Radiology

Link, Thomas M.

doi: 10.1148/radiol.2483080763pmid: 18710965

In Vivo Quantification of Cortical Bone Water with Ultrashort Echo-Time MR Imaging: A New Parameter to Measure Bone Quality? Thomas M. Link , MD Department of Radiology, University of California San Francisco, 505 Parnassus Ave, Box 0628, San Francisco, CA 94143, [email protected] SUMMARY In this issue of Radiology, Techawiboonwong et al (1) report on a method to quantify water content of cortical bone by using ultrashort echo-time radial magnetic resonance (MR) imaging, which may be used as a surrogate marker for cortical bone porosity. The investigators validated the technique in cortical bone specimens before using it clinically at the tibial midshaft in healthy pre- and postmenopausal women and in patients receiving maintenance hemodialysis. In vitro, the investigators found excellent agreement with cortical water assessed with an isotope exchange experiment. In vivo, substantial differences in cortical bone water between the three subject groups were found. THE SETTING Clinicians and researchers have learned that bone mineral density (BMD) has limitations with regard to explaining bone strength and fragility. To describe characteristics of bone responsible for its strength but separate from bone mass and BMD, the term bone quality was introduced by the National Institutes of Health Consensus Conference on Osteoporosis in 2001 (2). Among the most important parameters responsible for bone quality are those that measure trabecular and cortical bone micro- and macrostructure (3). Cortical bone porosity … Full Text of this Article

Alderson, Philip O.; Becker, Gary J.

doi: 10.1148/radiol.2483080861pmid: 18710966

The New Requirements and Testing for American Board of Radiology Certification in Diagnostic Radiology 1 Philip O. Alderson , MD and Gary J. Becker , MD 1 From the Department of Radiology, Saint Louis University School of Medicine, 1402 S Grand Blvd, Room 268, St Louis, MO 63104 (P.O.A.); and American Board of Radiology, Tucson, Ariz (G.J.B.). Received May 15 and final version accepted May 15, 2008. Address correspondence to G.J.B. (e-mail: [email protected] ). Discuss this article online at www.rsna.org/radiology/discuss The time-tested certification process of the American Board of Radiology (ABR) is generally regarded as successful. Even so, it is continuously evaluated to determine if it reflects contemporary practice. Although the practice of diagnostic radiology has been changing rapidly, the certifying examination has not kept pace. Accordingly, after much thought and debate, the trustees of the ABR are developing an entirely new examination paradigm. The new format is designed to be compatible with the 4 years of residency training currently approved by the Radiology Residency Review Committee. The current process for ABR certification in diagnostic radiology consists of three examinations: (a) a qualifying (“written”) examination in radiologic physics that can be taken after the 2nd or later years of training, (b) a qualifying (“written”) examination in diagnostic radiology—also known as “the clinical examination”—taken early in the final year of training, and (c) an oral certifying examination that covers 11 subspecialties of diagnostic radiology, each of which must be passed. The certifying examination is taken near the end of the final residency year. Beginning with the residency class that starts in July 2010, there will be only two examinations. The first will be a “core examination” given at the end of the 3rd year of radiology training (36 months; end of postgraduate year 4). The core examination will include segments on all 11 clinical categories, plus basic and clinically applied physics. There will be no other physics examination. The core examination will include case-based material and, unlike the current qualifying examinations, will be image rich. Fifteen months after residency there will be a computer-based certifying examination bearing structural similarity to the examinations to be administered once each maintenance-of-certification (MOC) cycle throughout the diplomate's career. The decision to make these changes did not come to the … Full Text of this Article

Hall, Ferris M.; Janower, Murray L.

doi: 10.1148/radiol.2483080860pmid: 18710967

The New Requirements and Testing for American Board of Radiology Certification: A Contrary Opinion 1 Ferris M. Hall , MD and Murray L. Janower , MD 1 From the Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (F.M.H.); and 4301 N. Ocean Blvd, Boca Raton, Fla (M.L.J.). Received and final version accepted May 15, 2008. Address correspondence to F.M.H. (e-mail: [email protected] ). Discuss this article online at www.rsna.org/radiology/discuss In this article we present a contrary opinion regarding the decision by the American Board of Radiology (ABR) to change the format and timing of their certification examinations (1). We believe the rationale for these changes has not been entirely explained or appreciated and that the ramifications extend not only to residency training, but probably to the entire practice of radiology. We will point out the short-term winners and losers of the new examination sequence and speculate about the longer-term consequences. A major, but often unspoken, argument in favor of the certification examinations changes is that they are an essential precursor to planned modifications in residency training, which are necessary to increase imaging subspecialization (perhaps the more proper term is superspecialization or supersubspecialization). The proper balance of general and subspecialty radiology has long been debated, and many, particularly those in academic medicine, believe increasing specialization is the wave of the present and the future. Their assumption is that the current 9–12-month mini-fellowships during the last year of residency and/or a year of postresidency fellowship are inadequate to serve our increasingly sophisticated referring colleagues. As stated by Atlas (2), “subspecialization is one of the defining characteristics of American medicine” and that our embracing it is “the key to the survival of radiology.” However, many experts question the rush to specialization in American medicine, with the associated gradual disappearance of primary practice, the general internist, and even general surgeons (3). They question the cost-benefit of increasingly sophisticated health care, wonder who will coordinate the care of older patients with multiple coexisting diseases, and point out that “when it comes to reducing early deaths, medical care has a relatively minor role” compared with lifestyle changes (4). Other first-world countries have not chosen this path, and their emphasis … Full Text of this Article

Bossuyt, Patrick M. M.

doi: 10.1148/radiol.2483080868pmid: 18710968

STARD Statement: Still Room for Improvement in the Reporting of Diagnostic Accuracy Studies 1 Patrick M. M. Bossuyt , PhD 1 From the Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Room J1b-212, PO Box 22700, 1100 DE Amsterdam, the Netherlands. Received May 18, 2008; final version accepted June 5. Address correspondence to the author (e-mail: [email protected] ). In the clinical assessment of a medical test, the evaluation of its diagnostic accuracy is an essential step. In an evaluation of diagnostic accuracy, the results of the test are compared with the results of the reference standard in the same patients. Yet, one cannot unconditionally take the results from any particular study at face value. Many authors have pointed out the multiple risks of bias in diagnostic accuracy studies (1,2). Critical appraisal of published studies is therefore essential. Unfortunately, researchers in many published studies fail to report essential elements of study design and conduct, making critical appraisal hazardous, if not impossible (3,4). Authors fail to mention the inclusion criteria, how they identified eligible patients, whether all patients underwent both the test under evaluation and the reference standard, and whether the same standard was used in all patients. They do not always mention how many uninterpretable results there were and how these were accounted for in the analysis. To improve reporting, the Standards for Reporting of Diagnostic Accuracy (STARD) initiative was set up. Inspired by the successful Consolidated Standards of Reporting Trials (CONSORT) project (5) to improve the reporting of randomized clinical trials, a comprehensive group of researchers, editors, and members of professional organizations developed a single-page checklist, which was finalized during a 2-day consensus meeting in Amsterdam, the Netherlands. This 25-item checklist was accompanied by a clear motivation, which was based on the … Full Text of this Article

Eisenberg, Ronald L.

doi: 10.1148/radiol.2483080863pmid: 18710969

The Role of Abdominal Radiography in the Evaluation of the Nontrauma Emergency Patient: New Thoughts on an Old Problem 1 Ronald L. Eisenberg , MD, JD 1 From the Department of Radiology, Beth Israel Medical Center, 330 Brookline Ave, Boston, MA 02215. Received May 15, 2008; final version accepted May 16. Address correspondence to the author (e-mail: [email protected] ). More than one-quarter of a century ago, our group challenged the indiscriminate use of ordinary abdominal radiographs, demonstrating that 53.7% of them could be eliminated without missing any clinically important findings (1). We recommended that abdominal radiography could safely be restricted to those suffering from moderate to severe abdominal tenderness and patients with clinical signs and symptoms highly suggestive of bowel obstruction, ureteral calculi, ischemia, or gallbladder disease. However, our article had little effect on ordering patterns, despite the continuing need to control overuse of imaging resources and the emergence of newer technologies that may provide more precise and reliable answers to clinical questions. In this issue of Radiology , Kellow et al (2) again address this important and provocative issue. Showing a high incidence of positive computed tomography (CT), ultrasonography (US), or upper gastrointestinal imaging findings, even in patients whose abdominal radiograph was interpreted as normal or nonspecific (81% of the total studies), they confirm the frequent futility of conventional imaging for many abdominal conditions and the continuing overuse of abdominal radiographs 25 years after our article was published. They make the sweeping statement that, “with the exception of localization of catheter placement, there no longer remains a role for abdominal radiography in nontrauma emergency room patients,” arguing that “when imaging is needed, the emergency physician should be encouraged to immediately request more definitive imaging modalities eg, CT and US,” which were not readily available when our article was published. Although I completely agree that abdominal radiography is overused and … Full Text of this Article

McFarland, Elizabeth G.; Levin, Bernard; Lieberman, David A.; Pickhardt, Perry J.; Johnson, C. Daniel; Glick, Seth N.; Brooks, Durado; Smith, Robert A.

doi: 10.1148/radiol.2483080842pmid: 18710970

Revised Colorectal Screening Guidelines: Joint Effort of the American Cancer Society, U.S. Multisociety Task Force on Colorectal Cancer, and American College of Radiology 1 Elizabeth G. McFarland , MD , Bernard Levin , MD , David A. Lieberman , MD , Perry J. Pickhardt , MD , C. Daniel Johnson , MD , Seth N. Glick , MD , Durado Brooks , MD, MPH and Robert A. Smith , PhD 1 From St. Luke's Hospital, Center for Diagnostic Imaging, 232 S Woods Mill Rd, Chesterfield, MO 63017 (E.G.M.); University of Texas M.D. Anderson Cancer Center, Houston, Tex (B.L.); Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Ore (D.A.L.); Department of Radiology, University of Wisconsin Hospital and Clinics, Madison, Wis (P.J.P.); Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.D.J.); Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pa (S.N.G.); and Department of Cancer Control Science, American Cancer Society, Atlanta, Ga (D.B., R.A.S.). Received April 18, 2008; final version accepted May 13. Address correspondence to E.G.M. (e-mail: [email protected] ). Editor's Note: This editorial refers to the 2008 revised colorectal screening guidelines jointly published by the American Cancer Society (ACS) and the American Gastroenterology Association. The full guidelines are reprinted, with permission from the ACS, online at http://radiology.rsnajnls.org/cgi/content/full/248/3/717/DC1. Subsequent to publication in CA A Cancer Journal for Clinicians, an erratum was issued regarding the listing of authors of the original report (CA Cancer J Clin, 2008;58:160). On March 5 of this year, new multidisciplinary colorectal screening guidelines were released (1,2, http://radiology.rsnajnls.org/cgi/content/full/248/3/717/DC1). These guidelines joined for the first time the American College of Radiology (ACR), the American Cancer Society (ACS), and the U.S. Multisociety Task Force on Colorectal Cancer (composed of the three gastroenterology societies: the American Gastroenterology Association, American Society for Gastrointestinal Endoscopy, and American College of Gastroenterology). A broad range of screening modalities were reviewed, including various forms of stool tests, flexible sigmoidoscopy, colonoscopy, barium enema, and computed tomographic (CT) colonography. After careful analysis of the evidence, two new screening tests were recommended: CT colonography and stool DNA testing. The guidelines also strongly emphasize the importance of cancer prevention, along with the need to adhere to high quality-assurance guidelines across tests. Colorectal cancer remains the third most common cancer diagnosis in the United States and the second leading cause of cancer-related deaths. Each year, about 150 000 people will receive a diagnosis of colon cancer, and about 50 000 will die of it. However, if detected early, the 5-year survival rate for colon cancer exceeds 90%. The new guidelines emphasize that the primary goal of screening is cancer prevention. For the first time, tests were grouped into two major categories: tests used primarily to detect cancer and tests used to detect adenomatous polyps and cancer (Table). Tests used primarily to detect cancer are the stool tests, including guaiac–fecal … Full Text of this Article

Pomerantz, Stuart R.

doi: 10.1148/radiol.2483080952pmid: 18710971

Net Assets: Special Collections 1 Stuart R. Pomerantz , MD 1 From the Department of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Gray 2-B285, Boston, MA 02114. Received and final version accepted May 30, 2008. Address correspondence to the author (e-mail: [email protected] ). In previous Net Assets articles (1,2), we examined how cutting-edge Web sites and services, including the Yottalook radiology-centric search engine ( http://www.yottalook.com/ ) and the Really Simple Syndication (known as RSS) organizer Google Reader ( http://www.google.com/reader ), can boost clinical productivity and educational opportunities for the busy radiologist. The Web sites we will explore here are remarkable not for their technologic wizardry but rather for the uniqueness of their radiologic content; whether old or new, immensely practical or simply whimsical, the special Web collections of radiologic content explored here are all worth browsing. WHONAMEDIT.COM Each day in radiology, we find ourselves repeatedly invoking such names as Valsalva, Luschka, and Meckel with nary a thought to the life and times of the men and women behind the eponyms. Though we may delight in the occasional opportunity to employ more esoteric attributions, such as Adamkiewicz, Maffuchi, and Marchiafava-Bignami, the backstory of these personages may remain elusive unless we have the chance to visit the Web site Who Named It? ( http://www.whonamedit.com/ ). Whonamedit.com is published and maintained by Norwegian medical historian Ole Daniel Enersen and contains an exceptionally rich and well-organized collection of medical eponyms. A biographic sketch is usually included in addition to a short bibliography, which often includes the landmark paper that established the eponymous connection (Fig 1). Not every entry has all three features, but at the current time over 8000 eponyms are described that are linked to over 3000 people. The site contains a generalized search box, as well as listings according to disease category, last name, and country of origin, and there is even a special list of female entries (Fig 1). Figure 1: Screen capture from whonamedit.com. (Courtesy of Ole Daniel Enersen, Oslo, Norway.) Besides being a … Full Text of this Article

Lloyd, Kristen M.; DelGaudio, John M.; Hudgins, Patricia A.

doi: 10.1148/radiol.2483070362pmid: 18710972

Cerebrospinal fluid (CSF) leak occurs when there is an osseous and dural defect at the skull base, with direct communication of the subarachnoid space to the extracranial space, usually a paranasal sinus. Recognition of the leak site and source and appropriate treatment are necessary to avoid rhinorrhea or otorrhea, low-pressure headaches, and meningitis, known complications of CSF leak. The imaging evaluation has evolved over the past several decades. Description of current techniques available to direct treatment options, including multidetector thin-section computed tomography, and imaging recommendations are presented.

Jacobson, Jon A.; Girish, Gandikota; Jiang, Yebin; Sabb, Brian J.

doi: 10.1148/radiol.2483062112pmid: 18710973

In the presence of joint space narrowing, it is important to differentiate inflammatory from degenerative conditions. The presence of osteophytes, bone sclerosis, and subchondral cysts and the absence of inflammatory features such as erosions suggest osteoarthritis. Typical osteoarthritis involves specific joints at a particular patient age. When osteoarthritis involves an atypical joint, occurs at an early age, or has an unusual radiographic appearance, then other causes for cartilage destruction should be considered, such as trauma, crystal deposition, neuropathic joint, and hemophilia. There are several types of arthritis, such as juvenile chronic arthritis and gouty arthritis, that may have a variable appearance compared with that of other common inflammatory arthritides.

Steenburg, Scott D.; Ravenel, James G.; Ikonomidis, John S.; Schönholz, Claudio; Reeves, Scott

doi: 10.1148/radiol.2483071416pmid: 18710974

Despite recent advances in prehospital care, multidetector computed tomographic (CT) technology, and rapid definitive therapy, trauma to the aorta continues to be a substantial source of morbidity and mortality in patients with blunt trauma. The imaging evaluation of acute aortic injuries has undergone radical change over the past decade, mostly due to the advent of multidetector CT. Regardless of recent technologic advances, imaging of the aorta in the trauma setting remains a multimodality imaging practice, and thus broad knowledge by the radiologist is essential. Likewise, the therapy for acute aortic injuries has changed substantially. Though open surgical repair continues to be the mainstay of therapy, percutaneous endovascular repair is becoming commonplace in many trauma centers. Here, the historical and current status of imaging and therapy of acute traumatic aortic injuries will be reviewed.