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Abdominal pain is one of the most common reasons for patients to present to the emergency department (ED) in the USA, with an estimated seven million visits in 2007-2008, a figure which represents 8 % (±0.2 %) [2] of all ED visits and a 31.8 % increase from 1999-2000. Abdominal pain has a broad differential diagnosis that encompasses multiple organ systems and can provide a significant diagnostic challenge to the ED physician. Although magnetic resonance imaging (MRI) currently plays a limited role in the assessment of abdominal pain presenting to the ED in the nongravid population, its utility in the pregnant and pediatric population has already been proven. A proven diagnostic track record, lack of ionizing radiation and the ability to provide excellent tissue contrast without the use of nephrotoxic iodinated contrast, makes MRI an attractive imaging modality. As physicians and patients become more aware of the potential risks associated with exposure to ionizing radiation, ED MRI utilization is likely to increase. In this article, we discuss the MRI appearance of some of the most common diagnoses, which present as abdominal pain to the ED.

In patients with suspected pulmonary thromboembolism (PTE), coronary artery calcification (CAC) can be an incidental finding on pulmonary CT angiography. We evaluated the frequency of CAC not being reported and its association with a diagnosis of acute coronary syndrome (ACS).Data of 469 consecutive patients who were referred to the emergency radiology department for pulmonary CT angiography of suspected PTE were reviewed. Radiology reports were rechecked and positive CAC findings were recorded. All pulmonary CT angiograms were reevaluated by one radiologist and CAC findings were recorded. The rates of ACS and PTE as final diagnoses for that hospital admission were calculated. The association between CAC and ACS diagnosis was assessed in different subgroups of patients.Approximately 11.1% of patients had PTE and 43.8% had CAC. The incidence of CAC was significantly higher in patients with an ACS diagnosis than in those without ACS (56.2% vs 40.4%, respectively; odds ratio [OR] = 1.9). There was a strong positive association (OR = 3.5) between CAC and ACS in younger patients (men ≤ 45 years and women ≤ 55 years), patients without PTE (OR = 2.2), and those without cardiometabolic risk factors (OR = 3.8). CAC was not reported in 45% of patients (n = 98) with positive CAC findings on imaging. ACS was the final diagnosis in 31.6% of patients with unreported CAC. There was a significant association between CAC and ACS in patients with unreported CAC (OR = 2.2). This association was more prominent in the subgroups described.CAC is often not reported in pulmonary CT angiography studies. CAC is a significant predictor of ACS particularly in younger patients, patients without PTE, and those without cardiometabolic risk factors. Especially in these subgroups, radiologists should assess CAC findings.

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

The American Society of Emergency Radiology (ASER) was founded in 1988 and is celebrating its 25th Anniversary. ASER is thriving and emergency radiology has never enjoyed greater popularity than at present. This history describes the genesis of the Society, its growth and current state of affairs. It is based on the recollections and personal files of the authors, one Founder and both former ASER Presidents and Gold Medalists, the ASER archives, and interviews and correspondence with many ASER members. It is hoped that this brief review will be interesting to the reader, provide some insight into ASER evolution over the years, and hold some lessons moving forward.

It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax.

Newer cardiac computed tomographic (CT) technology has permitted comprehensive cardiothoracic evaluations for coronary artery disease, pulmonary embolism, and aortic dissection within a single breath hold, independent of the heart rate. We conducted a randomized diagnostic trial to compare the efficiency of a comprehensive cardiothoracic CT examination in the evaluation of patients presenting to the emergency department with undifferentiated acute chest discomfort or dyspnea. We randomized the emergency department patients clinically scheduled to undergo a dedicated CT protocol to assess coronary artery disease, pulmonary embolism, or aortic dissection to either the planned dedicated CT protocol or a comprehensive cardiothoracic CT protocol. All CT examinations were performed using a 64-slice dual source CT scanner. The CT results were immediately communicated to the emergency department providers, who directed further management at their discretion. The subjects were then followed for the remainder of their hospitalization and for 30 days after hospitalization. Overall, 59 patients (mean age 51.2 ± 11.4 years, 72.9% men) were randomized to either dedicated (n = 30) or comprehensive (n = 29) CT scanning. No significant difference was found in the median length of stay (7.6 vs 8.2 hours, p = 0.79), rate of hospital discharge without additional imaging (70% vs 69%, p = 0.99), median interval to exclusion of an acute event (5.2 vs 6.5 hours, p = 0.64), costs of care (p = 0.16), or the number of revisits (p = 0.13) between the dedicated and comprehensive arms, respectively. In addition, radiation exposure (11.3 mSv vs 12.8 mSv, p = 0.16) and the frequency of incidental findings requiring follow-up (24.1% vs 33.3%, p = 0.57) were similar between the 2 arms. Comprehensive cardiothoracic CT scanning was feasible, with a similar diagnostic yield to dedicated protocols. However, it did not reduce the length of stay, rate of subsequent testing, or costs. In conclusion, although this "triple rule out" protocol might be helpful in the evaluation of select patients, these findings suggest that it should not be used routinely with the expectation that it will improve efficiency or reduce resource use.

The objective of our study was to prospectively determine how CT affects physicians' diagnostic certainty and management decisions in the setting of patients with nontraumatic abdominal complaints presenting to the emergency department.We included 584 patients presenting with nontraumatic abdominal complaints to the emergency department from November 2006 through February 2008. Emergency department clinicians were prospectively surveyed both before abdominal CT (pre-CT) and after abdominal CT (post-CT) to determine the leading diagnosis, the diagnostic certainty, and the management decisions. Changes were assessed by Fisher's exact test and the log likelihood ratio.The most common diagnoses were renal colic (119/584, 20.4%) and intestinal obstruction (80/584, 13.7%). CT altered the leading diagnosis in 49% of the patients (284/584, p0.00001) and increased mean physician diagnostic certainty from 70.5% (pre-CT) to 92.2% (post-CT) (p0.001; log likelihood ratio, 2.48). The management plan was changed by CT in 42% (244/583) (p0.0001). Physicians planned to admit 75.3% of the patients (440/584) to the hospital before CT; that plan was changed to hospital discharge with follow-up in 24.1% of patients (106/440) after CT. Surgery was planned for 79 patients before CT, whereas hospital discharge was planned for 25.3% of these patients (20/79) after CT.In the management of patients presenting to the emergency department with nontraumatic abdominal complaints, CT changes the leading diagnosis, increases diagnostic certainty, and changes potential patient management decisions.

The size of a pneumothorax is an important index to guide the emergency treatment of trauma patients--chest tube drainage. The purpose of this study was to develop and validate an automated computer-aided volumetry scheme for detection and measurement of pneumothoraces for trauma patients imaged with MDCT.Three pigs and 68 trauma patients with at least one diagnosed occult pneumothorax (23 women and 45 men; age range, 14-89 years; mean age, 41 +/- 19 years) were selected for the development and validation of our computer-aided volumetry scheme for pneumothorax. Computer-aided volumetry of pneumothorax consisted of five automated steps: extraction of pleural region, detection of pneumothorax candidates, delineation of the detected pneumothorax candidates, reduction of false-positive findings, and report of the volumetric measurement of pneumothoraces.In the animal study, our computer-aided volumetry scheme yielded a mean value of 24.27 +/- 0.64 mL (SD) compared with 25 mL of air volume manually injected in each scan. The correlation coefficients were 0.999 and 0.997 for the in vivo and ex vivo comparison, respectively. In the patient study, the sensitivity of our computer-aided volumetry scheme was 100% with a false-positive rate of 0.15 per case for 32 occult pneumothoracesor = 25 mL. The correlation coefficient was 0.999 for manual volumetry comparison. This automated computer-aided volumetry scheme took approximately 3 minutes to finish the detection and measurement per case.The results show that our computer-aided volumetry scheme provides an automated method for accurate and efficient detection and measurement of pneumothoraces in MDCT images of trauma patients.

Fractures and dislocations of the carpal bones are more common in young active patients. These injuries can lead to pain, dysfunction, and loss of productivity. Conventional radiography remains the primary imaging modality for evaluation of suspected carpal fractures and dislocations. However, multidetector computed tomography (CT) is playing an increasingly important role, especially in the following situations: (a) when results from initial radiographs are negative in patients with suspected carpal fractures, (b) when initial radiographic findings are indeterminate, and (c) when knowledge of the extent of carpal fractures or dislocations is required before surgical treatment. The advantages of multidetector CT include quick and accurate diagnosis with availability in most emergency centers. Multidetector CT can easily display the extent of carpal fractures and dislocations, often depicting fractures that are occult at radiography. In addition, with multiplanar (two-dimensional) and volumetric (three-dimensional) reformation, pathologic conditions and anatomic relationships are better perceived. This information can be easily conveyed to orthopedic and trauma surgeons and can be crucial for surgical treatment and planning.

Thoracic injuries are significant causes of morbidity and mortality in trauma patients. These injuries account for approximately 25% of trauma-related deaths in the United States, second only to head injuries. Radiologic imaging plays an important role in the diagnosis and management of blunt chest trauma. In addition to conventional radiography, multidetector computed tomography (CT) is increasingly being used, since it can quickly and accurately help diagnose a wide variety of injuries in trauma patients. Furthermore, multiplanar and volumetric reformatted CT images provide improved visualization of injuries, increased understanding of trauma-related diseases, and enhanced communication between the radiologist and the referring clinician.

In the imaging evaluation of Emergency Department patients presenting with facial pain, there is a condition that can mimic the radiographic appearance of a periapical dental abscess. This condition, cemento-osseous dysplasia, may appear similar on dental X-rays, panoramic radiographs, and computed tomography examinations to and must be distinguished from the more common periapical abscess in order to avoid inappropriate intervention. This review highlights the easy confusion of these two entities based on radiographic appearance and the clinical implications of such a mistake and suggests some approaches to avoid this error.

The aim of this study was to evaluate the efficacy of magnetic resonance (MR) without oral contrast in the assessment of suspected acute pathologies of the pelvis in pregnant and non-pregnant patients. Sixty-seven patients who had MR of the lower abdomen and pelvis for acute abdomen were included in the study. The MR examinations were evaluated for indication of the study, type of MR sequences, and sensitivity of MR in diagnosing the disease. T2 single shot fast spin echo (SS-FSE), T2 FSE, short tau inversion recovery, pre-gadolinium T1, and post-gadolinium T1 sequences were utilized. There were 30 pregnant and two postpartum women in the study group. Positive pelvic MR findings were seen in 73% (49/67). Final diagnoses were acute appendicitis (n = 12), ovarian torsion (n = 6), abscess (n = 3), tubo-ovarian abscess (n = 2), ovarian tumor (n = 2), degenerating fibroid (n = 3), and perianal fistula (n = 2). For acute appendicitis, sensitivity was 100% (12/12), and positive predictive value was 92% (12/13). Post-gadolinium T1-weighted sequences and T2 SS-FSE with FS were the sequences, which were most likely to best demonstrate the acute appendicitis. For ovarian torsion, the sensitivity was 86% (6/7), and positive predictive value was 100% (6/6). MR imaging is an efficacious means of diagnosing acute appendicitis, ovarian torsions, and other adnexal diseases in the acute setting. The four sequence protocol without oral contrast offers an excellent means of investigating the cause of acute lower abdominal and pelvic pain.

Fournier gangrene is a rapidly progressing necrotizing fasciitis involving the perineal, perianal, or genital regions and constitutes a true surgical emergency with a potentially high mortality rate. Although the diagnosis of Fournier gangrene is often made clinically, emergency computed tomography (CT) can lead to early diagnosis with accurate assessment of disease extent. CT not only helps evaluate the perineal structures that can become involved by Fournier gangrene, but also helps assess the retroperitoneum, to which the disease can spread. Findings at CT include asymmetric fascial thickening, subcutaneous emphysema, fluid collections, and abscess formation. Subcutaneous emphysema is the hallmark of Fournier gangrene but is not seen in all cases. Compared with radiography and ultrasonography, CT provides a higher specificity for the diagnosis of Fournier gangrene and superior evaluation of disease extent; however, diagnosis and evaluation can also be performed with these other modalities. The administration of broad-spectrum antibiotics and aggressive surgical débridement of the nonviable tissue are both essential for successful treatment. An awareness of the CT features of Fournier gangrene is imperative for prompt diagnosis and effective treatment planning.

Acute appendicitis is the most common surgical abdominal emergency. Although the clinical diagnosis can be made accurately in typical cases, imaging plays an important role in improving diagnostic accuracy of this condition, especially when the clinical diagnosis is uncertain. Magnetic resonance imaging is an emerging promising technique for the diagnosis of acute appendicitis, especially in patients with nondiagnostic ultrasound and in patients where radiation is a clinical concern. In the following review, the role of magnetic resonance in the diagnosis of appendicitis will be discussed.

Acute abdominal and pelvic processes account for more than half of all surgical procedures performed in the emergency setting. Rapid and accurate diagnosis in the emergency department is essential for the appropriate management of these acute conditions. Magnetic resonance (MR) imaging is an attractive modality for diagnostic imaging in patients for whom the risks of radiation or the potential nephrotoxicity of iodinated contrast agents is a major concern, such as pregnant and pediatric patients. MR imaging is most useful for evaluating pregnant patients with acute lower abdominal pain believed to have an extra-uterine cause, such as appendicitis or ovarian torsion. Other patients with other conditions commonly seen in the emergency setting may be better evaluated with another cross-sectional imaging modality. Imaging protocols should be adapted to the constraints of acute illness, with emphasis placed on minimizing the duration of image acquisition, and should include strategies to decrease motion-related artifacts. A prudent approach is to select the imaging modalities that can best depict a particular subset of clinical conditions to help narrow the differential diagnosis. Disadvantages of MR imaging include its high cost, the limited availability of MR imaging systems and trained radiologists, and the incompatibility of MR imaging systems and the equipment used for intensive care and monitoring of patient status.

Intramural gastric abscess is a rare condition representing a localized form of suppurative gastritis, which was described in the time of Galen. Cases are usually diagnosed either with a combination of imaging modalities such as upper gastrointestinal series, ultrasound, computed tomography (CT), and endoscopic ultrasound or in conjunction with endoscopy and laparotomy. The authors describe a case of intramural gastric abscess in which the diagnosis was made preoperatively using axial, coronal, and sagittal reformations obtained with multidetector CT.

Adrenal injuries, although an uncommon consequence of abdominal trauma, are important to recognize. If bilateral, adrenal trauma could result in life-threatening adrenal insufficiency. Furthermore, in the setting of trauma, adrenal injury can point to other concomitant injuries and has been associated with overall increased morbidity and mortality. In the past, before the advent of computed tomography (CT), detection was difficult, and the diagnosis was often made only at surgery or postmortem. Today, the diagnosis of adrenal injuries can be quickly and accurately made with CT. This retrospective review was carried out to identify, describe, and analyze different CT appearances of adrenal injuries and correlated with associated injuries and observed clinical context and outcomes. A patient cohort of CT-detected adrenal injuries was identified through a radiology software research tool by searching for keywords in radiology reports. The identified CT scans were reviewed and correlated with the patients' available clinical chart data and follow-up. Between April 1995 and October 2004, 73 cases of CT-detected adrenal injuries were identified, including 48 men and 25 women, with an age range 6 to 90 years and a mean age of 42.7 years. Of the cases, 77% were right-sided, 15% were left-sided, and 8% were bilateral. The causes of injuries were motor vehicle collisions (75%), falls (14%), sports related (4%), and miscellaneous causes (7%). Associated trauma included injuries of the liver (43%), spleen (23%), lung (19%), and kidney (18%), as well as pneumothoraces/hemothoraces (22%). Skeletal injuries included fractures of the ribs, clavicles, and/or scapulae (39%), pelvis and hips (30%), and the spine (23%). Isolated adrenal trauma was seen in only 4% of the cases. The CT findings of adrenal trauma were focal hematoma (30%), indistinct (27%) or enlarged (18%) adrenal gland, gross (15%) or focal (7%) adrenal hemorrhage, and adrenal mass (11%). Associated CT findings included periadrenal fat stranding (93%), retroperitoneal hemorrhage (22%), and thickened diaphragmatic crura (10%). Active adrenal bleeding was seen in one case (1.4%). The incidence of adrenal trauma was estimated to be 0.86%. Surgical management was required only for the associated injuries. The most common CT manifestations of adrenal trauma include focal hematoma, indistinct or ill-defined adrenal gland, adrenal enlargement or mass, and gross or focal adrenal hemorrhage in a normal-sized gland. Periadrenal stranding is very common. Retroperitoneal hemorrhage and crural thickening are also important associated findings. Operative intervention is typically required only for the associated injuries, which commonly accompany adrenal trauma.

The quality of healthcare has become a target of increasing public scrutiny and governmental concern while radiologic evaluation has assumed an increasingly important role in the diagnosis and management of patients (1). Public attention and awareness have increased and amplified the focus on the quality of healthcare (2). Some medical errors are extremely costly particularly with respect to patient morbidity and mortality. Patients referred to the tertiary care centers often arrive with radiologic imaging having already been performed at the primary institution. As part of the care to be delivered by the radiologists at the referral center, a second-opinion interpretation of the imaging studies is often requested, and the formal reports are incorporated into the patient’s permanent medical record at the referral institution where the patient’s management and treatment are determined. The added value of the point-of-care second interpretations can be viewed from the medical perspective of guiding and expediting appropriate treatment as well as from the financial perspective of avoiding unnecessary studies, at times incurring additional patient radiation exposure, when initial examinations need to be repeated or when additional examinations are suggested by the radiologist at an outside institution (3). Multidetector CT is an essential part of the assessment of patients suspected of having cervical spine injury after trauma. Despite all the advantages of multidetector CT, suspected spinal injury continues to be a daily challenge in clinical practice (4). Spine injuries are frequently missed; therefore, a second opinion can potentially improve the diagnosis (5). The purpose of this study was to evaluate the effectiveness of second-opinion radiology consultations to reassess the cervical spine CT scans of the trauma patients referred to our hospital.

Computed tomography (CT) scanning is an essential diagnostic tool and has revolutionized care of patients in the acute care setting. However, there is widespread agreement that overutilization of CT, where benefits do not exceed possible costs or harms, is occurring. The goal was to seek consensus in identifying and prioritizing research questions and themes that involve the comparative effectiveness of "traditional" CT use versus alternative diagnostic strategies in the acute care setting. A modified Delphi technique was used that included input from emergency physicians, emergency radiologists, medical physicists, and an industry expert to achieve this.

CT cystography has replaced conventional cystography in the evaluation of patients with suspected bladder rupture in most trauma centers. We performed this retrospective review to determine the accuracy of CT cystography and the role of multiplanar reformation in the diagnosis of bladder injury.The patient cohort was composed of trauma patients with clinically or CT-suspected bladder ruptures who were evaluated with CT cystography using two different MDCT scanners at our level 1 trauma center. The patients were identified through Folio, a radiology research tool software system. The CT cystography results were compared with the findings at surgery, clinical follow-up, or both.Between January 1, 2000, and December 31, 2004, 234 patients were examined in our level 1 trauma center with CT cystography. From the total of 234 examinations, 216 (92.3%) were interpreted as negative and 18 examinations (7.7%) were interpreted as positive. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Surgical bladder exploration and repair were performed in nine of the 18 cases. Seven (77.8%) of the nine cases had operative findings consistent with the CT cystogram findings. The overall sensitivity and specificity of CT cystography in diagnosing bladder rupture were each 100%. For extraperitoneal bladder rupture, the sensitivity and specificity were 92.8% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively.CT cystography is accurate for diagnosing bladder rupture. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture.

To retrospectively review the authors' experience with multi-detector row computed tomography (CT) for detection of aortic dissection in the emergency setting.The investigation was institutional review board approved, did not require informed patient consent, and was HIPAA compliant. In 373 clinical evaluations in the emergency setting, 365 patients suspected of having aortic dissection and/or other aortic disorders underwent multidetector CT. Criteria for acute aortic disorder were confirmed by using surgical and pathologic diagnoses or findings at clinical follow-up and any subsequent imaging as the reference standard. Positive cases were characterized according to type of disorder interpreted. Resulting sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated by using two-way contingency tables. All cases found to be negative for acute aortic disorders were grouped according to alternative CT findings.Sixty-seven (18.0%) of the 373 cases were interpreted as positive for acute aortic disorder. One hundred twelve acute aortic disorders were identified in these 67 cases: 23 acute aortic dissections, 14 acute aortic intramural hematomas, 20 acute penetrating aortic ulcers, 44 new or enlarging aortic aneurysms, and 11 acute aortic ruptures. Three hundred five (81.8%) cases were interpreted as negative for acute aortic disorder. In 48 negative cases, multidetector CT depicted alternative findings that accounted for the clinical presentation. Of these, three included both acute aortic disorders and alternative findings, and 45 included only alternative findings. One (0.3%) case was indeterminate for acute aortic disorder. Overall, 112 findings were interpreted as positive for acute aortic disorder, an alternative finding, or both at CT. No interpretations were false-positive, one was false-negative, 67 were true-positive, and 304 were true-negative. Sensitivity, specificity, PPV, NPV, and accuracy were 99% (67 of 68), 100% (304 of 304), 100% (67 of 67), 99.7% (304 of 305), and 99.5% (371 of 373), respectively.The positivity rate for acute aortic dissection or other acute aortic disorder in 373 cases examined at multi-detector row CT was 18.0%.

Purpose To maintain accreditation by the Liaison Committee on Medical Education and to form up-to-date educational objectives for medical students rotating through radiology clerkships, the authors investigated the influencing factors from instructors’, students’, and the medical community’s perspectives in the setting of traditional radiology medical student education. Method Radiology instructors’ perspectives were studied via literature, experience, and consensus. The medical community’s perspectives were studied via literature, most specifically the recommendations of the Liason Committee on Medical Education. Medical students’ perspectives were studied via a survey questionnaire eliciting the goals of the students as their clerkships began. Results Radiology instructors’ goals for radiology clerkships centered on anatomy, pathology, technology, and foundation. The medical community’s goals for radiology clerkships centered on history taking, physical examination, procedures, diagnosis, management, prevention, data analysis, communication, professionalism, cultural competence, careers in medicine, and models of health care delivery. Thirteen medical students were surveyed, and 13 responded (100%). Medical students’ goals for their radiology clerkships centered on appropriateness, science, film interpretation, and confidence. Conclusion The objectives for radiology clerkships in medical schools should be reevaluated and rewritten frequently. The formulation of the optimal objectives should be multifactorial, including the input of medical students, radiology instructors, and the medical community. These factors should be incorporated in the setting of traditional educational values with special consideration to current medical students’ needs. The authors have provided the objectives that they recently adopted, which they feel appropriately address the currently important issues.

CT has replaced conventional radiography of the face in many trauma centers. Concern exists that increased costs are associated with increased use of CT. Our goal was to compare the amount of CT and radiography performed for facial trauma at a level 1 trauma center in 1992 and in 2002 and to determine hospital costs for the imaging of these patients.The changes in volume and types of facial imaging examinations were determined comparing 1992 and 2002. Hospital costs of different imaging examinations were determined for 2002. Current costs of imaging facial trauma were compared with what 2002 costs would have been if the practice pattern in 1992 had continued.In 1992, 890 patients were evaluated for facial trauma. Six hundred seventy-one had only radiography, 153 only CT of the face, and 66 both CT and radiography. In 2002, 828 patients were evaluated. Five hundred eighty-four patients had only CT of the face; 228, only radiography; and 16, both CT and radiography. The number of facial imaging examinations per patient in 1992 and 2002 was 1.23 and 1.03, respectively. The 2002 hospital cost of a facial CT examination was $121 and of a facial radiography series was $154. Using CT instead of radiography for evaluating facial injury resulted in an overall cost savings of 22% per patient in 2002.The availability of CT has not resulted in increased use of facial imaging. The increased use of CT from 1992 to 2002 results in decreased current costs for the hospital.

OBJECTIVE. The purpose of this study was to describe the presence and CT distribution of nontraumatic fluid collections and edema in the abdomen and pelvis after initial fluid resuscitation of patients with major (≥ 25% total body surface area) thermal burns.CONCLUSION. Awareness of the presence and expected CT distribution of nontraumatic fluid after initial fluid resuscitation in patients with major burns can assist the radiologist in differentiating such collections from those caused by mechanical trauma.

Radiation dose data were collected from a calibrated multi-detector row computed tomographic (CT) scanner during trauma CT. One protocol (used with 10 case subjects) involved a single-pass continuous whole-body acquisition from cranial vertex to symphysis pubis, while the other, conventional protocol (used with 10 control subjects) involved scouting and scanning body segments (head, cervical spine, chest, abdomen, and pelvis) individually. Technical factors were kept constant within each body segment for the single-pass and the segmented protocols. Statistics included univariate analysis, two-tailed t testing to evaluate statistical significance of the summary statistic, and power and subject population contingency tables. The mean dose length product (DLP) with the single-pass protocol was 17% lower than the sum of the DLPs of each of the individual body segment scans (P.001). Analysis of power and subject population by using a difference in mean of 500 mGy. cm and an alpha of.05 revealed a (1-beta) of higher than 0.90 for a sample of 10 patients. Thus, a whole-body single-pass trauma protocol, compared with a typical segmented acquisition protocol matched for imaging technique, resulted in reduced total radiation dose. The reduction in radiation dose is thought to represent a reduction in redundant imaging at overlap zones between body segments scanned in the segmental protocol but not in the continuous acquisition.

Previous studies evaluating quantitative cerebral white matter diffusion anisotropy indexes have shown alteration in patients after trauma. To date, no clinically applicable scale exists by which to gauge and test the relevance of these findings. We propose the cerebral fractional anisotropy score in trauma (C-FAST) as an index of white matter injury, and we correlate C-FAST with several predictor and outcome variables.Fifteen patients were randomly selected from the trauma surgery service. Thirty control patients were randomly selected from the emergency department. All patients were subjected to MRI evaluation, including a diffusion-weighted sequence. Data extracted from the record of each subject included Glasgow Coma Scale, revised trauma score, Abbreviated Injury Scale, initial head CT results, patient disposition, length of hospital stay, and length of stay in intensive care unit. Region of interest measurements were made in fractional anisotropy maps in each of 12 white matter regions. Univariate statistics and a two-tailed t test were performed on the raw fractional anisotropy data. Data were then dichotomized using thresholds from univariate statistics. A C-FAST score was devised from the dichotomized data. Logistic regression analyses were performed among the C-FAST, outcome, and predictor data.Good correlation was noted between the C-FAST and death, hospital stay greater than 10 days, and intensive care unit stay greater than 5 days. Correlation with discharge to rehabilitation facility was good when adjusted for age and sex. Glasgow Coma Scale, revised trauma score, and Abbreviated Injury Scale show good correlation as predictors of a critical C-FAST.The C-FAST is a promising index derived from MRI diffusion fractional anisotropy measurements that shows successful correlation with outcome and predictor variables. A larger investigation is needed to verify the validity and stability of the correlations.

Acute appendicitis has long been recognized as a leading cause of abdominal pain in both adults a'2 and children. 3-5 Accurate and timely diagnosis of appendicitis is necessary to decrease the possibility of morbidity and mortality related to complications, including, most seriously, abscess formation with appendiceal rupture. 6'7 Despite a long history of acute appendicitis as a leading differential diagnosis in acute abdominal pain, a solely clinical diagnosis remains difficult, s especially in young patients. TM Moreover, acute appendicitis has many clinical differential diagnoses, which may further hinder a solely clinical assess

Purpose: Recent revisions of the advanced cardiac life support guidelines support the use of amiodarone in treating acute cardiac arrhythmia. Chemically, amiodarone has two atoms of iodine per molecule (39.3% wt/wt). We propose that at antiarrhythmic doses as prescribed by advanced cardiac life support guidelines, enhancement resulting from the bound amiodarone iodine is not significantly different from routine noncontrasted screening cerebral computed tomography (CT) studies. Method: Six patients presenting to the our emergency department with successful resuscitation after cardiac arrhythmia were identified before obtaining a screening CT scan and subsequent transfer to the cardiac catheterization laboratory for intervention. The total dose of amiodarone (bolus + drip) was calculated up to the moment of the CT scan. Subjects were age and gender matched with two control subjects. Hematocrit value and CT density measurements in the pons, putamen, centrum semiovale, and cerebral venous blood pool were recorded. Paired t test and linear regression analyses were performed. Amiodarone dose and hematocrit were used as covariates in the regression model to correct for altered density as a result of relative anemia. Results: Mean density in the blood pool was increased in the amiodarone subjects in both the univariate and regression models. Although the mean density difference of 3 HU was statistically significant, it is not likely detectable by the eye. All other brain area measurements showed nonsignificant differences in mean density for both the univariate analysis and regression model. Conclusion: Amiodarone administered at doses recommended by the American Heart Association for treatment of cardiac arrhythmia does not interfere with interpretation of the precatheterization noncontrasted screening cerebral CT scan.

The multiple trauma patient is usually initially imaged with a portable "trauma series" consisting of a lateral cervical spine film, a portable chest film, and a portable pelvis film (PPF). An investigation was performed to determine whether the screening PPF could be eliminated for multiple trauma patients being examined by abdominopelvic CT scan (APCT). A retrospective investigation analyzed all patients evaluated in our level I trauma center from 1 January to 31 December 2000 who were examined with a "trauma series" followed by an APCT scan within 8 h. The numbers and types of fractures diagnosed by PPF and by APCT were compared and correlated with clinical follow-up. Of 397 patients imaged by both PPF and APCT, 43 patients were diagnosed with 109 individual fractures by CT scan. The PPF did not detect 51 of the 109 individual fractures (47%) and failed to diagnose 9 of the 43 patients (21%) with a pelvic fracture. The PPF most often failed to detect sacral and iliac fractures. The four cases in which the PPF reported a fracture not listed in the APCT report were due to reporting errors or film artifacts. No soft tissue injuries were seen by PPF that were not also seen by APCT. We conclude that the screening PPF appears to be an unnecessary exam in multiple trauma patients about to be imaged by APCT scan.

The aim of this study was to retrospectively review the growth rate in emergency radiology volume at an urban academic trauma center from 1996 to 2012.The authors reviewed aggregated billing data, for which the requirement for institutional review board approval was waived, from 1,458,230 diagnostic radiologic examinations ordered for emergency department (ED) visits from 1996 to 2012. The growth rate was calculated as the average annual percentage change in imaging examinations per ED visits. The growth rates between 1996 to 2003 and 2004 to 2012 were statistically compared using a t test.ED patient visits showed continual growth at an average of 3% per year. Total imaging per ED visit grew from 1996 to 2003 at 4 ± 4% per year but significantly decreased from 2004 to 2012 at -2 ± 3% per year (P = .01). By modality, statistically significant decreased growth was observed in CT and MRI from 2004 to 2012. Ultrasound and x-ray showed unchanged growth from 1996 through 2012. ED physician ultrasound data available for 2002 to 2011 also showed increased growth.When adjusting ED imaging volume by ED visits, significantly decreased growth of overall ED imaging, specifically CT and MRI, was observed during the past 9 years. This may be due to slowing of new imaging indications, improved awareness of practice guidelines, and increased use of ultrasound. Although the national health care discussion focuses on continual imaging growth, these results demonstrate that long-term stability in ED imaging utilization is achievable.

Purpose: CT scanners with helical capability are commonplace. Evaluation of multiple trauma patients using this technique is fast, and easily performed as part of the radiological evaluation. Our purpose was to ascertain the clinical effectiveness of cervical spine screening with helical CT in a large sample population of multitrauma patients. Materials and methods: A retrospective review was carried out using screening helical CT scans from multitrauma patients referred to the Massachusetts General Hospital emergency department. The radiographic diagnosis was evaluated and tallied along with the clinical diagnosis and outcome for each patient included in the study. Results: Six hundred seventy-six patients conformed to the inclusion criteria. In this series, 59 true-positive, 616 true-negative, 1 false-negative, and no false-positive findings were encountered. These data result in a sensitivity of 98.3 %, a specificity of 100 %, and an accuracy of 99.9 %. Conclusions: Screening helical CT in the evaluation of trauma patients has a high diagnostic accuracy, and is sensitive and specific in diagnosing clinically relevant fractures of the cervical spine.

Purpose: To test the clinical feasibility and utility of a single-pass, whole-body multidetector CT (MDCT) protocol in the evaluation of the multiple trauma patient. Materials and methods: A whole-body, single-pass MDCT protocol was designed for optimal imaging quality and maximum flexibility for retrospective reconstruction and multiplanar reformation. Five consecutive trauma patients with moderate to severe mechanisms of injury were scanned on an MDCT scanner using the single-pass protocol. Times were recorded for the scan alone and for time spent in the CT bay. Times were compared with those for five random trauma patients scanned on a single-detector helical CT (SDHCT) scanner who were matched for body segments imaged and trauma severity. Results: Compared to SDHCT, MDCT scan times were shortened by a factor of 10 (3 min for MDCT vs 41 for SDHCT) and patient throughput times by a factor of 3 (23 min for MDCT vs 65 for SDHCT). Image quality was mildly compromised in MDCT by beam hardening due to arm position, but overall was comparable to segmental imaging. Conclusion: Whole-body MDCT is feasible and offers a marked time advantage over conventional segmental imaging in multiple trauma patients. Added flexibility through reformation of image data allows imaging evaluation as needed even after the patient has left the scanner bay.

Purpose: To compare the sensitivity and specificity of CT versus ultrasonography for the diagnosis of appendicitis in a population of pregnant women. Materials and methods: Radiology records (1988–1999) were searched for results of examinations performed on pregnant patients with suspected appendicitis. Subjects included only women with known intrauterine pregnancies. Thirty-two pregnant women were identified who had been studied by CT, ultrasound, or both. Ten patients had undergone focused abdominal CT with colon contrast, while 29 had undergone abdominal or pelvic ultrasonography with attention to the appendix. Results were compared to surgical pathology or follow-up findings. Results: CT sensitivity was 100 %, specificity 100 %, positive predictive value (PPV) 100 %, negative predictive value (NPV) 100 % and accuracy was 100 %. Ultrasound sensitivity was 100 %, specificity 83 %, PPV 50 %, NPV 100 %, and accuracy 21 %. Conclusion: In this small cohort of gravid females with suspected appendicitis, the sensitivity of focused abdominal CT with colon contrast was equal to that in the nonpregnant patient. In contradistinction to this, abdominal ultrasonography was frequently indeterminate. We hypothesize that ultrasonography is less accurate due to body habitus and the variable location of the appendix during pregnancy.

Purpose: This investigation examines whether there is a continued role for the initial screening lateral portable radiograph in patients whose cervical spine is “cleared” by a CT examination. Methods: A retrospective review of 200 multiple trauma patients suspected of cervical spine injury (CSI) was performed. All patients had a screening lateral portable cervical spine radiograph (LPCSR) followed by cervical spine CT (CSCT). All scans were helical and included coronal and sagittal reformations. Reports of both examinations were compared for all patients. For those patients with signs of acute CSI, the two reports were compared to determine whether the LPCSR contained any information affecting patient outcome that was not detected by CSCT. Results: The CSCT showed no signs of acute CSI injury in 190 patients. Ten CSCT scans showed signs of fracture. In these 10 patients, the screening LPSCR showed signs of fracture in 1 patient, question of fracture in 2 patients, and no fracture in 7 patients. No LPCSR demonstrated significant information not seen on the accompanying CSCT. No LPSCR showed a finding that altered patient management prior to CSCT. Conclusion: The data suggest that an initial LPCSR is unnecessary if the patient is having a screening CSCT.

Rationale and Objectives The competency of medical students in radiology clerkships is traditionally evaluated with film images, projected slides of photographed films, or printed reproductions of films. As radiology departments switch to filmless imaging, it seemed appropriate to determine the feasibility of an electronic evaluation prepared directly from digital images. Materials and Methods The image-based portion of a multiple-choice final examination was prepared as a PowerPoint presentation that included images downloaded from the departmental picture archiving and communication system (PACS) or digital teaching collections. The images were downloaded as bitmap files, imported to Adobe Photoshop for image editing, converted to tagged image file format, and finally imported to PowerPoint, where they were combined with text to create 50 questions. A liquid crystal diode projector displayed the questions, with a timer set to advance them automatically. Results The examination was easy and inexpensive to prepare (no photography costs). In an initial survey of 25 students, 17 (71%) of 24 students rated the resolution of images as excellent and five (21%) as good. No student gave an image a poor rating. Students preferred that images cover at least 40%–50% of the slides, and most approved of a blue background. An original allowance of 30 seconds per slide was reported to be too fast; the interval was increased to 45 seconds. Conclusion An electronic final examination for medical students, prepared with images downloaded from PACS or digital teaching collections, is feasible, easy to prepare, and cost-effective, and it provides an excellent display of test images.

Purpose: Today patients with suspected diverticulitis are commonly imaged with a CT scan utilizing a variety of methods of contrast medium administration. Although CT with rectally administered colon contrast has demonstrated a high diagnostic accuracy, concerns have been raised over its safety in patients with diverticulitis. The following retrospective investigation was undertaken to answer this concern. Materials and methods: Between January, 1997, and July, 1999, 308 patients with suspected diverticulitis were examined in the Emergency Radiology Division of the Massachusetts General Hospital by means of a helical CT scan performed with rectally administered colon contrast material. The patients' CT findings were correlated with their clinical courses and/or surgical findings. Results: Of the 308 CT scans, 115 (37.3 %) were positive for diverticulitis. Of 193 patients without diverticulitis, 91 (47.1 % of patients without diverticulitis) had alternative diagnoses made by CT, such as small bowel obstruction, epiploic appendagitis, and urinary tract calculi. No complications due to colon contrast material were noted. Even in cases where there was free extraluminal air, no extravasated contrast material was seen. Rectally administered colon contrast was well tolerated by patients and provided excellent large bowel opacification. This method saved imaging time in an emergency setting, as there was no need to wait for oral contrast to reach the colon. Conclusion: Out of 308 CT scans, there were no complications from the use of rectally administered colon contrast material. No case of traumatic bowel perforation secondary to colon contrast material was observed. Rectally administered colon contrast material is safe in the CT examination of patients with suspected diverticulitis.

Purpose: To compare the accuracy of spine plain films with chest and abdominal trauma CT in detection of spine fractures. Methods: The study prospectively enrolled 329 multiple trauma patients. Of these, 38 patients had both chest CT for trauma and thoracic spine plain films, and 87 patients had both abdominal CT for trauma and lumbar spine plain films. Results: Of the fractures visible at either chest trauma CT or thoracic spine plain film examination, all were diagnosed on CT and 62 % on plain films. Of fractures visible at either abdominal trauma CT or lumbar spine plain films, 94 % were diagnosed on CT and 67 % on plain films. The one false negative CT involved an articular process fracture, which was visible but not mentioned, in a patient with a sacral fracture. Conclusion: Evaluation of the digital scout images and bone windows when a patient has chest and abdominal trauma CT appears to be as accurate as thoracic and lumbar spine plain films in the evaluation of spinal trauma.

Rationale and Objectives Because digital imaging and the picture archiving and communication system (PACS) are replacing radiographic film, the effect of PACS on residents' perceptions and their educational experience was investigated. Materials and Methods Residents taking part in large diagnostic radiology training programs at two hospitals were surveyed. Approximately 75% of radiographic studies were reviewed with the use of PACS at both hospitals. Survey topics included technical and didactic issues based on direct and indirect comparison with analog (conventional film) images. Results Fifty residents were polled (20 respondents). The majority has been using PACS for more than 1 year (14 of 20, 70%) to interpret 75%–100% of cases (11 of 20, 55%). The majority believed that PACS improved patient care (15 of 20, 75%) and their educational experience (15 of 20, 75%). A minority believed that increased patient throughput was harmful to the educational experience (five of 20, 25%) because it permitted attending radiologists to review cases too quickly (four of 20, 20%). Residents favored PACS over hard-copy images for ease of manipulation, resolution, and ability to see pathologic conditions and normal anatomic characteristics. Conclusion Residents believe that PACS has positively affected their learning experience and does not negatively affect the quality of resident education.

Rationale and Objectives Traditional oral and written examinations can be limited in predicting future clinical performance. Therefore Objective Structured Clinical Examinations (OSCEs) have been introduced in other specialties. The authors assessed their value in radiology. Materials and Methods The study includes 122 Harvard medical students who undertook 1-month compulsory clerkships at one of three hospitals (A, B, or C) in their 3rd and 4th year and a compulsory OSCE in their 4th year. The OSCE was constructed from five cases. Each had eight or nine standardized questions designed to test, within a set time, the perception of essential findings, their interpretation, and clinical judgment (maximum possible score, 100). Clerkship grades were high honors (score of 3), honors (score of 2), satisfactory (score of 1), and fail (score of 0). Predictors of OSCE scores—clerkship grade and affiliated hospital—were modeled as linear functions. Time elapsed between clerkship and OSCE was modeled as a nonlinear function. Results Although there was a positive relation between clerkship grade and OSCE grade, it accounted for an increase of only 5.7% in OSCE score per clerkship grade and did not predict performance of individual students. Students who trained in hospital B showed significantly higher OSCE grades. OSCE scores were highest when the examination was taken 8 months after the clerkship. Conclusion The OSCE may be useful to uncover deficits in individuals and groups beyond the ones detected with traditional clerkship evaluations and provide guidance for remediation. The improved performance after additional clinical exposure suggests that the OSCE may be well suited to test the integration of radiologic and clinical knowledge.

Trauma patients with low clinical suspicion of cervical spine fracture are often examined with a plain X-ray cervical spine series rather than with cervical spine computed tomography (CT). The authors have been concerned by the absence of fractures in the group of patients examined with plain X-ray. The objective of this investigation was to determine the usefulness of plain X-ray examinations in suspected cases of cervical spine fracture compared to CT. A retrospective review was performed of all trauma patients undergoing imaging for suspected cervical spine fracture in our Emergency Department over a one-year period (January 1, 2007 to December 31, 2007). During the study period, 254 cervical spine plain X-ray and 3,080 cervical spine CT examinations were performed. Of the 254 plain X-ray examinations, 237 were interpreted as negative for fracture, 11 were suboptimal examinations, and six were interpreted as possible fractures (later ruled out by further imaging). Of the 3,080 CT examinations, 2,884 were interpreted as negative for fracture and 196 as positive. The overall positivity rates for acute cervical spine fracture were 0.0% in plain X-ray and 6.4% in CT examinations. These data confirm the authors' concern that plain X-ray imaging for patients with low clinical suspicion for cervical spine trauma in our hospital may have too low a yield to justify its use. However, the 6.4% positivity rate in the group of patients selected for CT examination justifies its use in this group.