The Online Radiology Elective

1. The Online Radiology Elective AKA RWJMS StudentPACS 2 wk Elective Salil Soman, MD, MS Radiology Resident, UMDNJ RWJMS Spring 2009

2. Welcome • Welcome to the Robert Wood Johnson Medical School Department of Radiology Interactive Radiology Elective – Student PACS. • We look forward to having you rotate with us!

3. See One, Do One, Teach One • On this rotation students are introduced to a selection of disease entities represented in imaging studies. • They then independently re-review the cases at PACS workstations and select images that best visualize the disease for presentation in SPACS modules. • They also research the disease process and create a series of questions which convey pertinent facts about the presentation, diagnosis, and management of that entity. • Their final modules are then added to the Student PACS web site as tutorial modules.

4. Finding A Needle In a Hay Stack • Aside from the act of recognizing a identifying a finding on a single image, radiologists often have to search through a series of images (from tens to thousands per study) to find the pertinent findings • These modules seek to simulate this process of searching not only on a single 2D image, but through a series of them.

5. First Steps • Get registered for the elective through registrar • Complete Our Online form prior to first day of rotation (As early as possible after officially being registered for the rotation) • Make an appointment to meet with a supervising resident on the first day of rotation • If you own them, bring your laptop and USB drive to the first day meeting (not required)

6. Expectations • Self Directed Work • Goal Oriented Reference Searches • Delivery of Final Products by decided guidelines • Usually completion of 6 to 7 modules by end of rotation • Usually submission of first draft of all modules by Monday of second week.

7. About The Web Site http://rwjradiology.umdnj.edu under “Educational Material” section • StudentPacs subsection: • http://www2.umdnj.edu/radpweb/SPACS2/index.html • Site Highlights • About the project • Current Staff • Instruction manuals • Example modules • Modules of previous rotation students • Rotation registration form.

8. About SPACS Flash Modules • Created by RWJMS Alumni and Radiology Dept Faculty & Residents • The SPACS module is a Macromedia Flash™ animation that presents serial images, like those from a CT or MRI study, in a simulated PACS interface. • It allows medical students and residents to experience the human body like they would at the expensive PACS workstations from any computer. • Users can flip through images, zoom in, and pan around to follow structures through slices of images at their own pace. • Pre-defined areas of interest, which we call "findings“, can be selected by the user, prompting the program to ask a set of questions. • Because the modules are created in Flash, they are inherently easy to distribute, either over the web or other means. File sizes relatively small and the compatibility is nearly universal.  

9. Process Overview • Select and Review Cases • Acquire Relevant Images and Reports with NO PATIENT INFORMATION • Create Tutorials Via Software • Send first draft to supervising resident • (html and swf files only) via email • Revise and expand as apropriate • Review tutorials with an attending radiologist. • Turn in final products • (.swf /.html /.fla files, txt of report with no patient information, all used source jpg’s, word doc of all text used in modules, your title, description, difficulty rating, radlex keywords, html code for upload)

10. Typical 2 week Elective • Student Register for elective, complete online registration form, and review online introduction prior to elective • Students Shadow attending Radiologists in main department and collect cases of interest for creating tutorials • Student reviews edited modules with attending radiologist in main department and gets final edit recommendation • Students research medical topics related to case, and then create SPACs Module • Students oriented by supervising Radiology Resident • Students independently review cases in PACS, output images that optimally represent findings, w NO personal health information • First draft flash file emailed to reviewing resident, who provides feedback. • Student selects Radlex keywords, and labeled case made available on elective web site.

11. Getting Cases • Review study with Faculty Radiologist or Radiology Resident • During this session write down Accession Number (will allow you to look up case later to acquire images and report) • Focus questions and note taking on clinical aspects of cases (including all pertinent aspects of radiology)

12. Case History • Try to collect the information the radiologist had available to best simulate experience of reading the case • Requisitions (often scanned in as a series in study) • In Clinical History portion of current report or available prior reports • May often be information clinician provided when directly consulting radiologist reading the study

13. What to Get • From Supervisor • Accession Number • Pertinent Available Hx (Simulate actual experience) • From PACS computer (on your own) • JPG’s windowed as you wish with NO patient information • Create a txt file of report with NO patient information

14. Background About CT • Algorithms • Bony vs Soft Tissue • Leverage Multislice Scanner • Slice Thickness • Reformats • Window and Level • Different settings highlight different structures

15. Selecting Images • Choosing Series • Different Algorithms • Different Recons • Minimize Number of Images • Images to best convey information • Optimal windowing

16. Making Questions Information Relevant to Radiology

17. Radiology Relevant Information • NAME THE TYPE OF STUDY (for out of the ordinary cases) • DESCRIBE FINDINGS; USE “BUZZ” WORDS IF DIAGNOSIS IS CERTAIN • OFFER DIFFERENTIALS IF ANY • DISCUSS MANAGEMENT, ESPECIALLY CASES THAT REQUIRE EMERGENT ATTENTION

18. Your File Structure • Create a folder titled with your name • Within that folder create subfolder for each of your modules titled with the module name, containing: • A folder with all of the source jpeg images you used • when creating a new module, tell software to save it into the folder created for that module, which will make .fla file • When you publish your project, it should create .html and .swf files in the module’s folder • A word document with all of the text you entered into the software for each finding, answer, etc • use for spell checking and later for indexing the modules for search • The text file with your html for the module (see later slide) • A word document which lists what image numbers your findings are on, and which contains your title, description and radlex keywords.

19. Overview Creating Cases Flash 8 Professional Student PACS extension Using the Student PACS extension

20. Using the Extension in Flash I • Create a new module with extension panel • Name and save the file as described on the “Your File Structure” slide. • Direct the subsequent dialogue box to the location of your jpeg images • Create hot spots on your images • For each hotspot create findings and questions • MAKE SURE THE “In Order” option IS SELECTED

21. Using the Extension in Flash II • At the end of EVERY explanation should be a reference • At the end of the last question for each finding, add text as a new paragraph after the reference for the explanation of the last question giving the user a CLUE that they go look for another finding (for all explanations except the LAST finding). • Choose the close or save option from the SPACS panel once you are done working on the module. • When you are ready to view the module in a web browser choose “Publish” from the SPACS menu on the SPACS panel within flash.

22. If You Can’t Find the SPACS Panel • Open Flash Professional • Create a new blank document • Then look under the “Windows” drop down menu, choose the “Other Panels” option and StudentPACS should be an option under the subsequent menu.

23. Versioning • When you create a module, all of your work gets save as a “.fla” file. • We recommend keeping a copy of the last working version of each .fla file when making changes • (so you can go back to the older file that worked in case something goes wrong with your changes) • This should be done manually from the computer using the copy command (not using Save As from within flash)

24. About References • EVERY answer in the module, regardless how fundamental needs to have a reference (textbook, journal article, web site less preferable) including at least a chapter number, though page number is preferred. • All references should be in standard MLA format. • If you find it helpful, UMDNJ provides a free copy of EndNote to all UMDNJ students (http://www.umdnj.edu/librweb)

25. Search Tools / Resources • Google / Google Scholar / Yottalook (Google tailored for Radiology by RSNA) • http://www.yottalook.com/ • Pub Med • http://www.ncbi.nlm.nih.gov/pubmed/ • UMDNJ Library Digital Resources (Radiology and Other Textbooks, E Journals) • http://www.umdnj.edu/librweb • Evidence Based Radiology • http://evidencebasedradiology.net/ • Free Large file email Transfer Web Service • e.g. http://yousendit.com

26. The Development Process • Once you have created your first draft of your first module, select the “Publish” option from the SPACS menu on the SPACS panel. • This will result in a .html and a .swf file being created in your folder for your module. • Email your supervising resident the .html and .swf files for your first module along with a list of on what image number in your .swf each finding is on. • This will require you to look at the html file in a web browser to get the image numbers. • You may need a send file service like “yousendit.com” to send the swf and html files. • (yousendit allows you to send files up to 100 MB for free).

27. Radlex Classification • Ontology created by RSNA for classifying radiological entities, similar to the SNOMed and MESH ontologies which are used in indices like PubMed • Radlex Term browser at http://radlex.org • Terms help make modules discoverable via searches • Each module should have radlex terms identified.

28. Choosing RadLEX terms • Highlighted structures are (i.e. internal carotid artery, small bowel, pancreas) • Body part imaged • Imaging modality used / type of study • Teaching points (i.e. pneumatosis coli, pancreatitis, aspergillosis) • Radiographic signs (i.e. signet ring sign) • Miscellaneous terms introduced through questions

29. Choosing Difficulty Ratings • Overall tutorial difficulty • Difficulty of imaging findings • Difficulty of questions

30. Add Final Author Information • In the final version of each module as it’s own paragraph after the patient history please list the author, supervising resident and editors.

31. HTML Code for Web Site I • Create a copy of the following code for each of your modules with the following information filled in: • Name of Module • Date of final submission • Description • Radlex Terms • Your name as Author • Supervising Resident • Editors • Image numbers on which each of the findings are present (e.g. Finding 1: images 2-7, Finding 2: Image 4-5) • Difficulty Ratings: overall difficulty, findings difficulty and questions difficulty (rate as easy/medium/difficult)

32. HTML Code for Web Site II NOTE : EVERYTHING IN BOLD BELOW SHOULD BE REPLACED WITH THE INFO FOR YOUR MODULES COPY THE TEXT BELOW INTO A TEXT FILE FOR EACH MODULE AND EDIT ACCORDINLY. <!-- Start Post --> <div class="post"> <div class="date"> <span class="month">Oct</span> <span class="day">9</span> <span class="year">2008</span> </div> <p><span class="title style1"> <a href="http://www2.umdnj.edu/radpweb/SPACS/Elective_Cases/Lauren%20Kovacs/bowel/AbdominalPain2.html" target="case"> [ Bacteremia and abdominal pain ]</a></span> 76 year old male with bacteremia and abdominal pain with history of clostridium difficile colitis.<BR> <span class="title">Author:</span> Lauren Kovacs, MS III</span><BR> <span class="title">Resident Supervisor:</span> Salil Soman, MD, MS<BR> <span class="title">Editors:</span> A. Masand, MS III, S.Soman, MD, MS, JK Amorosa, MD<BR> <span class="title">Radlex Terms:</span> pneumatosis coli (air in the bowel wall), causes: bowel perforation, ischemic bowel disease, blunt abdominal trauma; clostridium difficile; pneumoperitoneum; upper GI barium study; CT Abdomen/Pelvis without contrast <BR><span class="title">Clues:</span> Finding 1: images 1-5, Finding 2: images 7-9, Finding 3: images 4-5 <BR><span class="title">Difficulty:</span><b>Overall</B> Easy, <b>Findings:</B> Easy, <b>Questions:</B> Medium</p></div> <!-- End Post -->

33. Final Products (ALL WITHOUT ANY PATIENT INFORMATION!) • Source JPG’s • Report of Case • Word Document with ALL text entered into the case (use this to do your spell checking) • A title, brief description and difficulty rating of each module (has 3 parts – overall, findings, and questions) • .fla source file • .html and .swf files • File with image numbers of findings (e.g. finding 1: slices 1-3) • Radlex terms of module • HTML Code for each module in a text file

34. On Last Day of Rotation • Copy the folder you created titled with your name (which contains all your final materials for each of your modules) to the C:\studentPACS directory on the computer in MEB 405 • Turn in a CD (or DVD) of this folder with your name and rotation dates written on it to the department elective coordinator (Mary Ellen Hobler) in Radiology Department Office in MEB • If necessary, you can create this disc using the CD or DVD burners on the computer in MEB 405.

35. Again, Welcome to the Rotation We look forward to having you rotate with us. Photo: Salil Soman 2008