The Online Radiology Elective

The Online Radiology Elective AKA RWJMS StudentPACS 2 wk ElectiveSalil Soman, MD, MSRadiology Resident, UMDNJ RWJMSSpring 20091WelcomeWelcome to the Robert Wood Johnson Medical School Department of Radiology Interactive Radiology Elective Student PACS.We look forward to having you rotate with us!2See One, Do One, Teach OneOn 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.3Finding A Needle In a Hay StackAside 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 findingsThese modules seek to simulate this process of searching not only on a single 2D image, but through a series of them.4First StepsGet registered for the elective through registrarComplete 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 rotationIf you own them, bring your laptop and USB drive to the first day meeting (not required)5ExpectationsSelf Directed WorkGoal Oriented Reference SearchesDelivery of Final Products by decided guidelinesUsually completion of 6 to 7 modules by end of rotationUsually submission of first draft of all modules by Monday of second week.6About The Web Sitehttp://rwjradiology.umdnj.edu under Educational Material sectionStudentPacs subsection:http://www2.umdnj.edu/radpweb/SPACS2/index.htmlSite HighlightsAbout the projectCurrent StaffInstruction manualsExample modulesModules of previous rotation studentsRotation registration form.7About SPACS Flash ModulesCreated by RWJMS Alumni and Radiology Dept Faculty & ResidentsThe 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.

8Process OverviewSelect and Review CasesAcquire Relevant Images and Reports with NO PATIENT INFORMATIONCreate Tutorials Via SoftwareSend first draft to supervising resident(html and swf files only) via emailRevise and expand as apropriateReview tutorials with an attending radiologist.Turn in final products (.swf /.html /.fla files, txt of report with no patient information, all used source jpgs, word doc of all text used in modules, your title, description, difficulty rating, radlex keywords, html code for upload)9Typical 2 week ElectiveStudent Register for elective, complete online registration form, and review online introduction prior to electiveStudents oriented by supervising Radiology ResidentStudents Shadow attending Radiologists in main department and collect cases of interest for creating tutorialsStudents independently review cases in PACS, output images that optimally represent findings, w NO personal health informationStudents research medical topics related to case, and then create SPACs ModuleFirst draft flash file emailed to reviewing resident, who provides feedback.Student reviews edited modules with attending radiologist in main department and gets final edit recommendationStudent selects Radlex keywords, and labeled case made available on elective web site. 10Getting CasesReview study with Faculty Radiologist or Radiology ResidentDuring 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)11Case HistoryTry to collect the information the radiologist had available to best simulate experience of reading the caseRequisitions (often scanned in as a series in study)In Clinical History portion of current report or available prior reportsMay often be information clinician provided when directly consulting radiologist reading the study12What to GetFrom SupervisorAccession NumberPertinent Available Hx (Simulate actual experience)From PACS computer (on your own)JPGs windowed as you wish with NO patient informationCreate a txt file of report with NO patient information13Background About CTAlgorithmsBony vs Soft TissueLeverage Multislice ScannerSlice ThicknessReformatsWindow and LevelDifferent settings highlight different structures14Selecting ImagesChoosing SeriesDifferent AlgorithmsDifferent ReconsMinimize Number of ImagesImages to best convey informationOptimal windowing15Making QuestionsInformation Relevant to Radiology16Radiology Relevant InformationNAME THE TYPE OF STUDY (for out of the ordinary cases)DESCRIBE FINDINGS; USE BUZZ WORDS IF DIAGNOSIS IS CERTAINOFFER DIFFERENTIALS IF ANYDISCUSS MANAGEMENT, ESPECIALLY CASES THAT REQUIRE EMERGENT ATTENTION

17Your File StructureCreate a folder titled with your nameWithin 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 usedwhen creating a new module, tell software to save it into the folder created for that module, which will make .fla fileWhen you publish your project, it should create .html and .swf files in the modules folderA 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 searchThe 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.18Overview Creating CasesFlash 8 ProfessionalStudent PACS extensionUsing the Student PACS extension19Using the Extension in Flash ICreate a new module with extension panelName and save the file as described on the Your File Structure slide.Direct the subsequent dialogue box to the location of your jpeg imagesCreate hot spots on your imagesFor each hotspot create findings and questionsMAKE SURE THE In Order option IS SELECTED20Using the Extension in Flash IIAt the end of EVERY explanation should be a referenceAt 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.

21If You Cant Find the SPACS PanelOpen Flash ProfessionalCreate a new blank documentThen look under the Windows drop down menu, choose the Other Panels option and StudentPACS should be an option under the subsequent menu.22VersioningWhen 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)23About ReferencesEVERY 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)

24Search Tools / ResourcesGoogle / 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 Radiologyhttp://evidencebasedradiology.net/Free Large file email Transfer Web Service e.g. http://yousendit.com

25The Development ProcessOnce 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).26Radlex ClassificationOntology created by RSNA for classifying radiological entities, similar to the SNOMed and MESH ontologies which are used in indices like PubMedRadlex Term browser at http://radlex.orgTerms help make modules discoverable via searchesEach module should have radlex terms identified.

27Choosing RadLEX termsHighlighted structures are (i.e. internal carotid artery, small bowel, pancreas)Body part imagedImaging modality used / type of studyTeaching points (i.e. pneumatosis coli, pancreatitis, aspergillosis)Radiographic signs (i.e. signet ring sign)Miscellaneous terms introduced through questions28Choosing Difficulty RatingsOverall tutorial difficultyDifficulty of imaging findingsDifficulty of questions29Add Final Author InformationIn the final version of each module as its own paragraph after the patient history please list the author, supervising resident and editors.HTML Code for Web Site ICreate a copy of the following code for each of your modules with the following information filled in:Name of ModuleDate of final submissionDescriptionRadlex TermsYour name as AuthorSupervising ResidentEditorsImage 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)31HTML Code for Web Site IINOTE : EVERYTHING IN BOLD BELOW SHOULD BE REPLACED WITH THE INFO FOR YOUR MODULESCOPY THE TEXT BELOW INTO A TEXT FILE FOR EACH MODULE AND EDIT ACCORDINLY. Oct 92008 [ Bacteremia and abdominal pain ] 76 year old male with bacteremia and abdominal pain with history of clostridium difficile colitis.
Author: Lauren Kovacs, MS III
Resident Supervisor: Salil Soman, MD, MS
Editors: A. Masand, MS III, S.Soman, MD, MS, JK Amorosa, MD
Radlex Terms: 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
Clues: Finding 1: images 1-5, Finding 2: images 7-9, Finding 3: images 4-5
Difficulty:Overall Easy, Findings: Easy, Questions: Medium

32Final Products(ALL WITHOUT ANY PATIENT INFORMATION!)Source JPGsReport of CaseWord 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 filesFile with image numbers of findings (e.g. finding 1: slices 1-3)Radlex terms of moduleHTML Code for each module in a text file33On Last Day of RotationCopy 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 405Turn 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 MEBIf necessary, you can create this disc using the CD or DVD burners on the computer in MEB 405.34Again, Welcome to the RotationWe look forward to having you rotate with us.

Photo: Salil Soman 200835