Subspecialisation in Emergency Radiology: Proposal for a harmonised European curriculum.

Introduction: Radiology plays a crucial role in the emergency care setting by delivering early and precise diagnoses under pressure of time, right at the beginning of patient treatment. Although there is a need for postgraduate education in emergency radiology, most of the national bodies responsible do not offer it in a uniform fashion and a general proof of qualification is missing in Europe. Therefore, the European Society of Radiology (ESR) has founded the (Sub-)Society of Emergency Radiology (ESER), prompting them to develop a European curriculum. This trend, which is currently also encouraged in many other non-radiological specialties which demand the highest professional qualifications, often lacks expertise in medical education. Goals: The goal of this article is the general description of the curricular planning process for a European postgraduate subspecialisation programme, using the example of Emergency Radiology (European Diploma in Emergency Radiology, EDER), including the utilisation of TOOLS and recommendations derived from comparable projects. Project description: The project was divided into partial steps: the timeline displayed in a GANTT chart, and tasks and responsibilities assigned in a RASCI matrix. The curriculum was iteratively developed using the KERN approach and steps were prioritised using the PARETO principle. Furthermore, the following TOOLS were used: limitations and needs assessment, SWOT analysis, formulating learning objectives and categorising them after MILLER and SCLO, and using BLOOM's taxonomy for cognitive learning objectives and operationalising them according to MAGER. Psychomotoric and affective learning objectives were assigned to CANMEDS roles, grouped by topic using CLUSTERING, and then mapped by MATRIX analysis to appropriate learning and evaluation methods. Striving for continuous improvement, the curriculum was finally embedded in curricular quality management. Results: The standardisation of the EDER access, considering the different national conditions, the minimisation of European learners' attendance phases, restricting expenses by best possible use of existing structures, respecting the requirements and retaining the support of the European umbrella society ESR, finishing the project by a specific deadline and the demands of continuous improvement were particular challenges. A curriculum with the eligibility of five years' speciality training in general radiology has evolved on schedule. The subspeciality training lasts at least one year and is divided into webinars, workshops during congresses (e.g. the annual ESR and ESER congresses) and one year practical training at the individual learner's corresponding local hospitals, which adhere to a catalogue of requirements, comparable to national educational policies. The curriculum is completed by passing a written and oral exam (diploma) and re-accreditation every five years. Conclusions: Despite complex requirements, the TOOLS utilised allowed an almost seamless, resource-minimised, professional, location-independent distributed development of a European subspeciality curriculum within one year. The definitive implementation is still due. If any deviations from the draft presented should become necessary in the future, the embedment in the curricular quality management will lead to a redirection in the right way and, furthermore, secure a continuous improvement in the best way possible.

[Spinal trauma: first aid from cross-sectional imaging]. / Trauma der Wirbelsäule: erste Hilfe durch Schnittbildverfahren.

The diagnosis of the traumatized spine is one of the key issues for trauma radiologists. The cross-sectional imaging procedures, computed tomography (CT) and magnetic resonance imaging (MRI) are the essential methods in spinal trauma radiology. These modalities are of great help in accurately assessing injury patterns and extent and in providing indications of patient outcome. In contrast to cross-sectional imaging, radiography has a role in the evaluation of minor spinal trauma only. It is generally accepted that trauma radiologists do not use typical classifications to evaluate the spine partly because such an ideal classification system does not yet exist. Not least because of this classification difficulty, eponyms and synonyms are widely used to describe traumatology of the spine as a high level of specific information is included in these various terms. The members of the trauma team should be aware of the strengths and limitations of the methods used in the assessment of the spine. This article provides a brief outline of fundamental knowledge about the diagnosis of spinal trauma.

[Coxarthrosis - a radiological approach and guidelines]. / Koxarthrose - eine radiologische Annäherung und Leitfaden.

CLINICAL/METHODICAL ISSUE: Coxarthrosis is one of the most frequent indications in radiological practice with a prevalence as high as 8%. STANDARD RADIOLOGICAL METHODS: Radiography, sonography, computed tomography, magnetic resonance imaging. METHODICAL INNOVATIONS: Magnetic resonance arthrography for detection of early stages of labral and chondral pathologies as well as detection of osteonecrosis at an early stage. PERFORMANCE: Czerny C, Hofmann S, Neuhold A et al. (1996) Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 200(1):225-230. Czerny C, Oschatz E, Neuhold A et al. (2002) [MR arthrography of the hip joint]. Radiologe 42(6):451-456. Kramer J, Breitenseher M, Imhof H et al. (2000) [Diagnostic imaging in femur head necrosis]. Orthopade 29(5):380-388. ACHIEVEMENTS: Is already established in clinical practice. PRACTICAL RECOMMENDATIONS: Each modality has relevant indications.

[Sacroiliitis or pseudosacroiliitis?]. / Sakroiliitis oder Pseudosakroiliitis?

CLINICAL/METHODICAL ISSUE: When the presence of seronegative spondyloarthropathy is unrecognized there can be a delay in achieving an accurate diagnosis, as the typical inflammatory low back pain is similar to that found in degenerative diseases of the lumbosacral spine and the sacroiliac joints. Thus, seronegative spondyloarthropathy is often misinterpreted as a degenerative disease. The initial radiography of the sacroiliac joints is often normal which results in a delay in diagnosis of sacroiliitis of approximately 3-7 years. STANDARD RADIOLOGICAL METHODS: This illustrates the significance of an adequate imaging method for the early detection of sacroliliitis. METHODICAL INNOVATIONS: Contrast medium administration for magnetic resonance imaging (MRI) enables a differentiation between synovitis, capsulitis, enthesitis and effusion. PERFORMANCE: Sensitivity and specificity for detection of active inflammation by MRI is about 83-85%. Early active inflammation can be detected by MRI 3-7 years before structural changes are obvious by x-ray examination. PRACTICAL RECOMMENDATIONS: Pseudosacroiliitis can be differentiated from inflammatory sacroiliitis by the patient history, laboratory data, osteoproliferative and osteodestructive changes and the typical distribution pattern of bone marrow edema.

Reliability-based optimization of maintenance scheduling of mechanical components under fatigue.

This study presents the optimization of the maintenance scheduling of mechanical components under fatigue loading. The cracks of damaged structures may be detected during non-destructive inspection and subsequently repaired. Fatigue crack initiation and growth show inherent variability, and as well the outcome of inspection activities. The problem is addressed under the framework of reliability based optimization. The initiation and propagation of fatigue cracks are efficiently modeled using cohesive zone elements. The applicability of the method is demonstrated by a numerical example, which involves a plate with two holes subject to alternating stress.

Modeling of the variability of fatigue crack growth using cohesive zone elements.

By its nature, metal fatigue has random characteristics, leading to extensive scatter in the results. Both initiation and propagation of a fatigue crack can be seen as random processes. This manuscript develops a numerical analysis using cohesive zone elements allowing the use of one single model in the finite element simulation of the complete fatigue life. The present formulation includes a damage evolution mechanism that reflects gradual degradation of the cohesive strength under cyclic loading. The uncertainties inherent to the fatigue process are assumed to be caused by the variability of the material properties, which are modeled using random fields. An extrapolation scheme is proposed to reduce the computational time. First, the accuracy of the proposed formulation is assessed considering a deterministic crack growth problem. Second, the effect of randomness in the material properties on the total fatigue life of a structure is then analyzed.

Investigation of model uncertainties in Bayesian structural model updating.

Model updating procedures are applied in order to improve the matching between experimental data and corresponding model output. The updated, i.e. improved, finite element (FE) model can be used for more reliable predictions of the structural performance in the target mechanical environment. The discrepancies between the output of the FE-model and the results of tests are due to the uncertainties that are involved in the modeling process. These uncertainties concern the structural parameters, measurement errors, the incompleteness of the test data and also the FE-model itself. The latter type of uncertainties is often referred to as model uncertainties and is caused by simplifications of the real structure that are made in order to reduce the complexity of reality. Several approaches have been proposed for taking model uncertainties into consideration, where the focus of this manuscript will be set on the updating procedure within the Bayesian statistical framework. A numerical example involving different degrees of nonlinearity will be used for demonstrating how this type of uncertainty is considered within the Bayesian updating procedure.

[Who is who revisited: spinal trauma]. / "Who is who revisited": wirbelsäulentrauma.

The ideal classification of spinal trauma does not yet exist, primarily because the combination of morphological, biomechanical and clinical parameters in one single nomenclature has proved impossible. For radiologists and surgeons who work closely together, only a few classifications of injury patterns have been shown to be useful enough to provide rapid and stable therapy decisions. Many classifications are too complex to be practical for day-to-day practice, such as the Magerl classification, which has been adopted by the Arbeitsgemeinschaft für Osteosynthesefragen (AO). Not least because of this classification difficulty, eponyms and synonyms are widely used to describe trauma of the spine, comparable to the number of terms used to describe fractures of the upper and lower limbs. The members of trauma teams should be aware of the definitions of these terms as well as the strengths and limitations of the existing classifications of spinal trauma.

[Imaging of molecular structures of breasts with new sonography techniques]. / Bildgebung molekularer Strukturen der Brust mit neuen Techniken der Sonographie.

Sonography has become one of the most important imaging methods in breast diagnostics. Through the development of high-frequency transducers and the use of ultrasound contrast agents, the number of indications for sonography of the breast has continued to increase in recent years. Visualization of very small vessels under 100 µm enables sensitive detection and quantification of tissue perfusion. Thus, breast ultrasound can play an essential role in answering questions about certain pathologies. Further technical advances, such as automated breast ultrasound systems, provide an essential step for standardization of investigations. Targeted ultrasound is a new important development of this technique. Specific markers which are conjugated with the surface of contrast medium microspheres allow targeted molecular endothelial structures to be selectively visualized and quantified. These developments will strengthen the role of sonography in the future as a non-invasive and easy to use method.

[Mountain biking : Breezy ups and traumatic downs]. / Mountainbiking : Luftige Höhen und traumatische Tiefen.

For more than two decades the popularity of mountain biking as a national pastime as well as a competitive sport has been undiminished. However, its related risks are not monitored as closely as those, for example, of skiing. The injuries caused by mountain biking are specific and cannot be compared with those caused by other cycling sports. This is due not only to the characteristics of the terrain but also to the readiness to assume a higher risk compared to cycle racing.The particular value of radiology is in the acute trauma setting. Most often musculoskeletal lesions must be examined and digital radiography and MRI are the most useful techniques. Severe trauma of the cranium, face, spine, thorax and abdomen are primarily evaluated with CT, particularly in dedicated trauma centers. Therefore, radiology can play a role in the rapid diagnosis and optimal treatment of the trauma-related injuries of mountain biking. Thus, the unnecessarily high economical damage associated with mountain biking can be avoided.

[Who is who in the fractures of the upper and lower limb]. / Das Who Is Who der Extremitätenfrakturen.

The precision is a major factor in the communication of medical facts and data. Predominantly, it is reached by the use of classification systems. However, many of our classifications do not provide an unlimited use in the day-to-day practice. Thus, particularly in the field of traumatology, colloquialisms play a major role. They provide a high degree of information transmission. However, it is a must for all members of a trauma team to fully understand the definitions of such terms and use them in the same manner.

Can quantitative diffusion-weighted MR imaging differentiate benign and malignant cold thyroid nodules? Initial results in 25 patients.

BACKGROUND AND PURPOSE: The characterization of cold nodules of the thyroid gland is mandatory because approximately 20% of these nodules are of malignant origin. The purpose of this study was to evaluate the distinction of cold thyroid nodules by using quantitative diffusion-weighted MR imaging (DWI). MATERIALS AND METHODS: In 25 patients with cold nodules on scintigraphy and suggestive findings at fine-needle aspiration, thyroid carcinoma was suggested. In these patients, cold nodules and the normal parenchyma of the contralateral thyroid lobe were prospectively investigated with quantitative DWI (echo-planar imaging sequence; maximum b-value, 800 s/mm(2)) before surgery. The differences in the mean apparent diffusion coefficient (ADC) values in benign and malignant nodules were tested by using a Mann-Whitney U test. RESULTS: Histologically, there were 20 carcinomas with a minimum size of 8 mm and 5 adenomas. The mean ADC values (in 10(-3) mm(2)/s) differed significantly among carcinoma, adenoma, and normal parenchyma (P < .05). The ranges (95% confidence interval) of the ADC values for carcinoma (2.43-3.037), adenoma (1.626-2.233), and normal parenchyma (1.253-1.602) showed no overlap. When an ADC value of 2.25 or higher was used for predicting malignancy, the highest accuracy of 88%, with 85% sensitivity and 100% specificity, was obtained. CONCLUSIONS: Quantitative DWI seems to be a feasible tool with which to differentiate thyroid carcinomas from adenomas; however, further studies are required including larger numbers of patients to confirm our results.

[Evidence-based diagnosis of abdominal trauma]. / Evidenzbasierte Diagnostik des abdominellen Traumas.

Abdominal trauma is a common cause of death particularly in patients up to 40 years of age. In order to reduce mortality a rapid radiologic diagnosis is essential. At present, sonography plays a role only in the evaluation of minor trauma and as a "focused assessment with sonography for trauma" (FAST) to clarify free intraperitoneal fluid immediately on admittance in severely injured patients. However, computed tomography has proven to be a potent tool for the triage of patients with abdominal trauma, because, based on the results of the CT scan, patients can be referred for laparotomy or safely classified for "wait and see" treatment. Therapeutic decisions are largely based on injury severity scores and the radiologist must be familiar with them as well as with the associated therapeutic consequences.

Accuracy of ultrasound-guided, large-core needle breast biopsy.

Ultrasound-guided, large-core needle biopsy (US-LCNB) of suspicious breast lesions is acknowledged as less invasive and less expensive and less time consuming than surgical biopsy, and provides a histologic diagnosis with a comparable high degree. US-LCNB has been proven to help reduce the number of unnecessary surgeries for benign disease. Its limitations, however, are false-negative results and underestimation of disease. Thus, the demand for breast teams is to carefully adhere to the principles of triple assessment and imaging-histologic correlation, and follow-up of lesions with a specific benign histology after biopsy. Also, the acceptance of guidelines and rigorous quality controls help to reliably minimize the delay in the diagnosis of breast cancer in patients with false-negative biopsies. This paper aims to summarize the equipment and methods as well as the benefits and limitations of US-LCNB. Also, guidelines of quality assessment are suggested. Finally, recent developments which may help to overcome the limitations of US-LCNB will be discussed, i.e., directional vacuum-assisted biopsy (VAB), three-dimensional (3D) US-guided biopsy, as well as the use of tissue harmonic imaging (THI) and compound imaging (CI) during biopsy.

Does marathon running cause acute lesions of the knee? Evaluation with magnetic resonance imaging.

An investigation was conducted into whether running a marathon causes acute alterations in menisci, cartilage, bone marrow, ligaments, or joint effusions, which could be evaluated by magnetic resonance imaging (MRI). Twenty-two non-professional marathon runners underwent MRI of the knee before and immediately after running a marathon. Lesions of menisci and cartilage (five-point scale), bone marrow, ligaments (three-point scale), joint effusion, and additional findings were evaluated and a total score was assessed. Before the marathon, grade 1 lesions of the menisci were found in eight runners, and grade 2 lesions in five runners. After the marathon, an upgrading from a meniscal lesion grade 1 to grade 2 was observed in one runner. Before the marathon, grade 1 cartilage lesions were found in three runners, and grade 2 lesions in one runner, all of which remained unchanged after the marathon. Before and after the marathon, unchanged bone marrow edema was present in three runners and unchanged anterior cruciate ligament lesions (grade 1) were seen in two runners. Joint effusions were present in 13 runners in the pre-run scans, slightly increased in four runners after the marathon, and newly occurred in one runner after the marathon. A total score comprising all knee lesions in each runner showed an increase after the marathon in two runners, whereas no runner showed an improvement of the radiological findings (Wilcoxon signed-rank test, P>0.05). The evaluation of lesions of the knee with MRI shows that marathon running does not cause severe, acute lesions of cartilage, ligaments, or bone marrow of the knee in well-trained runners. Only subtle changes, such as joint effusions or increased intrameniscal signal alterations, were imaged after running a marathon.

Bronchial reactivity in hyperresponsive patients and healthy individuals: demonstration with high resolution computed tomography.

OBJECTIVE: High resolution computed tomography (HRCT) was used to assess the extent of bronchial reactivity after inhalative bronchoprovocation and dilation in hyperresponsive patients and healthy subjects. PATIENTS AND METHODS: Patients with mild intermittent asthma, 15 with a >20% decrease in FEV1 and a >10 mmHg (PC20+) in PaO2, 12 with a <20% decrease in FEV1 and a >10 mmHg (PC20-) in PaO2 after provocation, and eight healthy humans were included in the study. Changes in cross-sectional area in a total of 1256 bronchi and in bronchial wall area (792 bronchi) were evaluated after histamine-triggered bronchoprovocation and salbutamol-induced bronchodilation at high lung volumes (FVC 80%). Data were compared with the results of pulmonary function tests (FEV1, PaO2, PaCO2). RESULTS: In all groups, a significant decrease in bronchial cross-sectional area (P<0.001) and a significant increase in bronchial wall area (P<0.001) were observed subsequent to bronchoprovocation. After bronchodilation, the increase in cross-sectional area (P<0.001) and the further increase in airway wall area (P<0.01) were significant in all groups. In PC20+ and PC20- asthmatics, significant differences (P<0.05) in PaO2, >10 mmHg between baseline and provocation were observed. In healthy persons, the PaO2 decrease was <10 mmHg (P>0.05). After histamine provocation, the decrease in FEV1 was measured in the PC20+ group, whereas a <20% FEV1 decrease was found in the PC20- and the control groups, respectively. No significant correlations were observed between radiological data and the results of pulmonary function tests. CONCLUSIONS: HRCT demonstrated bronchial reactivity in hyperresponsive patients and, unexpectedly, in healthy subjects. The applied pulmonary function tests failed to characterize bronchial reactions in the healthy subjects. Based on these results, HRCT is a useful tool by which to achieve a comprehensive understanding of the pathophysiological processes in asthmatic patients.

[HRCT and bronchial asthma: visualization of the pathophysiologic changes of the pulmonary parenchyma after inhalation provocation]. / HRCT und Asthma bronchiale: Visualisierung pathophysiologischer Veränderungen des Lungenparenchyms nach inhalativer Provokation.

PURPOSE: To characterize parenchymal lung affections morphologically in patients with asthma and healthy subjects by high -resolution computed tomography (HRCT) subsequent to histamine-triggered inhalation bronchoprovocation and salbutamol-induced broncholysis, and to compare the results with pulmonary function tests. MATERIALS AND METHODS: Fifteen asthmatics with bronchial hyperreactivity, with a > 20% decrease in FEV1 and a > 10 mmHg decrease in PaO(2) after bronchoprovocation (PC20%+), twelve asthmatics with a < 20% decrease in FEV1 and a > 10 mmHg decrease in PaO(2) after bronchoprovocation (PC20%-), and eight healthy persons without bronchial hyperreactivity underwent inhalation bronchoprovocation and broncholysis. Spirometer-triggered HRCT at high lung volumes was performed, and total and peripheral lung densities and the amount of solid lung structures, representing predominantly vessels, were measured. RESULTS: After bronchoprovocation, we observed significant decreases in total and peripheral lung densities in all groups (p < 0.0005), and a significant increase in lung densities subsequent to bronchodilation (p < 0.0002). The morphological alterations in solid lung structure were not significantly different after bronchoprovocation or broncholysis (p > 0.05), as compared to the baseline measurements. In hyperreactive patients, PaO(2) significantly decreased after provocation and significantly increased after lysis (p < 0.05). In PC20%+ asthmatics, a mean reduction of 27.8% in FEV1 was observed, which was < 20% in the other groups. No significant correlations were observed between radiological data and the results of pulmonary function tests. In healthy persons, we demonstrated highly significant parenchymal response to bronchoprovocation and broncholysis, which was not otherwise documented by pulmonary function tests. CONCLUSION: In both PC20%+ and PC20%- patients as well as in healthy individuals, HRCT was efficient in the evaluation of pathoanatomical alterations of the lung parenchyma subsequent to inhalation provocation. In healthy individuals, these parenchymal alterations were not documented by pulmonary function tests.