiving corticosteroid premedication before a radiology study was compared to serum glucose in nonpremedicated controls between May 1, 2008, and September 12, 2009. Patients were categorized by type of nonionic contrast medium (intravenous [IV] or none) and route of corticosteroid premedication (oral, IV, none). Diabetes mellitus (types I and II) was evaluated as an independent risk factor. Patients without glucose estimations before and after premedication were excluded. Results were analyzed with analysis of variance and a stepwise linear regression analysis.There were 390 corticosteroid premedication episodes in 390 patients; 873 examinations in 844 patients served as controls. Cohorts receiving corticosteroid premedication experienced a brief (24-48 hour) increase in mean maximum postbaseline serum glucose (IV, +81 mg/dL; oral, +70 mg/dL) that was greater than the increase in nonpremedicated controls (+46 mg/dL). Type I (+144 mg/dL) and type II (+108 mg/dL) diabetics had a greater elevation than nondiabetics (+34 mg/dL). Both corticosteroid premedication (IV, P = .02; oral, P = .01) and diabetes mellitus (type I, P = .0002; type II, P.0001) were significant independent risk factors of hyperglycemia. The use of nonionic intravascular contrast medium was not (P = .7). There was no significant difference between IV and oral premedication (P = .6), or type I and type II diabetes mellitus (P = .8).Diabetes mellitus (type I and type II) and corticosteroid premedication (oral and IV) are significant independent risk factors for the development of brief hyperglycemia near the time of inpatient radiology studies.

OBJECTIVE: The aim of this study was to establish which materials afford better simulation of soft tissues in Oral Radiology studies. MATERIAL AND METHODS: The sample was composed of four materials in eleven different thicknesses to simulate the soft tissues of the face. The mean values of the relative amounts of radiographic contrast of the materials were determined and compared to a gold standard value, which was obtained from 20 patients who were referred to have periapical radiographs taken of the left mandibular molars. Data were subjected to statistical analysis with Dunnett's test (p

We describe a model of how physician assistants can be used in an academic medical center to expand radiologist productivity, and to enhance the departmental academic and educational missions. At Harborview Medical Center, following a training program and graduated responsibility under supervision, physician assistants provide initial interpretation of radiology studies, consultation to referring physicians, and perform less complicated interventional procedures. Acceptance of physician assistants by the radiologists, radiology residents, and referring physicians has been high. Although the impact of physician assistants on departmental clinical productivity is difficult to measure, our data suggest that radiologists are more efficient when physician assistants are assigned to service, both in terms of numbers of studies interpreted, and timeliness of reporting and billing. As a result of the success of our program, we believe that physician assistants can have an important role in radiology practice.

Among the problems facing many radiology groups today is how to cover after-hours studies, because the demand is increasing while the number of available radiologists is still relatively low. There are a number of possible solutions, each of which has its own pros and cons, and no solution is right for every group. Recently, there have been a number of companies whose sole business is providing outside teleradiology coverage of after-hours radiology studies, sometimes referred to as "nighthawk" services. This article describes one group's decision-making process in choosing to hire a nighttime teleradiology provider as well as its subsequent experiences and ideas for future solutions.

We tracked cultures submitted to a laboratory in 2004 in which mycobacteria other than Mycobacterium tuberculosis or Mycobacterium avium complex were grown (n = 11). We reviewed clinical information, other mycobacterial cultures, and radiologic findings. We measured the time from specimen submission to first growth and to final species identification. We assessed the response to this information based on notes, laboratory tests, consultations, and radiology studies. The median time to identification was 68 days (47–292 days). In 5 cases, the clinician failed to retrieve the data, and in 3 of these cases, there was a resultant loss of opportunity to treat. In 3 cases, the laboratory never reported a definitive species, and in 3 cases, the culture results were clinically unimportant. We show that the results of positive cultures of these mycobacteria are effectively lost because they are not available in a timely fashion, and even when available, the results are overlooked.

Tumors of the small intestine account for fewer than 5% of gastrointestinal neoplasms. Approximately 20% of small bowel neoplasms are gastrointestinal stromal cell tumors, a spectrum of mesenchymal tumors of the gastrointestinal tract that range from benign to highly malignant. Diagnosis of gastrointestinal stromal cell tumors is usually incidental, given their rarity and the limitations of traditional endoscopy and radiology studies in visualizing the small intestine. The advent of wireless capsule endoscopy has improved the definitive diagnosis of small bowel disorders. This article outlines the course of diagnosis and treatment for a patient who presented to our hospital with severe anemia and demonstrates the role of capsule endoscopy in identifying the causes of obscure gastrointestinal bleeding.

Background. To improve student skills specific to the evaluation of radiology studies during a required clerkship in surgery for 4th-year medical students, we initiated a self-study CD-ROM educational module midway through 2000–2001. We hypothesized that student performance would improve after implementation of this module and identified factors that predicted student performance. Materials and methods. Students (n = 98) chose one of two hospital sites for a clerkship that focuses on the care of acutely ill surgical patients. A standardized clinical final evaluation (Objective Structured Clinical Evaluation) contained two components: radiology (R score) and ICU clinical “flow sheet” interpretation (C score). We evaluated the effect of the CD-ROM educational module and other factors on student exam performance using univariate and multivariate analysis. Results. The site of the clerkship and use of the CD-ROM educational module were significant factors affecting the C score identified by ANOVA; P < 0.05. With the R scores from both sites combined, performance improved by 22% from a mean of 29.2 ± 1.1 to 35.7 ± 1.1 with use of the module. A stepwise multiple regression analysis testing the effect of site, time of year, educational module, and a prior radiology clerkship on the R score identified that the site and CD-ROM educational module modeled performance; R2 = 0.30, P < 0.01. The C score was affected by site (A: 72.5 ± 1.6 vs B: 67.3 ± 1.9, P < 0.05 by ANOVA). Regression analysis identified that time of year (later associated with increased score) and prior performance on the 3rd-year standardized exams (OSCE and NBME) modeled 4th-year C score; R2 = 0.20, P < 0.01. Conclusions. In a clerkship that already emphasized faculty-facilitated case-based learning, including evaluation of radiological studies, the addition of a self-study CD-ROM radiology module significantly improved test score. This study supports the efficacy of directed self-study to improve student skills.

The local tumor bed radiation boost used with whole breast radiation therapy (WBRT) in conservation breast cancer treatment has been controversial. Two decades ago, I wrote that patients with early-stage breast cancer resected with negative inked surgical margins could be well-treated with 50 Gy WBRT without a local boost. This was based on retrospective review of patients treated at our institution and the results of the NSABP B-06 study (1, 2). The local boost could be reserved for those patients with positive or unknown surgical margins. In an editorial in this journal in 1994, I concluded that radiation fibrosis was related to the use of the local boost (3). These recommendations proved to be controversial. Subsequently, the value of the local boost was studied in the major European Organization for Research and Treatment of Cancer (EORTC) 22881-10882 trial (4). In this landmark study of more than 5,000 patients, those who received WBRT with a local boost had statistically significantly fewer ipsilateral breast recurrences compared with those who only received 50 Gy WBRT. The magnitude of the absolute reduction was inversely related to patient age. Although patients over the age of 50 years had an absolute reduction of 3–4%, those 41–50 years of age had an absolute reduction of nearly 5% and those 40 years old or younger had an absolute risk reduction greater than 10%. Determination of the area to be treated by the local boost is usually based on a combination of factors including initial location of tumor within the breast based on physical exam and radiology studies, location of the surgical scar when the surgeon places it over the tumor site, site of a seroma pocket if visible on computed tomography simulation films, and location of surgical clips that may or may not have been placed at the time of lumpectomy. The local boost field size and dose may also depend on the pathologist’s assessment of cancer at the inked margin, distance between cancer and the closest

Rationale and objectives The authors propose an objective basis for critical evaluation of research trends and define and analyze a sample of radiology studies according to research phase. Methods A random sample of 146 original diagnostic studies from two radiology journals was categorized according to phase, modality, and design by three physician reviewers, collated with a microcomputer database, and analyzed using an SAS program. Results Phase 1 studies (technical evaluation) constituted 18.5% of publications: phase 2 (standardization and tissue characterization), 10.3%; phase 3 (spectrum of appearances), 40.4%; phase 4 (diagnostic efficacy), 21.2%; and phase 5 (clinical evaluation), 9.6%. Of 48 diagnostic efficacy studies, 42% were prospective (versus 35% for the total sample), 38% were controlled (median sample size, 53 [versus 30 for the total sample]). Only 27% of the 48 diagnostic efficacy studies were externally funded. Research in magnetic resonance imaging (MRI), which comprised 45% of all publications, was oriented toward phase 1 (32%) rather than phase 5 studies (0%). Phase 5 studies were the focus of 18% and 8% of ultrasound (US) and computed tomography (CT) studies, respectively. There were more prospective, controlled efficacy studies in US than in MRI or CT. Conclusions Analyses of research trends will be facilitated by use of a standard taxonomy which adopts a modality-based, phased approach.

AJR 2010; 195:W307 0361–803X/10/1954–W307 © American Roentgen Ray Society Mobile Telephone–Based Remote Orthopedic Consultation We very much enjoyed reading the article by Toomey et al. [1] in the February 2010 issue of the AJR, and we would like to share our success story with mobile telephone– based remote orthopedic consultation. TEREM Emergency Medical Centers is a medical services company that operates five urgent care facilities in the greater Jerusalem area. In 2009, we managed 200,000 urgent care visits, including nearly 10,000 fractures and 30,000 nonfracture traumas. Our clinics all have digital, on-site, computerized radiology during all operating hours. Our consultants carry smartphones with the capability of receiving and viewing radiographic images via a custom-developed Web page directly from our proprietary electronic medical record system. To initially validate our system, a sample of 41 images with both gross and subtle findings was viewed by an orthopedist on a mobile device. The reports of the orthopedic consultant were compared with the readings of our radiologists who read the same images via our regular PACS using diagnostic screens. All findings, both subtle and gross, were identified by both the orthopedist and the reporting radiologist. We published these findings in the Israeli Journal of Emergency Medicine [2]. Since the implementation of this system, we have had an additional 312 orthopedic radiology studies that have been initially reviewed by mobile telephone and then confirmed later via radiologist review. To date, no clinically significant fracture has been missed using the mobile device. Of special note is that since inception of this remote consultation system, we have seen a drop of nearly 50% in referrals from our clinics to the hospital. In many cases, the remote consultant was able to provide advice on local clinic management, thus saving the referral to the hospital emergency department. In summary, we have a great deal of clinical evidence that remote access to imaging can be a timeand money-saving tool for many practices. It has been shown to reduce the number of unnecessary hospital referrals and can lead to increased comfort of clinic physicians from knowing that they have received subspecialty input regarding the proper care and follow-up for their patients. Rachel Hammel Nahum Kovalski Deena R. Zimmerman TEREM Emergency Medical Centers D.N. Shimshon, Israel

A generalized order communications program has been developed for the transmission of requests within LDS Hospital (Figure 11.1). The program allows nurses and unit clerks to enter requests for ECGs, blood gases, and medical supplies. Use of the computer to order laboratory tests is planned for the near future. The requests are sent electronically to the appropriate hospital department. The same order entry program is used for the entry of information on patients requiring isolation precautions. The computer uses the entered data to determine automatically the appropriate isolation requirements and then automatically transmits a request for the necessary supplies to the central supply department. The order entry program is menu driven and has been created using the general questionnaire asking program (GQAP, a HELP system software development tool discussed in Chapter 4). The HELP system is also used by physicians, nurses, and clerks to enter orders for blood products, total parenteral nutrition, and radiology studies. These are discussed in detail in separate reports and will not be covered here.

Pelvic floor disorders are of interest to many surgeons who specialize in organ systems within this region. Colorectal surgeons are especially interested in disorders of the posterior compartment, which may broadly be divided into defecation disorders and fecal incontinence. These disorders distress patients socially and psychologically and greatly impair their quality of life. The underlying anatomical and pathophysiological changes are complex, are often incompletely understood, and cannot always be determined. However, over the past decades, advances in the understanding of these disorders, together with rational methods of evaluation in anorectal physiology laboratories, radiology studies, and new surgical techniques, have led to promising results. This review summarizes the evaluation and treatment strategies, as well as the recent updates on the clinical and the therapeutic aspects of pelvic floor disorders.

Radiology nurses functioning in the many areas of the radiology department strive to connect with their patients on many levels, often within a very short time. Creating a “circle of trust” for each patient supports both patient and nurse satisfaction in care received and delivered. Nurses begin their interaction with either the outpatient or inpatient through an initial review of their orders, indications, and important demographic variables that must be addressed during their diagnostic study or therapeutic intervention. Once registered nurses coordinate the radiology care for the patient, the registered nurse for the first department where the patient will be cared for first will initiate a transport request for the radiology transport team to bring the patient to the central patient holding area. As soon as the nurse is notified that the patient has arrived in the holding area, the patient is greeted by the registered nurse. The nurse verifies that the orders continue to be active and then escorts the patient to the first area of care. Each nurse, using his or her expertise, accompanies each patient through the entire stay in the department from entry to exit. Registered nurses are assigned to each of the radiology department areas: magnetic resonance imaging, interventional radiology, ultrasonography, diagnostic radiology, computed tomography, and nuclear medicine. Radiology requisitions are reviewed by the registered nurse to determine studies that require a nursing presence to facilitate and support care and treatment. Each radiology study or interventional procedure requisition generated for a patient during the stay identifies every radiology department area where the patient will need care from radiology personnel. For example, a patient with orders for computed tomography of the thorax for pulmonary embolism and also scheduled for an ultrasound duplex study of the lower extremities will have both studies printed on both requisitions to alert staff that this patient has several studies to be coordinated. The registered nurses in both areas work together to coordinate the care of this patient. Considerations to be included in the coordination effort include all patient data, inpatient or outpatient status, available recovery suite times if applicable, procedure times, possible imaging issues if one study is completed before another (often related contrast clearance times), technologist availability, and availability of physician staff. The nurse for the area where the patient is first scheduled will remain with the patient until all radiology studies/procedures are completed for the day. All registered nursing staff have expertise in each area in the department, although they might not be the primary nurse responsible in a specific area. For example, in interventional radiology, the registered nurse would remain with the patient through all procedures or studies. After any postprocedure observation, the nurse brings the patient to the central holding area where he or she is then transported to a room or to transportation home. Every attempt is made to have the nurse who cared for the patient follow up with the patient within the next 24 hours. The outcome measures for this innovation that was developed in a shared leadership format indicate tremendous improvement in patient self-identified satisfaction with time spent in the radiology department. Additionally, the radiology nurses express an increase in their job satisfaction, often stating that they “really feel as if I've made a difference.”