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RADIOLOGIC ® Journal of the American Society of Radiologic Technologists Vol. 82, No. 2 November/December 2010 Factors Influencing Success in RA Programs: A Survey The Role of Mobile Electronic Devices in Radiographer Education Domestic Violence Diagnosis and Treatment of Scaphoid Fractures American Society of Radiologic Technologists The ASRT Education and Research Foundation Jump 2011 Scholarship Programs Into Action! Professional Scholarships Elekta Radiation Therapy Educators Scholarship Four $5,000 scholarships Awarded to radiation therapy educators pursuing an undergraduate or graduate degree. Funding support provided by Elekta Inc. Medical Imaging Educators Scholarship Four $5,000 scholarships Awarded to medical imaging educators who are pursuing their bachelor’s, master’s or doctoral degree to enhance their position as a program director, faculty member, clinical coordinator or clinical instructor. Special thanks to our scholarship patrons for their financial support of this program. Siemens Clinical Advancement Scholarship Four $5,000 scholarships Awarded to medical imaging and radiation therapy professionals seeking to enhance their clinical practice skills and ability to provide excellent care. Funding support provided by Siemens Medical Solutions USA Inc. Professional Advancement Scholarship Several $1,500 scholarships Awarded to professionals who are obtaining an additional degree to advance their careers. Funding support provided by HEALTHeCAREERS and our scholarship patrons. Don’t Be Afraid. Get the Facts. MYTH There is no scholarship money for education in the radiologic sciences. FACT The Foundation will provide nearly $200,000 in professional and entry-level student scholarships during 2011. MYTH It is too difficult and time consuming to apply for a scholarship. FACT Submit your scholarship applications electronically! MYTH There are no scholarships available for my specific needs. FACT The Foundation offers almost 50 awards in a variety of scholarships for managers, educators, clinical professionals and entry-level students. Entry-level Student Scholarships Jerman-Cahoon Student Scholarship Five $2,500 scholarships Awarded to outstanding students attending entry-level radiologic sciences programs. Special thanks to our scholarship patrons for their financial support of this program. Royce Osborn Minority Student Scholarship Five $4,000 scholarships Awarded to outstanding minority students attending entry-level radiologic sciences programs. Special thanks to the American Registry of Radiologic Technologists for its major funding commitment to this scholarship program. Varian Radiation Therapy Student Scholarship Nineteen $5,000 scholarships Awarded to outstanding students attending entry-level radiation therapy programs. Funding support provided by Varian Medical Systems. Applications are available online. Contact the ASRT Education and Research Foundation at 800-444-2778, or e-mail [email protected] for more information. ASRT Education and Research Foundation ©2010 ASRT Education and Research Foundation. All rights reserved. Deadline to apply for all scholarships is Feb. 1, 2011. www.asrtfoundation.org Move to the front of the line Quality training and education that sets you apart. MTMI has what you need to move up. Cross-Training • Mammography • Breast Ultrasound • Stereo Breast Biopsy • MRI • CT • PACS • CR/DR • Bone Density • Management • Dosimetry CEU’s • Mammography • Breast Ultrasound • Stereo Breast Biopsy • MRI • CT • PACS • CR/DR • Bone Density • Cardiology • Trauma Imaging • Registry Reviews in MRI, CT, BD get all the details at w w w. m t m i . net or call 800-765-6864 A wide new window of opportunity 1,2 Introducing ABLAVAR®: the first and only blood-pool contrast agent for MRA1,2 A low-dose MRA contrast agent with the unique benefits of albumin binding3 • Time to acquire high-resolution first-pass and steady-state images3 • Imaging window up to 1 hour with a single, low-dose (0.12 mL/kg body weight [0.03 mmol/kg]) IV bolus1,3 • Diagnostic accuracy comparable to conventional X-ray angiography4,5 • Documented safety and tolerability with no reported cases of NSF* 6 *No reported cases of nephrogenic systemic fibrosis (NSF) to date in clinical use with nearly 90,000 patients. INDICATIONS: ABLAVAR® is indicated for use as a contrast agent in magnetic resonance angiography (MRA) to evaluate aortoiliac occlusive disease (AIOD) in adults with known or suspected peripheral vascular disease. CONTRAINDICATIONS: History of a prior allergic reaction to a gadolinium-based contrast agent. IMPORTANT SAFETY INFORMATION: WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF) Gadoliniumbased contrast agents increase the risk of nephrogenic systemic fibrosis (NSF) in patients with: • acute or chronic severe renal insufficiency (glomerular filtration rate <30 mL/min/1.73m2), or • acute renal insufficiency of any severity due to the hepato-renal syndrome or in the perioperative liver transplantation period. In these patients, avoid use of gadolinium-based contrast agents unless the diagnostic information is essential and not available with non-contrast enhanced magnetic resonance imaging (MRI). NSF may result in fatal or debilitating systemic fibrosis affecting the skin, muscle, and internal organs. Screen all patients for renal dysfunction by obtaining a history and/or laboratory tests. When administering a gadolinium-based contrast agent, do not exceed the recommended dose and allow a sufficient period of time for elimination of the agent from the body prior to any re-administration. To order, call 1-800-299-3431 www.ABLAVAR.com ABLAVAR® Injection: As with other contrast media: the possibility of serious or life-threatening anaphylactic or anaphylactoid reactions, including cardiovascular, respiratory and/or cutaneous manifestations, should always be considered. As with other paramagnetic contrast agents, caution should be exercised in patients with renal insufficiency due to the possibility of further deterioration in renal function. In clinical trials, a small increase (2.8 msec) in the average change from baseline in QTc was observed at 45 minutes. These QTc prolongations were not associated with arrhythmias or symptoms. Caution should be used in patients at high risk for arrhythmias due to baseline QTc prolongation. Have emergency resuscitative equipment available prior to and during ABLAVAR® administration. Please see brief summary, including boxed WARNING regarding Nephrogenic Systemic Fibrosis (NSF), on the following page. References: 1. ABLAVAR® [package insert]. North Billerica, MA: Lantheus Medical Imaging, Inc.; 2009. 2. U.S. Food and Drug Administration Web site. http://www.fda.gov/drugs. Accessed February 1, 2010. 3. Goyen M. Gadofosvesetenhanced magnetic resonance angiography. Vasc Health Risk Manag. 2008;4(1):1-9. 4. Goyen M, Edelman M, Perreault P, et al. MR angiography of aortoiliac occlusive disease: a phase III study of the safety and effectiveness of the blood-pool contrast agent MS-325. Radiology. 2005;236(3):825-833. 5. Rapp JH, Wolff SD, Quinn SF, et al. Aortoiliac occlusive disease in patients with known or suspected peripheral vascular disease: safety and efficacy of gadofosveset-enhanced MR angiography–multicenter comparative phase III study. Radiology. 2005;236(1):71-78. 6. Data on file, Lantheus Medical Imaging, Inc. ABLAVAR is a registered trademark of Lantheus Medical Imaging, Inc. © 2010 Lantheus Medical Imaging, Inc. All rights reserved. Printed in USA. AB-JA-Aug 2010 BRIEF SUMMARY WARNING: NEPHROGENIC SYSTEMIC FIBROSIS (NSF) Gadolinium-based contrast agents increase the risk of nephrogenic systemic fibrosis (NSF) in patients with: • acute or chronic severe renal insufficiency (glomerular filtration rate <30 mL/min/1.73m2), or • acute renal insufficiency of any severity due to the hepato-renal syndrome or in the perioperative liver transplantation period. In these patients, avoid use of gadolinium-based contrast agents unless the diagnostic information is essential and not available with noncontrast enhanced magnetic resonance imaging (MRI). NSF may result in fatal or debilitating systemic fibrosis affecting the skin, muscle, and internal organs. Screen all patients for renal dysfunction by obtaining a history and/or laboratory tests. When administering a gadoliniumbased contrast agent, do not exceed the recommended dose and allow a sufficient period of time for elimination of the agent from the body prior to any re-administration [see Warnings and Precautions] INDICATIONS AND USAGE Ablavar is indicated for use as a contrast agent in magnetic resonance angiography (MRA) to evaluate aortoiliac occlusive disease (AIOD) in adults with known or suspected peripheral vascular disease. DOSAGE AND ADMINISTRATION agents. These reports have not always identified a specific agent. Prior to marketing of Ablavar, where a specific agent was identified, the most commonly reported agent was gadodiamide (Omniscan™), followed by gadopentetate dimeglumine (Magnevist®) and gadoversetamide (OptiMARK®). NSF has also developed following sequential administrations of gadodiamide with gadobenate dimeglumine (MultiHance®) or gadoteridol (ProHance®). The number of post-marketing reports is subject to change over time and may not reflect the true proportion of cases associated with any specific gadolinium-based contrast agent. The extent of risk for NSF following exposure to any specific gadoliniumbased contrast agent is unknown and may vary among the agents. Published reports are limited and predominantly estimate NSF risks with gadodiamide. In one retrospective study of 370 patients with severe renal insufficiency who received gadodiamide, the estimated risk for development of NSF was 4% (J Am Soc Nephrol 2006; 17:2359). The risk, if any, for the development of NSF among patients with mild to moderate renal insufficiency or normal renal function is unknown. Screen all patients for renal dysfunction by obtaining a history and/ or laboratory tests. When administering a gadolinium-based contrast agent, do not exceed the recommended dose and allow a sufficient period of time for elimination of the agent prior to any re-administration. NSF was not reported in clinical trials of Ablavar [see Clinical Pharmacology and Dosage and Administration]. Hypersensitivity Reactions Ablavar may cause anaphylactoid and/or anaphylactic reactions, including life-threatening or fatal reactions. In clinical trials, anaphylactoid and/or anaphylactic reactions occurred in two of 1676 subjects. If anaphylactic or anaphylactoid reactions occur, stop Ablavar Injection and immediately begin appropriate therapy. Observe patients closely, particularly those with a history of drug reactions, asthma, allergy or other hypersensitivity disorders, during and up to several hours after Ablavar administration. Have emergency resuscitative equipment available prior to and during Ablavar administration. Pounds (lb) Milliliters (mL) 40 88 4.8 50 110 6.0 60 132 7.2 70 154 8.4 80 176 9.6 90 198 10.8 100 220 12.0 110 242 13.2 120 264 14.4 130 286 15.6 Acute Renal Failure In patients with renal insufficiency, acute renal failure requiring dialysis or worsening renal function have occurred with the use of other gadolinium agents. The risk of renal failure may increase with increasing dose of gadolinium contrast. Screen all patients for renal dysfunction by obtaining a history and/or laboratory tests. Consider follow-up renal function assessments for patients with a history of renal dysfunction. No reports of acute renal failure were observed in clinical trials of Ablavar [see Clinical Pharmacology]. QTc Prolongation and Risk for Arrhythmias In clinical trials, a small increase (2.8 msec) in the average change from baseline in QTc was observed at 45 minutes following Ablavar administration; no increase was observed at 24 and 72 hours. A QTc change of 30 to 60 msec from baseline was observed in 39/702 (6%) patients at 45 min following Ablavar administration. At this time point, 3/702 (0.4%) patients experienced a QTc increase of > 60 msec. These QTc prolongations were not associated with arrhythmias or symptoms. In patients at high risk for arrhythmias due to QTc prolongation (e.g., concomitant medications, underlying cardiac conditions) consider obtaining baseline electrocardiograms to help assess the risks for Ablavar administration. If Ablavar is administered to these patients, consider follow-up electrocardiograms and risk reduction measures (e.g., patient counseling or intensive electrocardiography monitoring) until most Ablavar has been eliminated from the blood. In patients with normal renal function, most Ablavar was eliminated from the blood by 72 hours following injection [see Clinical Pharmacology]. 140 308 16.8 ADVERSE REACTIONS 150 330 18.0 160 352 19.2 Dosing Guidelines Administer Ablavar as an intravenous bolus injection, manually or by power injection, at a dose of 0.12 mL/kg body weight (0.03 mmol/kg) over a period of time up to 30 seconds followed by a 25-30 mL normal saline flush. (See Table 1 for weight-adjusted dose volumes). TABLE 1. Weight-Adjusted Volumes for the 0.03 mmol/kg Dose Body Weight Kilograms (kg) Volume Inspect the Ablavar vial visually for particulate matter and discoloration prior to administration. Do not use the solution if it is discolored or particulate matter is present. Ablavar is intended for single use only and should be used immediately upon opening. Discard any unused portion of the Ablavar vial. Do not mix intravenous medications or parenteral nutrition solutions with Ablavar. Do not administer any other medications in the same intravenous line simultaneously with Ablavar. Imaging Guidelines Ablavar imaging is completed in two stages: the dynamic imaging stage and the steady-state imaging stage. Both stages are essential for adequate evaluation of the arterial system, and dynamic imaging always precedes steady-state imaging. During interpretation of the steady-state images, Ablavar within the venous system may limit or confound the detection of arterial lesions. To assess the initial distribution of Ablavar within the arterial system, begin dynamic imaging immediately upon injection. Begin steady state imaging after dynamic imaging has been completed, generally 5 to 7 minutes following Ablavar administration. At this time point, Ablavar is generally distributed throughout the blood. In clinical trials, steady-state imaging was completed within approximately one hour following Ablavar injection. DOSAGE FORMS AND STRENGTHS Ablavar is a sterile solution for intravenous injection containing 244 mg/ mL (0.25 mmol/mL) gadofosveset trisodium [see How Supplied/Storage and Handling] CONTRAINDICATIONS History of a prior allergic reaction to a gadolinium-based contrast agent. WARNINGS AND PRECAUTIONS Nephrogenic Systemic Fibrosis Gadolinium-based contrast agents increase the risk for nephrogenic systemic fibrosis (NSF) in patients with acute or chronic severe renal insufficiency (glomerular filtration rate <30 mL/min/1.73m2) and in patients with acute renal insufficiency of any severity due to the hepato-renal syndrome or in the perioperative liver transplantation period. In these patients, avoid use of gadolinium-based contrast agents unless the diagnostic information is essential and not available with non-contrast enhanced MRA. For patients receiving hemodialysis, physicians may consider the prompt initiation of hemodialysis following the administration of a gadolinium-based contrast agent in order to enhance the contrast agent’s elimination. Ablavar binds to blood albumin and use of a high-flux dialysis procedure is essential to optimize Ablavar elimination in patients receiving chronic hemodialysis. The usefulness of hemodialysis in the prevention of NSF is unknown [see Boxed Warning and Clinical Pharmacology]. Among the factors that may increase the risk for NSF are repeated or higher than recommended doses of a gadolinium-based contrast agent and the degree of renal function impairment at the time of exposure. Post-marketing reports have identified the development of NSF following single and multiple administrations of gadolinium-based contrast Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Clinical Studies Experience Anaphylaxis and anaphylactoid reactions were the most common serious reactions observed following Ablavar injection administration [see Warnings and Precautions]. In all clinical trials evaluating Ablavar with MRA, a total of 1,676 (1379 patients and 297 healthy subjects) were exposed to various doses Ablavar. The mean age of the 1379 patients who received Ablavar was 63 years (range 18 to 91 years); 66% (903) were men and 34% (476) were women. In this population, there were 80% (1100) Caucasian, 8% (107) Black, 12% (159) Hispanic, 1% (7) Asian, and < 1% (6) patients of other racial or ethnic groups. Table 2 shows the most common adverse reactions (≥1%) experienced by subjects receiving Ablavar at a dose of 0.03 mmol/kg. Table 2 Common Adverse Reactions in 802 Subjects Receiving Ablavar at 0.03 mmol/kg Preferred Term n (%) Pruritis Headache Nausea Vasodilatation Paresthesia Injection site bruising Dysgeusia Burning sensation Venipuncture site bruise Hypertension Dizziness (excluding vertigo) Feeling cold 42 (5) 33 (4) 33 (4) 26 (3) 25 (3) 19 (2) 18 (2) 17 (2) 17 (2) 11 (1) 8 (1) 7 (1) Post-marketing Experience Because post-marketing reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The profile of adverse reactions identified during the post-marketing experience outside the United States was similar to that observed during the clinical studies experience. DRUG INTERACTIONS Following injection, Ablavar binds to blood albumin and has the potential to alter the binding of other drugs that also bind to albumin. No drug interaction reactions were observed in clinical trials. Consider the possibility of Ablavar interaction with concomitantly administered medications that bind to albumin. An interaction may enhance or decrease the activity of the concomitant medication [see Clinical Pharmacology]. Warfarin In a clinical trial of 10 patients receiving a stable dose of warfarin, a single dose of Ablavar (0.05 mmol/kg) did not alter the anticoagulant activity of warfarin as measured by the International Normalized Ratio (INR). USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C There are no adequate and well-controlled studies of Ablavar in pregnant women. In animal studies, pregnant rabbits treated with gadofosveset trisodium at doses 3 times the human dose (based on body surface area) experienced higher rates of fetal loss and resorptions. Because animal reproduction studies are not always predictive of human response, only use Ablavar during pregnancy if the diagnostic benefit justifies the potential risks to the fetus. In reproductive studies, pregnant rats and rabbits received gadofosveset trisodium at various doses up to approximately 11 (rats) and 21.5 (rabbits) times the human dose (based on body surface area). The highest dose resulted in maternal toxicity in both species. In rabbits that received gadofosveset trisodium at 3 times the human dose (based on body surface area), increased post-implantation loss, resorptions, and dead fetuses were observed. Fetal anomalies were not observed in the rat or rabbit offspring. Because pregnant animals received repeated daily doses of Ablavar, their overall exposure was significantly higher than that achieved with a single dose administered to humans. Nursing Mothers It is not known whether gadofosveset is secreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Ablavar is administered to a woman who is breastfeeding. The risks associated with exposure of infants to gadoliniumbased contrast agents in breast milk are unknown. Limited case reports indicate that 0.01 to 0.04% of the maternal gadolinium dose is excreted in human breast milk. Studies of other gadolinium products have shown limited gastrointestinal absorption. These studies were conducted with gadolinium products with shorter half-lives than Ablavar. Avoid Ablavar administration to women who are breastfeeding unless the diagnostic information is essential and not obtainable with non-contrast MRA. In animal studies, less than 1% of gadofosveset at doses up to 0.3 mmol/kg was secreted in the milk of lactating rats. Pediatric Use The safety and effectiveness of Ablavar in patients under 18 years of age have not been established. The risks associated with Ablavar administration to pediatric patients are unknown and insufficient data are available to establish a dose. Because Ablavar is eliminated predominantly by the kidneys, pediatric patients with immature renal function may be at particular risk for adverse reactions. Geriatric Use In clinical trials, no overall differences in safety and efficacy were observed between subjects 65 years and older and younger subjects. Whereas current clinical experience has not identified differences in responses between elderly and younger patients, greater susceptibility to adverse experiences of some older individuals cannot be ruled out. NONCLINICAL TOXICOLOGY Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term animal studies have not been performed to evaluate the carcinogenic potential of gadofosveset. Gadofosveset was negative in the in vitro bacterial reverse mutation assay, CHO chromosome aberration assay, and the in vivo mouse micronucleus assay. Administration of up to 1.5 mmol/kg (8.3 times the human dose) to female rats for 2 weeks and to male rats for 4 weeks did not impair fertility [see Use in Specific Populations]. HOW SUPPLIED/STORAGE AND HANDLING Ablavar Injection is a sterile, clear, colorless to pale yellow solution containing 244 mg/mL (0.25 mmol/mL) of gadofosveset trisodium in rubber-stoppered glass vials with an aluminum seal. Ablavar Injection is supplied as follows: NDC 11994-012-01 - 10 mL fills in 10 mL single use vials packages of 10 vials NDC 11994-012-02 - 15 mL fills in 20 mL single use vials in packages of 10 vials Store Ablavar Injection up to 25°C (77°F: excursions permitted to 15 to 30°C [59 to 86°F]). Protect from light and freezing. PATIENT COUNSELING INFORMATION Instruct patients receiving Ablavar Injection to inform their physician or healthcare provider if they: • are pregnant or breast feeding • have a history of allergic reaction to contrast media, a history of bronchial asthma or allergic respiratory disorder • have a history of kidney and/or liver disease • have recently received a gadolinium-based contrast agent • have a history of heart rhythm disturbances, or cardiac disease • are taking any prescription or over-the counter medications Gadolinium-based contrast agents, including Ablavar, increase the risk for NSF in patients with severe renal insufficiency or acute renal insufficiency of any severity due to the hepato-renal syndrome or in the perioperative setting of liver transplantation. Patients with less severe renal insufficiency who receive repetitive administrations of a gadoliniumbased contrast agent may have an increased risk for the development of NSF, especially if the time interval between the administrations precludes clearance of the previously administered contrast agent from the body. If Ablavar is administered in these situations, instruct patients to contact their physician or healthcare provider if they develop signs or symptoms of NSF, such as burning, itching, swelling, scaling, hardening and tightening of the skin, red or dark patches on the skin, stiffness in joints with trouble moving, bending or straightening of the arms, hands, legs, or feet, pain deep in the hip bones or ribs, or muscle weakness [see Warnings and Precautions (5.1)]. Inform patients that they may experience: • reactions at the injection site, such as: redness, mild and transient burning or pain or feeling of warmth or coldness • side effects of itching or nausea To report SUSPECTED ADVERSE REACTIONS, contact Lantheus Medical Imaging, Inc. at 1-978-667-9531/1-800-362-2668 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch Distributed by Lantheus Medical Imaging, Inc., 331 Treble Cove Road, North Billerica, MA 01862, United States US Patents: 7,060,250; 7,229,606; and 5,919,967 515903-1009 October 2009 An Official Journal Radiologic Technology (ISSN 0033-8397) is the official scholarly/professional journal of the American Society of Radiologic Technologists. It is published bimonthly at 15000 Central Ave SE, Albuquerque, NM 87123-3909. Months of issue are January/February, March/April, May/June, July/ August, September/October and November/December. Periodical class postage paid at Albuquerque, NM, and at additional mailing offices. 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For questions regarding subscriptions or missing issues, phone Member Services at 800-444-2778 or e-mail [email protected]. 110 For questions about submitting an article, e-mail [email protected]. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY .................................................................................. . . . . . . . . . . . . . . . . . . . CONTENTS November/December 2010 Volume 82/Number 2 P EE R- RE VIE WE D ARTICL E S Factors Influencing Success in RA Programs: A Survey Rebecca Ludwig, Joanne Huck, Jeffrey S Legg. . . . . . . . . . . . . . . . . . . . . . . . . 113 On the Cover: “Bare Bones” is the second in a series of cover images created by Dr Kai-hung Fung, a radiologist from Hong Kong. This artistic rendering of a 3-D computed tomography scan shows bone stripped to its matrix at the distal end of the femur. The marrow is shown in blue; the yellow structure at the bottom is the patella. The Role of Mobile Electronic Devices in Radiographer Education Jason S Applegate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 D I R E CTE D RE ADIN G ARTICL E S Domestic Violence Bryant Furlow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Diagnosis and Treatment of Scaphoid Fractures Cynthia N Patrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 C OL U MN S & DE PARTME N TS Open Forum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Teaching Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 My Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Writing & Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Technical Query . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Literature Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 RE: Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Student Scope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Patient Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 111 ........................................................................................................... open forum CT Dose: Medical Residents Take Note Open Forum is open to all individuals interested in commenting on matters of concern to the radiologic sciences. Writers should e-mail their letters to communications@ asrt.org. Letters may be edited to conform with the Journal’s space or style requirements. Views expressed in this column do not necessarily reflect the views of the ASRT. Editor: In the March/April 2010 issue of Radiologic Technology, Gudjonsdottir, Ween and Olsen methodically outlined how newly developed automatic exposure controls(AECs) in computed tomography (CT) scanners can effectively keep patient dose to mutually agreed upon accepted limits, if they are used properly and according to the manufacturer’s recommendations. If the scientific community agrees that CT scanning dose limits can be set and standardized, and the latest AEC technology can be employed, patient dose should be as low as reasonable. In other words, the technology is in place to do its job. Radiographers will use the AEC equipment as instructed, and all will be just fine. Not so fast. Walk around a radiology department these days and hear what technologists have to say about CT scanning and freshly minted doctors ordering CT scans for a study that just a few years ago could be handled with an anteroposterior and a lateral plain image. For instance, why would a doctor order a CT scan for a thumb? Yes, that’s right — a thumb. How we got to this point is not the issue. How new physicians can be taught to correctly request a radiologic examination is the question. Robert J Slothus, R.T.(R) (via e-mail) 112 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ............................................................................. . . . . . . . . . . . . . . . . . . . . . . peer review Factors Influencing Success In RA Programs: A Survey Rebecca Ludwig, PhD, R.T.(R)(QM), FAEIRS Joanne Huck, RRA, R.T.(R), RDMS Jeffrey S Legg, PhD, R.T.(R)(CT)(QM) Purpose To assess the factors registered radiologist assistants and radiologist assistant (RA) students perceive to be most significant for success in an RA educational program. Methods An electronic survey was sent to graduates of and students currently enrolled in RA programs (N = 99) via their program directors. The response rate was 60.6% and represented 8 RA programs. Factor analysis was used to examine the relationships among the variables. Results Four factors accounted for nearly 93% of the variance, with 3 of the 4 related to the role of the radiologist preceptor. Although the quality of the program itself seemed to be somewhat important, personal characteristics were perceived as contributing little to student success. Conclusion This study supports the importance of developing strategies to engage radiologist preceptors in the RA educational process. S ince inception of the radiologist assistant (RA) model for advanced practice in medical imaging, educators anticipated that instruction for RAs would be markedly different from the teaching techniques used in traditional radiography programs. All RA programs would require extensive preceptorships with a radiologist or radiologists. Some programs would deliver courses using new distance education formats, either as a supplement to conventional classroom courses, or entirely as distance learning programs via online courses. Many RA students would be the only such students at their clinical affiliate site, rather than part of a cohort rotating through the same facility. The RA students themselves also would be distinctly different from other radiologic science students; all would be experienced radiographers with diverse workplace backgrounds and highly motivated to advance their imaging careers. Because of the novelty of this advanced-practice model, educators could only guess which factors would likely determine the success of RA students and graduates. This project focuses on the perceptions of students and graduates in identifying the major factors enabling them to successfully complete an RA program. The researchers assumed that a combination of factors related to the educational program, the clinical preceptorship experience, the clinical affiliate site and the student himself or herself likely affect academic success for any given individual. Identifying specific factors that are perceived to enhance the success of many students would significantly assist educators in developing ways to maximize this benefit. Literature Review Research on the education of RAs is limited because the profession is so new. The RA program at Loma Linda University in California, which celebrated its seventh anniversary in the fall of 2010, was the first of only 9 RA programs recognized by the American Registry of Radiologic Technologists (ARRT) at the time of this study.1 A tenth program recently received recognition from the ARRT. Graduates of ARRTrecognized programs are eligible to become registered radiologist assistants (RRAs) through an examination process. Until more data become available regarding the education and clinical practice of RRAs, studies of other physician-extender professions and medical students or residents provide the closest parallel for comparison. The literature search included MEDLINE using PubMed, CINAHL Plus, HealthSource Nursing/ Academics, PsychINFO and Web of Science (SCI & SSCI), all limited to Human and 2003-2009. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 113 ........................................................................................................... SUCCESS IN RA PROGRAMS Expanding the Table 1 topic of factors for Rank of Top 10 Factors for Student Success2 student success to all Rank Category Item Important Important health professions to Learning to Learning yielded one study of (N = 1642) (%) 1642 medical students and residents in 5 1 Site Effective teachers 1569 98.4 Canadian medical 2 Site Opportunity to see patients independently 1592 97.3 schools that closely 3 Preceptor Is open to questions 1540 96.7 matched this study’s subject and became 4 Preceptor Gives constructive feedback 1522 95.6 the foundation for 5 Preceptor Demonstrates enthusiasm for teaching 1515 95.1 this project.2 The 6 Site Opportunity to see large variety of patients 1511 94.8 investigators surveyed the medical students 7 Preceptor Reviews differential diagnosis 1507 94.6 and residents on 24 8 Site Opportunity to see adequate number of 1496 93.9 site characteristics patients and 38 preceptor 9 Preceptor Delegates appropriate responsibility for 1491 93.7 behaviors. Findings patient care suggested that the top 10 most important 10 Site Preceptors readily available 1490 93.5 factors for student suc- Adapted with permission from Schultz K, Kirby J, Delva D, et al. Medical students’ and residents’ cess clustered around preferred site characteristics and preceptor behaviours for learning in the ambulatory setting; a crossthe themes of opporsectional survey. BMC Med Educ. 2004;4:12. tunity to perform procedures and engage in communication with the released in 2009 by the U.S. Department of Education.3 preceptor (see Table 1). Controlled studies comparing the different versions of Preceptor behaviors were items such as gives cononline learning were evaluated for students in college, structive feedback, demonstrates enthusiasm for teachgraduate studies and professional training. This metaing, delegates appropriate responsibility for patient analysis supported the inclusion of online opportunities care and makes student feel like a valued member to provide extra time for learning, additional resources, of the practice. Site characteristics included items or opportunities for collaboration and reflection. The such as opportunity to see an adequate number of findings indicated that distance learning, alone or in patients, large variety of patients, seeing patients combination with conventional classroom instruction, independently, performing procedures, observing resulted in stronger learning outcomes than exclusively preceptors and interacting with referring physicians. face-to-face classroom teaching. Rather than having Site characteristics also encompassed items related to information simply provided and explained by an the characteristics of the respective programs such as instructor, distance learning requires more studenteffective teachers, teaching of time management skills, directed and independent learning. Distance or clearly defined objectives for the site rotation and close blended learning appears to yield better outcomes than proximity of the clinic to the program’s campus. The strictly traditional classroom learning because to some inability to separate program characteristics from site degree the students assume more responsibility for the characteristics may somewhat limit the generalizability learning process. of the study findings to other situations. Also, the stuAssuming that the academic outcomes are essendent’s individual characteristics were not considered, tially the same for learning completely online, or for and these might also potentially influence the student’s online learning blended with classroom instruction, ability to succeed academically. the importance of one delivery format over the other Considering the type of educational format, the most likely relates to issues of convenience for the individual comprehensive study comparing online learning to student. With few RA programs in the U.S., students conventional classroom performance is a meta-analysis with employment or preceptors and potential clinical 114 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... LUDWIG, HUCK, LEGG affiliate sites located far away from academic programs would logically choose online course offerings. If distance is not a consideration, then students would seem more likely to prefer the nearest program as a matter of convenience. The personal experience of the investigators supports this notion. Program applicants frequently cite the convenience of an online learning format, or conversely the convenience of close proximity, as primary reasons for interest in a particular RA program. At least informally, whichever educational environment is most convenient for the student appears to be his or her preference. A growing body of medical literature validates the importance of the preceptor to the clinical learning experience. A 5-year study of 6527 medical students and 16 583 physician residents at U.S. Department of Veterans Affairs facilities reported that factors influencing satisfaction were similar for the 2 groups. Four domains were evaluated: learning environment, clinical faculty, working environment and physical environment. Clinical faculty members’ enthusiasm, willingness to delegate responsibility and providing feedback were highly valued by the medical students, whereas medical residents indicated that the variety of patients and evaluating patients independently were important.4 All 5 of these factors also were associated with the earlier study by Schultz et al, as listed in Table 1.2 Similar themes regarding effective preceptors emerged in a review of 110 reflective journals written by medical students at a private midwestern medical school. The 5 attributes ranked highest by the students were demonstration of professional expertise, actively engaging the students in learning, creating a positive environment, demonstrating collegiality and professionalism and discussing discipline-specific topics and issues. Interestingly, the characteristics associated with ineffective preceptors included too much time spent shadowing, comments discouraging students to ask questions and a lack of interest in getting the student involved in performing procedures. The factors identified in the study for success in medical education reinforce the critical role of preceptors in involving students in learning, encouraging autonomy and providing feedback.5 Another study of medical students’ opinions found that the students associated their preceptors’ effectiveness with enthusiasm, availability, inspiring confidence, explaining decisions and giving feedback. The analysis was based on 276 evaluation forms submitted by all third-year medical students completing 12-week rotations at an outpatient facility. Based on the student responses, the investigators recommended that preceptors actively involve students in developing clinical skills.6 Although this study was restricted to a limited practice situation, the strength of the data further validates themes found in the other studies. Methods Dr Karen Schultz gave permission for the investigators to adapt a survey instrument she designed for her study of medical students and residents,2 and the proposed project was approved by the Internal Review Board at the University of Arkansas for Medical Sciences. The formatting was changed to facilitate online delivery of a 68-item survey using Survey Monkey with a similar Likert scale plus the choice of “not applicable.” The demographic items specific to medical students or residents were replaced with items related to RA students or graduates. Nineteen of the 31 items related to preceptor behaviors were drawn directly from the original survey. The remaining 12 items for preceptor behaviors were suggested via panel discussions with faculty and current RA students. Eight of the 21 items for affiliate site characteristics came from the original survey. The other 13 items for the affiliate site also were suggested by panel discussion. Ten additional items were created to specifically target characteristics of the academic program, such as instructional methods, access to library resources and effectiveness of instructors. Six items were added about the respondents’ personal characteristics, including separating clinical activities from paid employment, distance from the program and clinical site, and being married or having family obligations. Finally, participants were given the opportunity to add comments at the end of the survey. Only 9 RA programs with limited numbers of graduates and enrolled students existed when this project was undertaken. In an effort to capture as large a sample as possible, all 9 RA program directors were e-mailed a link to the survey with a request to forward the link to their currently enrolled students and program graduates. The program directors also were asked to reply to the e-mail with the numbers of students and graduates receiving the forwarded message so that a return rate could be calculated. Eight programs participated, with 52 students and 47 graduates receiving the link to the survey, yielding a study sample of 99 people. Individual respondents were completely anonymous to the investigators. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 115 ........................................................................................................... SUCCESS IN RA PROGRAMS Data were analyzed using Table 2 SPSS for Windows, version 16.0. Demographic Characteristics of Survey Respondents Descriptive statistics were comN (%) piled for the respondents’ demographic characteristics, clinical Sex site characteristics, preceptor Female 31 (51.7) behaviors, RA program characMale 29 (48.3) teristics and personal characteristics. An exploratory factor analyAge (y) sis was conducted using the scores 7 (11.7) from the Likert scale for the clini- 20-25 26-30 15 (25.0) cal site characteristics, preceptor behaviors and RA program 31-35 15 (25.0) characteristics. Factor analysis is > 35 23 (38.3) a multivariate statistical approach RA Program used to analyze the interrelationships among large numbers of Bloomsburg University (Bloomsburg, PA) 3 (5.1) variables and to explain the variLoma Linda University (Loma Linda, CA) 8 (13.6) ables by their common underlyMidwestern State University (Wichita Falls, TX) 13 (22.0) ing dimensions (ie, factors). The technique allows reduction of a Quinnipiac University (Hamden, CT) 1 (1.7) large number of variables into a University of Arkansas for Medical Sciences (Little Rock) 14 (23.7) smaller set of dimensions/factors 6 (10.2) with minimum information loss.7,8 University of Medicine and Dentistry of New Jersey (Newark) The dimensions/factors are interUniversity of North Carolina at Chapel Hill 10 (16.9) preted to identify the underlying Virginia Commonwealth University (Richmond) 4 (6.8) (ie, hidden) constructs that may Prior Experience as R.T. (y) be responsible for the observed variables and correlations. For <4 14 (23.3) this study, varimax rotation was 4-6 12 (20.0) used to create a factor structure in which each variable loads high- 7-10 15 (25.0) ly on one and only one factor. 11-15 7 (11.7) According to Sharma, varimax 16-20 11 (18.3) rotation results in each factor 8 representing a distinct construct. > 20 1 (1.7) Because this is a first-of-its-kind study for RAs, all study variables were used in the factor largest group of respondents was older than 35 years analysis; no subanalysis was conducted. old, with nearly 90% of respondents being 26 years or older. Nearly one-quarter of survey respondents Results had less than 4 years of experience as a radiologic A total of 99 surveys were e-mailed to current technologist (RT), and approximately 32% reported students (n = 52) and graduates (n = 47) of 8 RA pro11 years or more of experience in the profession. grams in the United States in 2008. Sixty surveys were Experience as an RA was low, as expected, considerreturned, for a response rate of 60.6%. One responing that this is a relatively new advanced practice area dent provided only some demographic informain radiologic technology. The majority of respondents tion; 6 others responded to some, but not all, items. (66.7%) described their primary clinical affiliate as Demographic characteristics of the survey responlarge; only 10% reported a small clinical affiliate. The dents are listed in Table 2. Men and women were repmajority of clinical affiliates were public teaching hosresented relatively equally among respondents. The pitals (54.2%). Private hospitals, both teaching and 116 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... LUDWIG, HUCK, LEGG were all ranked high. The effect of the preceptors’ monitoring of the quality of the clinical rotaN (%) tion (3.98) and teaching the use of community resources (3.76) were ranked as only sometimes 34 (56.7) enhancing the respondent’s 18 (30.0) clinical experience. Respondents’ perceptions 5 (8.3) regarding the effect of clini3 (5.0) cal site characteristics on their clinical experience are ranked in Table 4. Opportunities to 6 (10.0) observe and perform a vari14 (23.3) ety of procedures as well as 40 (66.7) interact with radiologists were consistently ranked as the most important issues. For example, 32 (54.2) the site characteristics with 10 (17.0) the highest mean scores were the opportunity to observe 12 (20.3) both radiologists/preceptors 5 (8.5) (4.76) and specialty procedures (4.68). Also highly valued were opportunities to interact with 27 (45.0) physicians (4.61) and perform a 23 (38.3) variety of radiologic procedures (4.53). The existence of a site coordinator (3.85) and the pres8 (13.3) ence of other students in the clinical site (3.60) were ranked lower in terms of their perceived effects on the quality of the clinical experience. Table 5 displays respondents’ perceptions of the RA program characteristics on their clinical experience. Again, respondents reported that program characteristics had an important, positive effect on their clinical experiences. Effective instructional methods (4.71), helpful course instructors (4.63) and online courses (4.61) were identified as the most important characteristics of the RA program pertaining to respondents’ clinical experiences. Interestingly, offering traditional classroom courses was ranked lowest, although with a mean rating of 4.21 traditional courses still “sometimes enhanced” the respondents’ clinical experience. Last, the effects of the respondents’ personal characteristics were assessed to determine their impact on clinical experiences (see Table 6). Unlike the previous categories discussed, personal characteristics were Table 2 (continued) Demographic Characteristics of Survey Respondents Experience as RRA (y) 0 1 2 3 Primary Clinical Affiliate Size Small Medium Large Primary Clinical Affiliate Type Public teaching Public nonteaching Private teaching Private nonteaching No. of Clinical Sites Used in Program 1 2-3 4-5 >5 2 (3.4) nonteaching, composed only 28.8% of clinical facilities. The largest percentage of respondents (45.0%) reported using only 1 clinical facility. Approximately 84% of respondents reported using between 1 and 3 clinical sites. Table 3 summarizes the perceived effect of preceptor behaviors on respondents’ clinical experience, ranked from highest to lowest: 5 = greatly enhanced internship, 4 = sometimes enhanced internship, 3 = no effect on internship, 2 = sometimes adverse effect on internship and 1 = adverse effect on internship. Overall, the mean scores for the Likert-scaled responses were very high, indicating the positive impact of the various preceptor behaviors on clinical experiences. For example, the preceptors’ demonstration of a caring attitude toward patients (4.65), discussion of their clinical reasoning (4.63), responsiveness to questions from the student (4.62) and provision of constructive feedback (4.62) RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 117 ........................................................................................................... SUCCESS IN RA PROGRAMS Table 3 Perceived Effect of Preceptor Behaviors on RA Clinical Experience Preceptor Behaviors Demonstrates a caring attitude toward patients N Mean (SD) Range 54 4.65 (.55) 2-5 Discusses own clinical reasoning processes 54 4.63 (.62) 2-5 Open to questions 55 4.62 (.73) 2-5 Gives constructive feedback 55 4.62 (.68) 2-5 Asks students challenging questions 53 4.60 (.72) 2-5 Reviews differential diagnoses 53 4.58 (.69) 2-5 Observes clinical interactions directly 53 4.55 (.70) 1-5 Tries to help student meet clinical objectives 55 4.51 (.86) 1-5 Provides a role model of professional behavior 55 4.49 (.79) 2-5 Demonstrates effective interactions with other health care providers 53 4.47 (.64) 3-5 Outlines specific task(s) to be done during a clinical encounter 52 4.46 (.70) 3-5 Suggests relevant reading 53 4.43 (.80) 2-5 Demonstrates a caring attitude toward students 55 4.42 (.71) 2-5 Demonstrates enthusiasm for teaching 55 4.40 (.91) 2-5 Gives timely feedback 54 4.39 (.90) 1-5 Provides a role model of balance between personal and professional life 54 4.39 (.79) 2-5 Teaches patient assessment skills 52 4.37 (.69) 2-5 Identifies and responds to student’s specific learning needs 55 4.36 (.85) 2-5 Defines student’s roles in the specific clinical setting 50 4.36 (.66) 3-5 Connects new concepts to existing knowledge 53 4.34 (.68) 2-5 Asks for student’s ideas before giving own 53 4.32 (.75) 2-5 Teaches appropriate use of health care resources 50 4.26 (.83) 2-5 Sets time aside to discuss topics that could not be discussed during busy clinical periods 51 4.22 (.86) 2-5 Provides background on patient before students sees patient 50 4.22 (.82) 2-5 Seeks to understand student’s ideas 53 4.19 (.79) 2-5 Facilitates student’s participation in follow-up care 52 4.17 (.79) 2-5 Teaches communication skills 49 4.14 (.87) 1-5 Practice group provides tuition assistance 29 4.10 (1.57) 1-5 Practice group provides income during clinical internships 28 4.07 (1.41) 1-5 Discusses limitations of his or her own knowledge 49 4.06 (.80) 2-5 Monitors quality of the rotation 48 3.98 (1.0) 1-5 Teaches use of community resources 42 3.76 (.98) 1-5 Abbreviation: SD, standard deviation. 118 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... LUDWIG, HUCK, LEGG Table 4 Perceived Effect of Clinical Site Characteristics on RA Clinical Experience Site Characteristic N Mean (SD) Range Opportunity to observe radiologists/preceptors if desired 51 4.76 (.55) 2-5 Opportunity to observe specialty procedures 50 4.68 (.71) 2-5 Opportunity to interact with physicians 51 4.61 (.72) 2-5 Radiologists readily available when needed by student 51 4.57 (.67) 2-5 Opportunity to do a variety of procedures 51 4.53 (.99) 1-5 Appropriate use of protocols during program 51 4.53 (.70) 2-5 Readily available equipment 50 4.52 (.76) 2-5 Adequate volume of procedures performed 51 4.49 (.92) 2-5 Adequate variety of procedures performed 51 4.49 (.99) 1-5 Availability of computer resources 51 4.43 (.81) 2-5 Opportunity to do a large number of procedures 51 4.43 (1.04) 1-5 Availability of library resources 50 4.38 (.78) 2-5 Supportive administrators/supervisors 52 4.38 (.91) 1-5 Opportunity to observe new technology in clinical operation 48 4.33 (.86) 2-5 Orientation to the radiology department 46 4.30 (.87) 2-5 Radiologic technologists demonstrate positive attitudes toward students 51 4.29 (1.06) 2-5 Orientation to the patient care areas 46 4.20 (.91) 1-5 Affiliate site provides income during clinical internships 26 4.19 (1.39) 1-5 Affiliate site provides tuition assistance 25 4.12 (1.56) 1-5 Existence of a site coordinator for students 34 3.85 (1.02) 1-5 Presence of other students in clinical site at the same time 40 3.60 (1.24) 1-5 Abbreviation: SD, standard deviation. rated as having a lesser effect, with means ranging from 2.50 to 3.72. For example, the 2 highest ranked personal characteristics were financial support from family (3.72) and distance from the clinical site most often used for meeting clinical requirements (3.51). However, the mean scores for the items separating employment from clinical activities (2.94), distance from the RA program location (2.84) and having children (2.50) tended to be more neutral or have a “sometimes adverse” effect on clinical education. Overall, respondents’ personal characteristics appear to have a more neutral or even less positive effect on RA clinical experiences. For the factor analysis, factor loadings of +.700 or greater were interpreted for the dimensions/factors. Four factors, accounting for 92.76% of the variance for all the study variables, were identified. Table 7 displays the interpretation of the factors along with the variables and their corresponding factor loadings. Factor 1, representing 41.24% of the variance, pertains to the teaching skills and methods of the supervising radiologist based on variables such as the preceptors’ teaching of patient assessment skills and use of community resources, connecting new concepts to existing knowledge, and so forth. Factor 2 explains an additional 24.00% of the variance (cumulative variance = 65.24%) and appears to represent a sense of “buy in” and commitment on the part of the physicians and practice. Key variables for this factor include the preceptor asking students challenging questions and openness to teaching. Factor 3, representing 14.38% of the variance (cumulative variance = 79.62%), is interpreted RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 119 ........................................................................................................... SUCCESS IN RA PROGRAMS influence on their success in the RA educational process. RA Program Characteristic N Mean (SD) Range Interactions with radiologists regarding Effective instructional methods 51 4.71 (.54) 3-5 patient care and medHelpful course instructors 51 4.63 (.66) 2-5 ical decision making, Online courses offered 51 4.61 (.90) 2-5 as well as involvement in procedures, Library resources through program 51 4.57 (.67) 3-5 appear critical for Expectations for professional development and growth 51 4.57 (.61) 3-5 enhancing RA cliniTimely response to inquiries 51 4.53 (.78) 2-5 cal education. Based on our findings, we Meaningful and relevant assignments 51 4.47 (.78) 2-5 suggest that RA proAssistance with addressing clinical issues 51 4.45 (.78) 2-5 gram faculty increase efforts to establish Communication of emerging professional issues and events 51 4.39 (.83) 1-5 positive relationships Traditional classroom courses offered 32 4.21 (.98) 1-5 and rapport between Abbreviation: SD, standard deviation. radiologist preceptors and students. In addition, respondents Table 6 cited the imporPerceived Effect of Personal Characteristics on RA Clinical Experience tance of radiology Personal Characteristic N Mean (SD) Range practices and cliniFinancial support from family 32 3.72 (1.25) 2-5 cal site staff to the educational process. Distance from clinical site used to meet most requirements 49 3.51 (1.29) 1-5 These factors should Being married 39 3.03 (1.16) 1-5 be emphasized when Separating employment from clinical activities 47 2.94 (1.28) 1-5 establishing clinical preceptor agreeDistance from RA program location 49 2.84 (1.20) 1-5 ments. Nonetheless, Having children 32 2.50 (1.02) 1-5 in the experience of Abbreviation: SD, standard deviation. the authors, involving radiologists in the educational process has proved challenging. This as representing the quality of the educational program. is especially true when the preceptors are located off Last, the fourth factor explains 13.14% of the variance campus, which is common among RA programs. Not (cumulative variance = 92.76%) and appears to focus only is further study warranted on the educational proprimarily on the clinical reasoning/meaningfulness of cess for radiologist-extenders, but perhaps even more the clinical education and experiences dimension. importantly, more effort is needed to develop mechanisms for involving preceptors in RA education in a Discussion meaningful way. The clinical training and supervision of RAs is Support from a variety of levels (clinical site, program unique among radiologic technology educational faculty and educational institution) also is perceived to programs because it requires an increased level of be an important influence on RAs’ clinical success. As radiologist involvement. As midlevel health care provida new element in radiologic technology, RAs have little ers, RAs have a higher level of responsibility and must precedent on which to build. RA students may feel wary incorporate activities and skills into their practice that and concerned about the newness of the profession as were formerly conducted by radiologists. Not surpriswell as their enhanced roles and opportunities while ingly, the responses of RA students and graduates forging ahead as midlevel radiologist-extenders. Thus, it strongly suggest that the preceptor has the greatest Table 5 Perceived Effect of RA Program Characteristics on RA Clinical Experience 120 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... LUDWIG, HUCK, LEGG Table 7 Factor Analysis Results for Study Variables Factor % of Variance Explained Cumulative Variance Explained (%) 41.24 41.24 Teaching skills of MD & resources Items Making up Factor Factor Loading Teach use of community resources .906 Discuss limitations of his or her own knowledge .879 Demonstrates a caring attitude toward students .875 Adequate volume of procedures performed .875 Opportunity to observe radiologist/preceptor if desired .875 Communication of emerging professional issues and events .871 Appropriate use of protocols during program .871 Presence of other students in clinical site at the same time .841 Define student’s roles in the specific clinical setting .840 Readily available equipment .840 Adequate variety of procedures performed .828 Opportunity to do a variety of procedures .828 Observes clinical interactions directly .828 Teaches communication skills .827 Demonstrates effective interaction with other health care providers .827 Teaches patient assessment skills .827 Teaches appropriate use of health care resources .820 Seeks to understand student’s ideas .820 Connects new concepts to existing knowledge .820 Helps students meet clinical objectives .808 Existence of site coordinator for the student .803 Orientation to the radiology department .798 Orientation to the patient care areas .798 Assistance with clinical issues .788 Expectations for professional development and growth .782 Library resources through program .782 Sets time aside to discuss topics unable to be discussed during busy clinical periods .728 Facilitates student’s participation in follow-up care .723 Provides background on patient before student sees patient .723 Outlines specific tasks to be done during a clinical encounter .712 Continued RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 121 ........................................................................................................... SUCCESS IN RA PROGRAMS Table 7 continued Factor Analysis Results for Study Variables Factor % of Variance Explained Buy-in and commitment of physician or practice 24.00 Items Making up Factor 65.24 Factor Loading Open to questions .959 Demonstrates enthusiasm for teaching .959 Asks students challenging questions .959 Practice group provides income during clinical internships .959 Practice group provides tuition assistance .959 Affiliate site provides income during clinical internships .959 Affiliate site provides tuition assistance .959 Gives constructive feedback .780 Suggests relevant reading .744 Provides a role model of balance between personal and professional life .711 Quality of educational program 14.38 79.62 Demonstrates a caring attitude toward patients .807 Online courses offered .788 Availability of library resources .749 Opportunity to interact with other MDs .749 Effective instructional methods used .749 Clinical reasoning & meaningfulness of clinical education 13.14 92.76 MD discusses own clinical reasoning .756 Distance from RA program .754 Meaningful and relevant assignments -.877 is important for RA programs and other organizations involved in developing the RA role (ie, the American College of Radiology, American Society of Radiologic Technologists and American Registry of Radiologic Technologists) to continue to communicate regarding issues facing RAs and the radiologists and health care institutions involved in educating them. This study has several limitations. The data collected are based on a survey created for a different health care profession with revisions made to reflect RAs. Laboratory learning experiences and specific preceptor behaviors were not addressed. Furthermore, there are 122 Cumulative Variance Explained (%) no reliability or validity data for the initial or current survey, although the original study encompassed a large sample. Because of the relative newness of the profession and the small study population, an attempt was made to capture as many RRAs and student RAs as possible. However, it is possible that some RAs were not included in the survey, so the findings should be interpreted with caution. Last, factor analysis requires interpreting data to determine hidden factors, and as with any interpretive activity, results may vary by researcher. Based on our review and the findings of other investigators, we believe the factor analysis interpretation is strong. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... LUDWIG, HUCK, LEGG Conclusion The emergence of the RA’s role as a midlevel practitioner can both advance the radiologic technology profession and increase opportunities for technologists. Benefits to radiologists, radiology groups and radiology departments are predicted, but have not been empirically studied yet. Considering the novelty of the profession and the opportunities for a variety of stakeholders, continued examination and review of the RA educational process, clinical role and impact on the clinical environment are crucial for the success of this profession. The findings of this study provide insight into the factors and attributes critical to the success of RA students. References 1. American Registry of Radiologic Technologists. Frequently asked questions about the ARRT registered radiologist assistant certification program. www.arrt.org. Accessed October 5, 2009. 2. Schultz K, Kirby J, Delva D, et al. Medical students’ and residents’ preferred site characteristics and preceptor behaviours for learning in the ambulatory setting; a crosssectional survey. BMC Med Educ. 2004;4:12. 3. Means B, Toyama Y, Murphy R, Bakia M, Jones K. U.S. Department of Education, Office of Planning, Evaluation, and Policy Development. Evaluation of evidence-based practices in online learning; a meta-analysis and review of online learning studies, 2009. www2.ed.gov/rschstat/eval /tech/evidence-based-practices/finalreport.pdf. Accessed August 25, 2010. 4. Cannon GW, Keitz SA, Holland GJ, et al. Factors determining medical students’ and residents’ satisfaction during VA-based training: findings from the VA learner’s perceptions survey. Acad Med. 2008;83(6):611-620. 5. Huggett K, Warrier R, Maio A. Early learner perceptions of the attributes of effective preceptors. Adv Health Sci Educ Theory Pract. 2008;13(5):649-658. 6. Elnicki DM, Kolarik R, Bardella I. Third-year medical students’ perceptions of effective teaching behaviors in a multidisciplinary ambulatory clerkship. Acad Med. 2003;78(8):815-819. 7. Hair J, Black B, Babin B, Anderson R, Tatham R. Multivariate Data Analysis. 6th ed. Upper Saddle River, NJ: Prentice Hall; 2005. 8. Sharma S. Applied Multivariate Techniques. New York, NY: John Wiley & Sons; 1996. Rebecca Ludwig, PhD, R.T.(R)(QM), FAEIRS, is an associate professor, chairman and director of the Radiologist Assistant Program at the University of Arkansas for Medical Sciences in Little Rock. Joanne Huck, RRA, R.T.(R), RDMS, works at Associated Radiologists, Ltd, in Jonesboro, Arkansas. Jeffrey S Legg, PhD, R.T.(R)(CT)(QM), is associate professor and chairman of the Department of Radiation Sciences at Virginia Commonwealth University in Richmond. He is also a member of the Radiologic Technology Editorial Review Board. The authors thank Dr Michael Anders from the Department of Respiratory Care of the College of Health Related Professions at the University of Arkansas for Medical Sciences for his inspiration and willingness to share ideas related to this project. Permission from Dr Schultz to adapt her survey instrument for this study was also greatly appreciated. Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail [email protected]. ©2010 by the American Society of Radiologic Technologists. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 123 . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................... peer review The Role of Mobile Electronic Devices in Radiographer Education Jason S Applegate, MSRS, R.T.(R)(CT), CNMT Background Students commonly use mobile electronic devices (MEDs) for everyday activities such as e-mailing, texting, talking and playing. Students’ familiarity with these devices may make it beneficial for educators to use MEDs to enhance classroom teaching and clinical learning. Methods This literature review examines the use of MEDs in radiography educational programs. Results Various potential uses for MEDs are discussed, such as clinical logs, archiving data, accessing reference material and evaluation tools and providing course materials. The author also addresses factors for selecting an MED, advantages and disadvantages of MEDs, their limitations and suggestions for future research. Conclusion Research suggests that there are several areas in the classroom and clinical situations where MEDs could benefit students and faculty. In particular, MEDs may improve efficiency in data collection and clinical evaluation and prove valuable as an information delivery tool. M obile electronic devices (MEDs) are popular tools that are similar to computers, but with more limited capabilities.1,2 In this article, MED refers to personal digital assistants (PDAs), Palm Pilots, I-pods, I-phones, Blackberrys, pocket PCs, handheld computers and smartphones. Students of all ages are regular users of MEDs such as cell phones and digital music players.3,4 Because students tend to be very comfortable using these devices and MEDs can conveniently store and process data, educators are interested in incorporating them in learning environments.5,6 Software companies have developed programs that help an individual customize a data collection and storage system unique to his or her needs.7,8 This allows collection of specific data tailored to the individual’s interest and can be used for various academic fields. For example, MEDs may be valuable in instruction and information gathering in the field of radiography. It is important to research the use of these devices as an instructional aid and clinical assessment tool to determine whether they could be used effectively in the educational setting. This article reviews research focused on either classroom use or clinical uses of MEDs. To determine uses for these devices in radiography education, it is necessary to explore both of these avenues. 124 Methods This article is a review of the peer-reviewed literature on the use of MEDs as an academic and data collection tool in radiography. Databases were accessed using the search terms “electronic devices in learning,” “handheld devices in learning,” “personal digital assistant,” “use of pdas,” “pda and education” and “PDA.” The Academic Search Complete database was accessed using the term “electronic devices in learning,” and 115 articles were retrieved. Narrowing the search by using “handheld devices in learning” produced 24 articles. Abstracts were reviewed to determine whether they directly related to the research topic. The MEDLINE database was then accessed using the term “PDA.” This searched yielded 35 results that also were reviewed for content relevance. The search terms “PDA” and “PDA and education” were used to search Academic Search Complete, and 127 articles were located. The Cumulative Index to Nursing and Allied Health Literature database was accessed using the search terms “personal digital assistant” and “handheld devices.” The Boolean term “or” was used, and the articles were limited to those in 2004 or later. This narrowed the results to 192 articles. MEDLINE was also accessed, and identical parameters were used to perform the search. The search results included 278 articles. Finally, Google Scholar was used to locate more articles of interest using the phrase “PDAs for November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... APPLEGATE education” and “use of PDAs” to search for articles unavailable through the other database searches. Each search was limited to articles published between 2004 and 2009, as well as selecting full-text articles that were peer reviewed. After review of the abstracts, articles were selected based on their relationship to the subject matter and quality of content. References cited by each article reviewed were researched to acquire additional information related to the research topic. Selecting an MED Taylor et al determined that cost and ease of use were critical factors in determining which MED to use.7 They specifically mentioned the use of disposable batteries, which reduced the need for recharging equipment or a docking station where an MED can be placed to charge batteries or transfer information to a host computer. The host computer is usually a laptop or a personal computer. Conversely, Anderson and Blackwood believed that rechargeable batteries were better because of their reusability.3 The Taylor study focused on the use of PDAs for a family medicine clerkship and included 85 medical students, whereas Anderson and Blackwood focused on higher education in general. The authors of another study selected devices based on recommendations provided by the software company that was used.9 This research focused on the use of PDAs to access pertinent information at the patient bedside and included clinical and library staff. White and associates used the expertise of the Center for Information Technology and Distance Learning (CITDL) to select an appropriate device.5 This use benefited the study because the CITDL staff could match the physical requirements of the devices to the specifications of the needed software. This approach also allowed the staff to become familiar with the devices before implementation so that their expertise could be used for technical support. Savill-Smith and Kent published a landmark literature review that focused on the use of MEDs in education.10 Their research suggested that the most common approach to selecting the devices was to find something users are comfortable with and stick with that choice for as long as feasible. The article also mentioned the use of specialized Web sites to help determine the type of device that would be suited to individual needs. Unfortunately, most articles reviewed did not give specific reasoning for the selection or mention whether the devices were already available to the research participants because of prior purchase. It appears that no one factor can be used to select a device best suited for a project; however, selection based on individual need is the most common approach. Introducing MEDs to Faculty and Students Any new device can create apprehension that may result in a lack of use. Successful implementation of MEDs requires that individuals feel comfortable using these devices. One of the articles reviewed discussed the implementation of PDAs in an undergraduate nursing program.11 Because of a lack of funding, only the students received PDAs; faculty were excluded. The researchers believed this led to a decrease in student use because faculty did not promote the value of the device. Several articles discussed the use of training sessions of an hour or more before implementation.5,8,12-14 Participants believed that the training sessions were helpful and likely would reduce their anxiety when actual implementation began. Other researchers used volunteers only.9,12,15-17 This likely would yield higher acceptance of the devices, but would bias any qualitative data collected on perceptions of usefulness and ease of use. Unfortunately, using a random sampling of participants may yield subjects who are unwilling to participate, which also biases the data. Even though participants in the research conducted by Lee17 were voluntary, there were some negative comments about using the device in the early stages. Later in the study, participants adapted to the devices and were more comfortable using them. Lee focused on Lewin’s change theory, which suggests that individuals go through stages when change is introduced. The first stage is “unfreezing.” According to the theory, in the unfreezing stage individuals resist change until a certain level of comfort has been reached. Lewin’s theory suggests that training and initial acclimation to the devices before use seems to be the logical method of introduction. This was also a suggestion in research conducted by Farrell and Rose.12 MEDs in the Classroom Literature that focuses on the use of MEDs in radiography education is very limited. Most relevant literature focused on the education of medical and nursing students, as well as uses in information technology (IT) courses. Rawlinson and Bartel introduced PDAs into an IT course at Central Washington University (CWU).1 Their research included a qualitative study RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 125 ........................................................................................................... MOBILE ELECTRONIC DEVICES IN RADIOGRAPHER EDUCATION of students using their devices for daily learning activities. The goal of the research was to introduce new technology to students who were entering the IT and administrative management program at CWU to determine whether use of PDAs could benefit the students educationally. The sample size of the survey was limited to 2 small groups of students enrolled in IT courses. The total number of students involved in the research was 74. This small sample size, as well as the lack of diversity in the research groups, unfortunately reduces the ability to generalize the results to a wider population and reduces reliability. Students were likely already interested in technology and therefore may have had interest in using new technology. This makes it difficult to determine whether the results can be generalized to radiography students. Students participating in the research study were required to purchase the devices for class and were asked to assess the PDA as a useful tool for learning by means of a survey instrument.1 Students evaluated the PDAs at the end of the semester. Results were based on their satisfaction with the device as a possible educational aid, what applications were most often used by the students and what future uses the students would find beneficial. According to the survey, the greatest response regarding usage (97%) was to access the Internet. Other commonly used applications were e-mail, games, file sharing and scheduling. Responses to future uses of the device were similar. Accessing the Internet could be both a beneficial and distracting function of MEDs. The students would gain access to useful information that is available on Web sites. Assignments could be developed that require the students to perform small amounts of research during class time. This may help to develop research skills and promote learning beyond the classroom. The downside would include surfing the Web while a lecture is in progress or checking e-mail during class sessions. A related obstacle is the need for a wireless Internet infrastructure, which is an important building block to implementation.1,18,19 The absence of this technical component would severely diminish the usability of the MEDs. Anderson and Blackwood’s article stated that educational institutions will need to move toward a better wireless infrastructure to accommodate the everincreasing growth in wireless devices such as MEDs.3 Song focused on the use of MEDs specifically as an educational tool, breaking down the uses into the following 6 categories: educational, managing, information seeking and handling, games and simulations, 126 data collection, and context awareness.18 Many of these categories have been broken down into subcategories. The most intensely discussed category is educational communication. Song discussed the use of PDAs for different types of communication in the educational setting, including several applications that were considered most frequently used by Rawlinson and Bartel.1 Sharing/exchanging ranked high in the research conducted by Rawlinson and Bartel, and Song mentioned it as one of the subcategories of educational communication. Wu and Lai also believed that sharing/ exchanging was a benefit of using MEDs.19 PDAs could be used as an effective way of transferring data to students in the classroom. Instead of using paper-based literature, a file exchange could be used to reduce costs for materials and services such as copying.1 Using this application to transfer course documents to students also could assure the instructor that students have the information they need for class rather than expecting students to purchase resources. Smordal and Gregory used this process to transfer an e-book to medical students.20 The process itself was a success but, according to the researchers, the students did not use the resource as much as anticipated. However, no data were provided to back up this claim. It would seem reasonable that radiography instructors could consider giving quizzes or assignments via MEDs to students in lieu of traditional paper-based formats. This use of MEDs is mentioned as an option for educators to consider.1,18,21 Other uses for MEDs in the classroom include podcasts, videocasts and polling devices.1,4,15,18,22 Using audio or video formats, lectures can be recorded before or during class to allow students the opportunity to study the material at a later time. Podcasts are audio or video recordings that are stored as a media file. These files can be accessed by students or faculty and downloaded to computing devices. This allows the student to focus on the lecture itself rather than taking notes during the lecture.22 The use of MEDs as a polling device enables the instructor to create an interactive class and deliver quizzes and assessments.1,22 Data can be quickly collected and organized by the instructor’s receiving device. MEDs in Clinical Settings Most research on the use of palmtops as a clinical assessment tool has focused on nursing and medical students. Radiographers increasingly use technology every day; therefore, it seems reasonable to suggest that integrating technology into the training of radiography November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... APPLEGATE students would be useful. The use of MEDs in the clinical setting may be valuable considering their small size and portability, and the ability to communicate with other computers via multiple channels.10,18 Farrell and Rose found that students thought the devices were easy to use and helpful in several aspects of clinical education.12 McKenney’s research at The Ohio State University Medical Center focused on the use of PDAs to create a mobile delivery option for learning materials used by medical students in clinical rotations.21 Learning modules were loaded onto the devices’ memory either by accessing the modules on an Internet site or using a data CD that was produced in-house. The modules consisted of Microsoft PowerPoint presentations (Microsoft Corporation, Redmond, Washington) and text documents. Other research has suggested that the MED is effective as a teaching tool because of its ability to provide information to students at the point of care.12,16,23 The use of a small MED for reference vs a cumbersome textbook seemed to be appealing to students.16,24 An adaptation of this to radiography students could include having anatomy and positioning information stored on the device for reference during clinical rotations. Martino and Odle pointed out that one facility stores imaging protocols on the devices for easy access at the point of care.4 This could foster a greater sense of independence and self-reliance in students. Fisher and Koren researched perceptions on the use of PDAs by undergraduate nursing students.16 Their study was based on qualitative data for a relatively small sample size (28), which raises concerns regarding the reliability of their results. They used focus groups with impartial facilitators to collect responses to open-ended questions about personal perceptions of MED use during clinical rotations. The answers were analyzed and grouped according to predetermined categories. Results indicated that students perceived the devices as a useful resource, but opinions were mixed regarding the devices’ usefulness for developing critical thinking and improving quality of care. Another aspect of research that has potential for cross-over into radiography education is the use of MEDs to capture images or video for use in the classroom or on discussion boards.20,21 The use of video has both advantages and disadvantages, considering patient privacy, but if the proper channels are followed, it could be used for numerous learning activities. One possibility would be to create videos of students performing a procedure during a clinical rotation and later use this to evaluate their performance. The image capture application may be used to store images of unusual pathology or anomalies for discussion in class or on an online discussion board. Covington and Claudepierre suggested this as an option in their research on use of PDAs in a dental hygiene educational program.15 White et al studied the use of student-written clinical journals in educating nursing students at Duke University.5 Student journals included descriptions of procedures performed or skills used, pertinent patient history and a reflective learning section. The journals were submitted to the faculty weekly. The researchers stated that this improved students’ organizational skills and accountability. The journals also forced students to recall their clinical experiences and reflect on what they had learned. Faculty benefited from the journals because they enabled tracking of students’ progress and aided in planning assignments or lectures. Using the devices to evaluate student performance in a clinical setting is another potential benefit of MEDs. Martino and Odle mentioned that some radiography programs are currently using MEDs to evaluate students’ clinical performance; however, there is no literature describing the successfulness of the devices in such a setting.4 Data collection with MEDs could be useful to faculty in the radiologic sciences. Teaching institutions are responsible for ensuring that students are exposed to the variety of examinations mandated by the American Registry of Radiologic Technologists’ competency requirements. By using MEDs to collect data on the number of examinations performed by each student, faculty can determine areas in which a student is weak or which types of examinations are lacking at a clinical site. This information could be used as documentation in accreditation reviews, for making clinical assignments, or as feedback to individual students. Approaches to Data Collection Many of the articles reviewed described approaches taken by researchers in the medical field. Research pertaining to the education of nurses and physicians was considered most relevant to the education of radiographers. Data collected from the field of nursing focused on patient care issues such as input/output data or medication-related data.17 Hardwick, Pulido and Adelson discussed the use of MEDs to collect data for nursing.25 The article mentions uses in specialty areas such as home health and orthopedics. The researchers also discussed the use of RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 127 ........................................................................................................... MOBILE ELECTRONIC DEVICES IN RADIOGRAPHER EDUCATION voice recording abilities to record patient observations when a link to the hospital’s medical records was not available. This would decrease the likelihood of lost or skewed data due to the time interval between observation and recording. This feature also could be useful to technologists who are observing students performing competencies during busy times. If the technologist does not have time to complete an evaluation form when the examination is completed, the recollection of events may become obscure, and an accurate evaluation may not occur. Treadwell investigated the use of PDAs as a replacement for paper-based clinical examinations.8 Treadwell mentioned several consistent problems with the paperbased form, including illegible handwriting and lost documents. The researchers used data collection software that was personalized to their needs. Luo and Ton also found the database software to be user-friendly with minimal training.26 The ability to tailor data collection software to the needs of the researcher appeared to be a significant strength of the devices. Treadwell focused on medical students, who are evaluated on specific competencies in a manner similar to the way radiography students are evaluated on performing competencies. The research was performed over a 3-year period on medical and dental students, and focused on increasing evaluation efficiency and user satisfaction. The research occurred in 2003, 2004 and 2005 with 309, 314 and 270 research subjects, respectively. The most notable finding of the study was the amount of time spent on preparing evaluations. Paperbased assessments required preparing checklists, photocopying and calculating evaluation results. Paper-based evaluations were used in the first year of the research, and the amount of time spent on preparation totaled 525 minutes. The amount of time spent using the PDAbased assessment initially totaled 120 minutes because of training in 2004, and only 35 minutes in 2005. The main reliability issue with this study was that the paper-based procedures were studied for only 1 year, whereas the use of PDAs was studied for 2 years. The results cannot be considered significantly reliable until research has been conducted for multiple years on each of the evaluation types. The data could be skewed because of internal or external factors. In addition, although the sample sizes were significant, the use of medical and dental students limits the study’s generalizability to radiography students. However, similar improvements in efficiency as a result of switching from paper-based evaluations to evaluations completed on 128 MEDs were detailed in other research studies.6,27 This may be a significant finding that could reduce instructors’ workload in evaluating radiography students. Data Collection Outcomes Data collection with MEDs can have many benefits over paper-based collection.25 Paper-based collection systems have several inherent problems. Falsification of data, failure to accurately recall data and illegible handwriting were noted in several studies.6,8,25,26-28 Software can be installed on MEDs to collect, process and display data. Collecting, entering and processing the data can be performed with one device rather than using a system of forms, clerical staff and a network of computer systems.7,8,26 Stengel et al found that the use of MEDs to assign International Classification of Diseases-9 codes to hospital patients resulted in fewer coding errors (P < .001).27 Although this appears to be the most significant research conducted on data collection using MEDs, the study was performed over a short period of time. If this data is indicative of efficiency improvements in data collection, the study should be replicated for a longer period of time to improve the reliability. Treadwell’s research results did not necessarily agree with those of Stengel and associates.27 Treadwell noted a nonsignificant difference between the paper-based evaluations vs the MED-based evaluations. Regardless of the difference in the 2 results, there does not appear to be a negative outcome when using MEDs to collect data. This seems to suggest that MEDs are at least comparable to paper-based methods. It may be that researchers will need to evaluate which method is most suited to their needs when selecting a data collection process. Guadagno and associates discovered a downside to using PDAs to collect data at the point of care.13 Their research focused on using PDAs to assess neglect of elderly patients who were brought to the emergency department. Participants in the study found it difficult to enter data while focusing their attention on the patient and his or her needs. This eventually led to participants collecting data with pen and paper first, then entering it on the MED. Participants reported that the MED interface made it challenging to focus on patient responses while entering text. In this case, the benefit of increased efficiency is countered by the redundancy in data logging. The researchers suggested creating a more userfriendly interface for the PDAs in which a drop-down box could be used to select certain variables. Other research also suggested this modification to simplify the November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... APPLEGATE data collection process. In the study by Guadagno et al, a poorly designed data collection process might have biased the research outcome.13 This underscores the need for a user-friendly device and interface to successfully implement the use of PDAs. In addition to reducing the time spent collecting data, MEDs could reduce the number of errors during calculation of evaluation scores, thereby making data collection and processing more accurate. Calculating midterm and final clinical grades from data input would be an area where this feature would be useful. The data processing could be performed by the MED, allowing clinical instructors to spend more time instructing students. Data collection with MEDs also may allow educators to increase the amount and type of data collected without increasing the time spent on collection.28 Ducut and Fontelo stated that some schools have shifted away from paper-based evaluations to PDA-based evaluations to cut costs.22 The ability to tailor data collection software allows the faculty or department leaders to collect data relevant to a program’s performance. Information on the number of examinations completed, diversity of examinations and individual workload could prove useful. Limitations of MEDs Although MEDs have many benefits over paperbased data collection processes, there are also limitations and undesirable characteristics. Data loss due to equipment failure is one issue discussed by Kho et al.28 However, data loss also was a problem with paper-based data collection.8,26 One specific reason cited for data loss with MEDs was the loss of power due to run-down batteries.26 Treadwell selected devices with a long battery life, which suited his research design.8 Luo and Ton mentioned the use of the MED alarm function to remind the user to synchronize the MED to a host computer.26 This function also could be used to alert the user that the batteries need to be recharged. This should alleviate the issue with data loss due to dead batteries. The user can transfer data stored on the MED to a host computer, thereby reducing the risk of a significant amount of data being lost as a result of equipment failure.3 Several articles suggested the use of memory expansion cards to ensure that data remain on the device without loss.7,9 The lack of available memory also is seen as an obstacle to widespread use of MEDs in educational and clinical settings.1,21,29 However, the expandability of the device’s memory by use of a secure digital (SD) card is an easy fix. McKenney gave the example that 1 megabyte (MB) of memory is equal to the contents of a 600-page book.21 The devices used in the research conducted by McKenney consisted of a 64-MB SD card, which was reported to be sufficient for the applications and data used in the research project.21 Considering that McKenney’s findings were documented in 2004, recent advances in technology have likely increased the amount of memory available for MEDs. Another issue with MEDs is confidentiality of patient and student information. When data are collected for any reason, the information must remain secure. MEDs can be used to store sensitive information that should not be seen by unauthorized individuals. This leads to a security issue with the MED. Hardwick et al addressed this issue in their research.25 The team discussed the use of password protection for the device against unauthorized use. If the device were to be left unattended or stolen, the information would remain secure because it could not be accessed without the proper password.13,17,25 Likewise, those researchers mentioned that when sensitive data are transferred to another computer for processing, the information should be encrypted to ensure security. The small screen on an MED also was found to be a significant limitation.1,29 Research suggested that screen size may create significant problems for individuals who have certain disabilities; however, Treadwell found no such problem.8 The limited screen size also forces the need for special programs and applications designed to fit the screen.21 The authors of several articles mentioned the size of the screen as a possible barrier to widespread use.1,20,21 The small screen makes viewing larger documents and Web pages difficult.8,20 In Treadwell’s research, a technique called “branching” was used to simplify large checklists used to evaluate medical students. Branch design is described as creating “steps” or “branches” to different items rather than having a large global view of a checklist. This process was made possible by a software system installed on the palmtop called HaPerT. (HaPerT was developed privately.) Treadwell’s study had a small sample size (42) and was not large enough to generalize to larger and more diverse groups.8 Treadwell researched practical performance assessment of medical students. Faculty members used MEDs to administer objective structured clinical examinations to medical students. The focus of the research was whether an MED could produce similar assessments as paper-based formats while RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 129 ........................................................................................................... MOBILE ELECTRONIC DEVICES IN RADIOGRAPHER EDUCATION maintaining or exceeding user satisfaction.8 Guadagno et al found that entering data on the small screens was cumbersome, and research participants found that a drop-down box with choices that could be selected by tapping on them was easier to use.13 The need for training users on the device was a common challenge for many of the research groups.1,8,16,21 Most of the researchers trained users before implementation and offered support by information technology personnel during the research.1,16,21 Research that focused on student use in the clinical setting mainly let the students explore the devices themselves, with technical support available to them. Considering the amount of time that might be spent learning the devices, it may be wise to offer training on the devices before their use in educational settings. Suggestions for Further Research The small size of MEDs allows them to be taken virtually anywhere with little effort. Despite their portability, little attention has been focused on the use of MEDs in educating radiography students. Small pilot programs should be started to assess the effectiveness of the devices as instructional aids in the classroom or clinical setting. Research should focus on the effectiveness of transferring course material electronically vs by traditional paper-based systems. Is this method as effective, or even more effective? Will students use the device more readily than books and paper resources? How much infrastructure would be required to facilitate wireless communication for classroom use of these devices? Research also should focus heavily on the use of the devices in clinical settings. It would be wise to assess the effectiveness of the devices as reference tools for radiography students in clinical settings. Research using MEDs to collect data also should be considered by all branches of health sciences including nursing, radiography and physical therapy. Use of MEDs as an evaluation tool or clinical data collection device has not been sufficiently researched. Research should focus on these areas, as well as the usefulness of MED data-collecting abilities in determining a program’s progress or effectiveness. There is also room for research into whether MEDs should be in the hands of students or with clinical evaluators. Both of these groups likely can benefit from the devices. Can these devices provide redundancy with other resources to facilitate student learning? Can faculty use the devices to collect useful data about the procedure trends occurring in their clinical facilities? Is it possible 130 for students to use the devices for time management during clinical rotations? Considering the lack of research on MEDs in the education of radiography students, it is difficult to suggest one area of focus. The door appears wide open for research in this area. Conclusion MEDs — small electronic devices with functions similar to computers — have been used for several years by students and faculty alike. Use of these devices in educating medical and nursing students has been documented in several articles with mixed results. It is likely that these devices hold some value as educational tools if used appropriately by student and faculty members in a radiography program. The devices can be used for making assignments and supplying course materials, administering quizzes and tests, and conducting research in the classroom. However, care should be taken to avoid the distractions that also come with these devices. Integrating MEDs into clinical settings could provide additional educational opportunities. For example, they could be used as a resource for anatomy and positioning information for radiography students. Instead of carrying around textbooks that can take up enormous amounts of space, students could have the reference material in their pockets. The devices also may be valuable for documenting student progress or interesting cases during clinical rotations. A joint effort will be required by the faculty and information technology professionals to develop and maintain curricula that include MEDs. Research on the use of these devices in the field of radiography is extremely limited. However, research on their use in the nursing and medical professions can help guide development of MED uses in the field of radiography, improving educational processes and methods of collecting and processing important data. Although there are limitations to the devices, the benefits may outweigh the limitations. Only through persistent research can we determine whether MEDs can effectively enhance the education of radiography students. References 1. Rawlinson D, Bartel K. Implementing wireless PDA technology in the IT curriculum. Educause Quarterly. 2006;1:41-47. 2. Whitsed N. Learning and teaching. Health Info Libr J. 2006;23(1):73-75. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... APPLEGATE 3. Anderson P, Blackwood A. Mobile and PDA technologies: their future use in education. Joint Information Systems Committee Technology Watch. Joint Information Systems Committee website. http://citeseerx.ist.psu.edu/viewdoc /download?doi=10.1.1.105.6184&rep=rep1&type=pdf. Published November 2004. Accessed August 20, 2009. 4. Martino S, Odle T. New models, new tools: the role of instructional technology in radiologic sciences education. Radiol Technol. 2008;80(1):67-74. 5. White A, Allen P, Goodwin L, Breckenridge D, Dowell J, Garvy R. Infusing PDA technology into nursing education. Nurse Educ. 2005;30(4):150-154. 6. Ranson SL, Boothby J, Mazmanian PE, Alvanzo A. Use of personal digital assistants (PDAs) in reflection on learning and practice. J Contin Educ Health Prof. 2007;27(4):227-233. 7. Taylor J, Anthony D, Lavalee L, Taylor N. A manageable approach to integrating personal digital assistants into a family medicine clerkship. Med Teach. 2006;28(3):283-287. 8. Treadwell I. The usability of personal digital assistants (PDAs) for assessment of practical performance. Med Educ. 2006;40(9):855-861. 9. Honeybourne C, Sutton S, Ward L. Knowledge in the palm of your hands: PDAs in the clinical setting. Health Info Libr J. 2006;23(1):51-59. 10. Savill-Smith C, Kent P. The use of palmtop computers for learning: a review of the literature. British Journal of Educational Technology. 2005;36(3):567-568. 11. Miller J, Shaw-Kobot J, Arnold M, et al. A study of personal digital assistants to enhance undergraduate clinical nursing education. J Nurs Educ. 2005;44(1):19-26. 12.Farrell M, Rose L. Use of mobile handheld computers in clinical nursing education. J Nurs Educ. 2008;47(1):13-19. 13. Guadagno L, VandeWeerd C, Stevens D, Abraham I, Paveza GJ, Fulmer T. Using PDAs for data collection. Appl Nurs Res. 2004;17(4):283-291. 14. Scollin P, Callahan J, Mehta A, Garcia E. The PDA as a reference tool: libraries’ role in enhancing nursing education. Comput Inform Nurs. 2006;24(4):208-213. 15. Covington P, Claudepierre K. Personal digital assistants: exploration of their use in dental hygiene education and practice (evidence for practice). Canadian Journal of Dental Hygiene. 2006;40(2):80-83. 16. Fisher K, Koren A. Palm perspectives: the use of personal digital assistants in nursing clinical education. A qualitative study. Online Journal of Nursing Informatics. 2007;11(2). http ://ojni.org/11_2/fisher.htm. Accessed September 30, 2010. 17. Lee T. Adopting a personal digital assistant system: application of Lewin’s change theory. J Adv Nurs. 2006;55(4):487-496. 18. Song Y. Educational uses of handheld devices: What are the consequences? Tech Trends. 2007;51(5):38-45. 19. Wu CC, Lai CY. Wireless handhelds to support clinical nursing practicum. Educational Technology and Society. 2009;12(2):190-204. 20.Smordal O, Gregory J. Personal digital assistants in medical education and practice. Journal of Computer Assisted Learning. 2003;19:320-329. 21. McKenney RR. The next level of distributed learning: the introduction of the personal digital assistant. J Oncol Manag. 2004;13(2):18-25. 22.Ducut E, Fontelo P. Mobile devices in health education: current use and practice. Journal of Computing in Higher Education. 2008;20(2):59-68. 23.Cornelius F. Handheld Technology and Nursing Education: Utilization of Handheld Technology in Development of Clinical Decision-Making in Undergraduate Nursing Students [dissertation]. Philadelphia, PA: Drexel University; 2005. 24. Koeniger-Donohue R. Handheld computers in nursing education: PDA pilot project. J Nurs Educ. 2008;47(2):74-77. 25.Hardwick ME, Pulido PA, Adelson WS. The use of handheld technology in nursing research and practice. Orthop Nurs. 2007;26(4):251-255. 26.Luo JS, Ton H. Personal digital assistants in psychiatric education. Acad Psychiatry. 2006;30(6):516-521. 27. Stengel D, Bauwens K, Walter M, Kopfer T, Ekkernkamp A. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records. J Bone Joint Surg. 2004;86(3):553-560. 28.Kho A, Henderson LE, Dressler DD, Kripalani S. Use of handheld computers in medical education. A systematic review. J Gen Intern Med. 2006;21(5):531-537. 29.Sandars J, Pellow A. Handheld computers for work based assessment: lessons from the recent literature. Work Based Learning in Primary Care. 2006;4:109-115. Jason S Applegate, MSRS, R.T.(R)(CT), CNMT, is an assistant professor of imaging sciences at Morehead State University in Morehead, Kentucky. He wishes to thank the faculties of Midwestern State University and Morehead State University Imaging Sciences Departments for their guidance and support. Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail [email protected]. ©2010 by the American Society of Radiologic Technologists. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 131 CE ....................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . DIRECTED READING Domestic Violence Bryant Furlow, BA Domestic violence is a neglected epidemic in the United States that affects millions of children and adults and leads to a sizable proportion of emergency department visits — and possibly the majority of nonfatal injuries among women. Health care encounters represent the most promising opportunities for identifying victims and intervening in patterns of abuse, and all health care professionals have an ethical obligation to help identify cases of abuse. In this Directed Reading, the epidemiology and outcomes of domestic violence are introduced, screening methods and reporting requirements are reviewed, and the roles of diagnostic imaging in detecting and characterizing frequently neglected but common domestic violence injuries are discussed. This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your area of interest. For access to other quizzes, go to www.asrt.org /store. After completing this article, readers should be able to: n Identify the types of and risk factors for domestic violence. n Explain the health care barriers to identifying domestic violence. n Describe the roles of diagnostic imaging in confirming physical domestic abuse in children and adults. n Explain patterns of injuries suggestive of domestic violence and the signs of shaken baby syndrome. n Summarize the effects of domestic violence on victims’ health and behavior, including child development. n Describe screening strategies used to identify domestic violence victims. n Explain health care workers’ screening and referral responsibilities, and states’ mandatory reporting requirements in suspected cases of domestic violence. D omestic violence includes child abuse, elder abuse and intimate partner violence (IPV). It represents both a major human rights abuse and a significant public health challenge, directly affecting millions of Americans’ lives and contributing to violence, adverse health outcomes, lost economic opportunities and substance abuse problems across the nation.1,2 Although gang conflict and stranger violence make headlines, the majority of interpersonal violence is domestic violence.3 IPV is the leading cause of nonfatal injuries among women in the United States; more than half of women’s visits to emergency departments result from domestic violence, and the lifetime risk of IPV for American women is as high as 50%.1,4-6 Child and elder abuse represent criminal aggression against dependent infants, children and elderly adults, respectively. IPV is criminal aggression occurring between married or unmarried partners RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 and is defined as physical, sexual or psychological harm by a current or former intimate partner or spouse.7,8 In the public health and medical literature, IPV generally excludes dating violence and acquaintance sexual assault. However, some suspected risk factors for dating violence and IPV (such as age and sex) overlap, and it therefore appears likely that victim populations also overlap.9 Because intimidation and threats are commonly integral to the pattern of domestic violence, victims are frequently reluctant to speak out. Domestic violence includes verbal coercion and the threat of violence, physical assaults and attempted or completed murder. Domestic violence is often systematic — a prolonged pattern of violence rather than an isolated incident — and frequently is perpetrated in an effort to exert control over the victim. It often escalates in severity over time; a leading risk factor for IPV homicides, for example, is previous, less serious IPV.10 133 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE Diagnostic imaging plays a potentially important role in confronting the domestic violence epidemic. First, all health care personnel have an ethical responsibility to identify and intervene in cases of abuse, although the most appropriate form of intervention remains controversial. Radiologic technologists and radiologist assistants are in a position to identify evidence of physical injuries resulting from domestic violence that may be missed by other health care providers. Particularly in the case of infants, young children and some elderly patients who may be unable to describe their abuse, imaging can play a crucial role in detecting and characterizing injuries. Health care professionals are also better equipped than many other potential interveners to deal with the denial, fear and anger that result from patients’ pain and distress and to respond to hostility with empathy. Second, diagnostic imaging plays a potentially important role in documenting the effects of suspected abuse, and the radiology report and proper documentation of evidence of abuse in the patient record can represent a significant source of forensic evidence in the legal prosecution of domestic violence cases.11 Fulfilling those roles requires an understanding of the: ■ Psychological, linguistic and cultural barriers to intervention. ■ Locally available resources for victims. ■ Patterns of injury resulting from IPV. ■ Screening strategies and their limitations. ■ Psychological and health sequelae of this pervasive problem. Although gunshots and stabbings are tragic and frequent outcomes of domestic violence, particularly IPV, these types of injuries are not discussed in this Directed Reading. Nor will this Directed Reading detail sexual trauma, which is largely assessed through clinical examination, or the diagnostic imaging techniques for postmortem autopsy assessments. Instead, emphasis is placed on more cryptic or ambiguously abuse-related musculoskeletal and neurologic injuries among survivors. Epidemiology and the Ecological Model of Domestic Violence The effects of violent acts and patterns of abuse ripple through the lives of victims, abusers, their families, communities, economies and society at large.3 As described in the following text, victims of domestic violence represent the obvious epicenter of these effects, which include profound degradation of quality of life, 134 neurologic or other injuries with lifelong effects, adverse health outcomes and behaviors, and the less readily quantified effects of chronic stress and post-traumatic stress disorder (PTSD) that can continue years after the victim has escaped an abusive relationship.12 In addition, that harm contributes to social ills outside the home, from poor educational and employment performance and increased medical costs to higher rates of abuse of street drugs and prescription medications. Just as the effects of domestic violence ripple throughout communities, its roots are multivariate and complex, and are not limited to the abusive household. Although widely considered to be a crime that occurs behind closed doors, many sociologists consider domestic violence to be the result of multiple intersecting factors involving the victim, the abuser, their relationship and socioeconomic status, families, community, culture and society at large. Domestic violence involves varying attitudes and levels of awareness among abusers’ peers, law enforcement and health care institutions.7,13,14 This “ecological” model of domestic violence subsumes more restrictive psychopathologic models that focus on risk factors regarding abusers and victims; the model also provides more opportunities for intervention than a closed-door model because any member of the community who encounters signs of abuse can help empower victims to escape their abusers.3,15 Home-visit programs during and soon after pregnancy, child welfare and social service visits, and employer referrals to IPV assistance programs are examples of intervention.8,15,16 Contact with health care professionals is an obvious opportunity to identify and intervene in domestic violence, whether or not contact results directly from abuse-related injuries. It is therefore the responsibility of all health care professionals to be aware of the problem and its signs, and to recognize opportunities to identify and responsibly intervene in possible cases of domestic violence. Typology of Domestic Violence The Centers for Disease Control and Prevention (CDC) identified 4 broad domains or types of domestic violence and described to varying degrees the range of child, elder and partner abuse.17 These types are: ■ Physical violence: traumatic assaults involving the intentional use of physical force that could or do cause injury, disability or death. Examples include strangling, slapping, shoving, scratching, throwing, grabbing, biting, burning, stabbing, shooting or restraining the victim. A leading November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING form of physical violence against infants is shaking, which can profoundly injure the infant’s brain and spinal cord in assaults as brief as 5 seconds and result in shaken baby syndrome. ■ Sexual violence: physically coercing sexual acts with the victim (molestation and rape); sexual conduct with individuals unable to understand the act or to refuse participating in the act, or unable to communicate their unwillingness to engage in the sexual act because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; or any abusive sexual contact with the victim. ■ Emotional and psychological violence: traumatic violence or threats of violence used to coerce and terrorize the victim. ■ Psychological and emotional abuse: humiliating or demeaning the victim, withholding access to resources (such as money) to increase the victim’s reliance on the abuser, and otherwise isolating a victim from social support outside the abusive relationship. The CDC also notes that stalking is considered a fifth type of IPV (but not other forms of domestic violence).17 Stalking generally refers to repeated harassing or threatening behavior, such as following the victim or appearing at the victim’s home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing her or his property.17 Although stalking behavior has not been well studied, it has been tied to acts of physical violence and homicide and always should be taken seriously. Prevalence and Risk Factors Linguistic and cultural barriers complicate efforts to quantify and study domestic violence.18 A recent systematic review of published studies found that reported lifetime prevalence of IPV for women in the United States varied from 1.9% in Washington state to 70% among Hispanic women in the southeastern states, for example.18 However, significant ascertainment bias issues confound such assessments, which are frequently based on data from psychiatric and gynecologic trauma clinics — patient populations in which IPV victims appear to be over-represented compared with other populations.18 There also are numerous controversies in the research community surrounding the definitions and measurement of domestic violence and its risk factors, such as survey and sampling methodology, that complicate quantifying the different forms of domestic violence.3 Inconsistencies between data on the proportions of victims and perpetrators who are women are difficult to reconcile and may reflect different sampling and survey methodologies. Intimate Partner Violence IPV against women represents an epidemic in many U.S. communities, and the 1994 U.S. Violence Against Women Act recommended examination of the epidemiology and incidence of IPV.1,18 However, because IPV is an under-reported and underdetected crime, incidence rates have been very difficult to estimate accurately, and different ascertainment systems yield different estimates of prevalence and incidence. Several surveillance systems attempt to capture data regarding the frequency and nature of IPV. Existing CDC estimates based on the National Crime Victimization Survey data for cases reported to law enforcement indicated that at least 467 000 Americans are victimized annually by IPV crimes.19 However, because this number is based only on reported crimes that led to the involvement of law enforcement agencies, it very likely vastly underestimates the real incidence of these crimes.7 Academic researchers have estimated that 1 million women suffer physical IPV each year.20 Between 65% and 80% of reported IPV victims overall are believed to be female, although thousands of heterosexual and homosexual men also fall victim to these crimes each year.7 Girls and women of childbearing age, particularly between the ages of 16 and 24 years, are at greatest risk for IPV; however, women of all ages are abused by their partners.8 There is some evidence that the severity of IPV assaults on African American women are frequently more severe and involve increased risk of head and brain injuries than other victim populations.21 It is surprising that despite the over-representation of girls and women in IPV victimization rates, some authors argue that differences in IPV perpetration rates by men and women are unclear or do not exist.3 For example, the National Family Violence Survey, based on self-reporting by women of their own and their partners’ violent behavior, reported nearly identical rates of assault by men and women.3 IPV is frequently bidirectional, involving retaliation by the victim or mutually abusive relationships.3 Bidirectional IPV ranges from 59% to 71% among couples with any history of violence, with women initiating physically violent interactions as frequently as do men.3 Some authors have argued that this represents evidence RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 135 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE against a self-defense model of female-initiated IPV incidents, but the available studies do not control for which partner first introduced violence into the relationship, or the possible role of anticipatory selfdefense by women who recognize the antecedent behaviors of physical violence. Meta-analyses pooling data from studies of sex differences in violence (including but not limited to IPV) found that physical aggression is more common among men regardless of age and culture, although the sex difference in violent behavior peaked between ages 20 and 30.22 One possible explanation for the seeming inconsistency between similar rates of IPV perpetrated by men and women on the one hand, and the over-representation of women among IPV victims on the other, is that violence against women may be more severe and thus may more frequently lead to hospitalization or the involvement of law enforcement agencies. Another explanation may be ascertainment inconsistencies for one or more of the datasets on which reported patterns are based. The CDC’s National Violent Death Reporting System, active in only 16 states, lists 1200 confirmed IPV-related homicides for 2005, an incidence rate of 0.8 per 100 000 Americans.7 African American and American Indian populations have significantly higher IPV death rates than other ethnicities: 1.5 per 100 000 and 2 per 100 000, respectively.7 Risk factors for IPV homicides include perpetrator access to a firearm, previous threatening by the perpetrator of the victim with a weapon, recent separation and the use of illicit narcotics by the perpetrator or victim.7 Physically and mentally disabled women are more likely to experience IPV. Other reported risk factors for IPV include intermittent perpetrator employment or recent unemployment and perpetrator education level lower than high school completion.1 Physical abuse of animals is associated with perpetrators’ IPV risk; women whose partners threaten or batter pets are 5 times as likely as other women to suffer IPV.23,24 Verbal abuse and male domination also have been reported as risk factors for physical IPV, but a recent systematic review of 11 studies found that recall bias, selection bias and resulting overestimations of such correlations are difficult to rule out.25 The CDC lists several risk factors, but does not detail the empiric strength of the evidence on which the list was based, other than stating that perpetrators’ own psychological abuse is consistently “one of the strongest predictors” of perpetrating IPV.19 Aside 136 from perpetrator histories of psychological abuse and poor or violent parenting as children, the CDC’s list of perpetrator risk factors includes: ■ Individual (perpetrator) risk factors: low selfesteem, low income, young age, aggressive behavior as a child or teen, heavy alcohol and drug use, depression, anger, hostility, antisocial or borderline personality disorders, history of physical abusiveness, social isolation, emotional insecurity, desire for control and belief in strict gender roles. ■ Relationship risk factors: marital conflict; marital instability (separations, recent divorce); dominating or domineering control of relationships; and economic stress or hardship. ■ Community, cultural and societal factors: poverty; crowding; low “social capital” (few institutions, support networks or social norms discouraging IPV); weak community sanctions (eg, neighbors’ reluctance to call the police); sexism and traditional gender norms (eg, beliefs that women should stay at home, avoid employment and be submissive, or that men should make household and economic decisions). A more accurate and precise picture of IPV rates may emerge in the near future. The National Intimate Partner and Sexual Violence Surveillance System (NISVSS) is a long-anticipated collaborative initiative started in 2010 by the CDC, Department of Defense and National Institutes of Justice.19,26 The NISVSS will collect population-based survey data in English and Spanish to provide more accurate and reliable incidence and prevalence estimates for IPV, sexual violence and stalking crimes in the United States.26 The program also will attempt to identify the frequency of these crimes in understudied American Indian and Alaska Native populations, female military personnel and military spouses.26 Child Abuse Violence directed at children and child neglect by parents is, like IPV, believed to be an underreported crime. Methodologic differences between studies further complicate quantification of the problem because some researchers include neglect and other forms of maltreatment, such as shouting, in definitions of child abuse, whereas others include only physical or sexual abuse.3 The World Health Organization includes neglect and commercial exploitation of children in its definition of child abuse, and also includes human rights verbiage about the dignity of the child, the abuse November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING of trust and the responsibility of the adult caregiver.3 The prevalence of child abuse in the United States is based primarily on data from law enforcement and social service agencies.3 Data from child protective service agencies suggest that more than 906 000 American children are victims of abuse or neglect each year, which represents an incidence rate of 12.4 per 1000 children.3 That estimated incidence rate was based on an estimated 2006 U.S. population of 307 million children. Of these, approximately 19% were physically abused, and 10% were sexually abused.3 Neglect represents 60% of child abuse cases. Infants and young children (younger than 3 years of age) suffer higher rates of abuse than older children (16.4 per 1000 vs 12.4 per 1000 for all ages).3 However, these statistics include nondomestic forms of child abuse, such as nonparent caregiver abuse, abuse by teachers, neighbors and strangers. Overall, parents are the perpetrators in 80% of child abuse cases.3 Girls are 4 times as likely to be sexually abused as are boys.3 Each year, approximately 1500 American children die as a result of physical abuse or neglect.3 The vast majority of child abuse deaths, 79%, involve children younger than 4 years of age.3 Federal statistics on child abuse are available online at http:www.acf.hhs.gov /programs/cb/pubs/cm08/cm08.pdf. Risk factors for child abuse include family poverty and economic stress, male perpetrator, low self-esteem of perpetrator, low levels of empathy and impulse control among perpetrators, young victim age (younger than 3 years old), and victim’s disability or medical complication. Low perpetrator educational attainment is a risk factor for child sexual but not physical abuse.3 Importantly, IPV appears to increase the risk of physical violence toward children.3 Community and cultural effects also have been identified; immigrant communities with extensive neighborhood ethnic social networks have lower rates of child abuse — even in impoverished neighborhoods.3 This is consistent with findings linking social isolation and small support networks with increased maternal abuse of children.3 Elder Abuse Elder abuse appears to be even more under-reported than child abuse or IPV. The research literature on elder abuse is relatively scant, but benefits from a consistent definition that includes neglect; this definition has been officially adopted by the International Network for the Prevention of Elder Abuse: “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.”3 The majority of research on elder abuse involves institutionalized patients in long-term, assisted-living facilities rather than domestic violence. In addition to verbal, physical and sexual abuse, elder abuse includes financial exploitation and medical-nutritional neglect.3 Between 700 000 and 2.5 million American elders are physically or sexually abused annually.27 Risk factors for elder abuse have not been as well investigated as those for IPV and child abuse, but appear to include factors that increase the needs of victims and demands on caregivers’ time, including advanced victim age, illness, disability and coresidence. History of violence in other relationships increases the risk of becoming a perpetrator of elder abuse.3 Mental illness, social isolation and substance abuse are other reported perpetrator factors.3 Victim Outcomes Domestic violence represents the most pervasive form of human rights abuse in the United States today. Victims’ quality of life and health status can be profoundly affected by domestic violence, and these effects ripple throughout society, the health care system and the economy. Published studies suggest IPV victimization may affect parenting skills, coping skills, employment and the success of subsequent intimate relationships. It also increases the risk of sexually transmitted disease and impairs cognitive performance and immune function.6,28 Victimization commonly leads to chronic or severe headaches, confusion, anxiety, fear, clinical depression and suicidality.6 As described in the following text, childhood abuse (and possibly childhood witnessing of IPV) can have lifelong neurologic and developmental impacts, including seizure disorders.29 Long-term physical and psychiatric sequelae contribute to prolonged need for health care, even among victims who are no longer in an abusive relationship. PTSD is common among IPV victims and abused children, as are traumatic brain injuries (TBIs). The health-specific outcomes of domestic violence, although poorly studied, are clearly many, complex and potentially profound. IPV is associated with an increased risk of human immunodeficiency virus/ acquired immunodeficiency syndrome infection, particularly among African-American women.30 Women with a history of IPV are more than twice as likely to report disabilities, including chronic pain, heart and RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 137 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE circulatory disease, back problems, arthritis, asthma and depression.31 IPV injuries are a dose-dependent risk factor for disabilities and chronic pain; women with more injuries directly attributable to physical IPV also report more chronic pain and other disabilities.31 IPV-victimized women use roughly twice (1.6 to 2.3 times) the health care resources used by non-IPV victims when health conditions and comorbidities are statistically controlled, but are significantly less likely to participate in screening for cervical or breast cancer.32,33 (One study found that hospitalization rates for IPV victims were 3.5 times higher than rates for nonIPV victims.34) Although IPV victims consume more health care resources than others, they are more likely to have negative interactions with health care professionals and are less likely to receive the health care services they need.6 Many hospitals lack the resources and programs, or even a consistent strategy, for helping the victims of domestic violence.6 Progress in health care assistance for IPV victims has been described as “limited.”6 IPV frequently occurs in front of (and frequently involves parallel or simultaneous victimization of) children in the home. Witnessing IPV is defined in many states’ laws and regulations as a form of child abuse, even in cases in which the child is not directly targeted by the perpetrator. However, studies have found that child welfare–related social services detection of IPV and interventions on behalf of the child do not always involve interventions that address IPV itself. 8 Children exposed to pet abuse are more likely to witness IPV of a parent as well, and are more likely to abuse companion animals than children from nonviolent homes.23,24 Boys raised in homes where IPV occurs appear to be more likely to become IPV perpetrators as adults. 35 The developmental and physiologic effects of IPV on children are evident as early as infancy in the form of abnormal attachment relationships; these effects may well begin before birth, with prenatal exposure to circulating maternal stress hormones and altered immunologic development in offspring. 8,36 IPV in the home has been identified recently as a risk factor for unstable child residential histories, substandard childhood housing, childhood asthma and preschool obesity — even after economic and family structure factors are statistically controlled. 37,38 Children who are abused or exposed to IPV suffer neurodevelopmental and cognitive development disruptions, including lower IQ scores. 39,40 138 Shaken Baby Syndrome Infants and children as old as 5 years, when vigorously shaken for as few as 5 seconds, can sustain neck, spine, eye and brain injuries resulting in shaken baby syndrome.40 Infants typically are shaken to quiet a crying spell, and the results can be catastrophic. Shaking can slam the brain against the skull repeatedly, causing brain contusions (bruising), swelling, pressure and bleeding.40 Tearing of meningeal veins along the brain’s exterior can cause bleeding and increased intracranial pressure, leading to permanent brain damage or death.40 Because infants’ heads are relatively large compared with their bodies and their neck muscles are poorly developed, shaken infants are prone to developing whiplash injuries to the muscles of the neck.40 Rib fractures, retinal detachment or bleeding in or around the eyes are commonly seen in shaken babies.40 However, behavioral symptoms may occur without any outward physical signs of injury such as bruising or pale or bluish skin. These include: ■ Seizures or convulsions. ■ Sudden extreme irritability. ■ Decreased alertness, lethargy, sleepiness and a failure to smile. ■ Coma or unconsciousness. ■ Loss of vision. ■ Lack of appetite or vomiting. Post-traumatic Stress Disorder IPV and child abuse are risk factors for posttraumatic stress disorder, a syndrome involving reduced emotional control, impaired memory and cognitive speed and function.41 The severity of PTSD symptoms is associated with the severity of domestic violence, and also is associated with higher reported levels of chronic pain among survivors.42 Wuest et al advised that the correlations are strong enough to justify routine assessment of pain clinic patients with PTSD symptoms for domestic violence.42 Child abuse–related PTSD and brain injuries may similarly disrupt brain structures and function. A 2005 meta-analysis pooling data from 9 studies of magnetic resonance (MR) imaging volumetric measurements of the hippocampus — a brain region involved in short-term memory and cognitive performance — found that chronic adult PTSD is associated with smaller hippocampal volumes.43 A larger 2008 meta-analysis of data from 19 brain imaging studies found that although PTSD resulting from childhood abuse is not associated with impaired hippocampal November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING growth during childhood, hippocampal volumes are significantly smaller among adults with childhood abuse–related PTSD compared with healthy controls.44 The meta-analysis also found atypical asymmetries between the right- and left-hemisphere hippocampus in adults with childhood abuse–related PTSD.44 The authors from the aforementioned study suggested that disruption of hippocampal developmental pathways does not yield volumetrically measurable effects until adulthood, years after exposure to traumatic abuse. More subtle hippocampal damage may be evident earlier in childhood, however, and may underlie the association between domestic violence and reduced child IQ noted previously. The authors also cautioned that their metaanalysis should be considered a preliminary finding until confirmed by longitudinal studies.44 (For example, it is possible that individuals with atypical adult hippocampus anatomies are more susceptible to developing PTSD.) Patterns of Physical Injury There is a long and controversial history of efforts to identify hallmark injuries or patterns of injuries for domestic violence screening purposes, an effort motivated by the very frequent false attribution by victims and perpetrators of victims’ injuries to household falls and other accidents. Relatively simple statistical models can differentiate accidental injuries from those resulting from IPV (eg, using age and injury patterns). However, these models differentiate probabilistically, and results do not represent proof of abuse in any given case.5 Generally speaking, most studies suggest that head, face and neck injuries are more indicative of domestic violence than other injuries. A systematic review and meta-analysis of 7 studies of physical injury patterns and IPV, published in 2010 by McMaster University researchers in Ontario, Canada, compared IPV head, neck and facial injuries with verifiable accidental injuries from witnessed falls or motor vehicle accidents.45 The authors found that IPV victims were 24 times as likely as accident victims to have head, neck and facial injuries, compared with women with injuries from verifiable accidents. In contrast, thoracic, abdominal and pelvic injuries were not more or less likely among IPV victims, and injuries to arms and particularly legs were significantly more likely to have been sustained during verifiable accidents than IPV.45 The authors concluded that unwitnessed head, neck or facial injuries are significant red flags for IPV, whereas extremity injuries alone are not indicative of IPV.45 The findings were consistent with previous findings that head and neck injuries are the most common injuries among women attending domestic violence counseling; the findings also support previous findings based on smaller emergency department data sets and calls in the medical and dental literature for both dentists and emergency department personnel to screen women with facial, head and neck injuries for IPV.4,46,47 Injuries to the soft tissues of the midface and the lower third of the face are the most common form of head and face trauma among female IPV victims.48 It is not surprising that, given the frequency of assaults targeting the head and face, brain injuries are common among IPV and child abuse victims, and neuroimaging is indicated in suspected cases of domestic violence victimization involving blows to the head or face. Strangulation, a life-threatening injury, commonly is associated with IPV. The victim is almost always a female partner. Strangulation always should trigger screening evaluations for domestic violence victimization and imaging examinations of the neck and brain. Strangulation assaults can be manual (the perpetrator uses the hands to cut off the victim’s air and blood supplies), ligature (using an object to strangle the victim) or involve a forearm choke hold.49 Strangulation tends to occur late in an abusive relationship, and may represent the fatal or near-fatal culmination of a progressively violent and dangerous pattern of IPV. 50 Fatal and nonfatal attacks have very similar patterns of injuries, which suggests similar intensities of violence. 50,51 Strangulation is an under-reported form of physical IPV. One 2001 study found that victims of multiple strangulation attacks by the same IPV perpetrator suffered throat and neck injuries, neurologic disorders and psychological sequelae; but as few as 39% of victims had sought medical care.51 Victims should be interviewed carefully about their stream of consciousness during the attack to determine the victim’s state of mind and the likelihood of loss of consciousness during the assault. Survivors report characteristic stages of thought patterns during the last moments of consciousness.52 These are: ■ Denial: A disconnected state of unreality prompting descriptions like “I couldn’t believe it was happening” or “It was like I was watching it on TV.”52 ■ Realization: Victims quickly come to terms with the reality that they are about to die. ■ Primal: Realization that death may be imminent prompts a frantic struggle to regain air supply. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 139 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE ■ Resignation: Unsuccessful resistance leads to the victim’s recognition that she has been overpowered and that she is likely to die, described by survivors as, “This is it — this is how I die.”52 All mothers surviving these attacks invariably reported during clinical interviews their final thoughts as being about who was going to care for their children. 52 Head, neck and face trauma alone are not reliable proof of domestic violence. The sensitivity of head, neck and face trauma for IPV (ie, accurate IPV-positive results) has been estimated to be 91%, but specificity (accurate IPV-negative results) is only 59%.53 Therefore, these injuries should be considered a trigger for questionnaire-based screening, described later in this article. Bruises exceeding 5 cm in diameter on the face, lateral right arm or back (posterior torso) are indicative of physical abuse.54 It is surprising that the McMaster University metaanalysis also found that multiple injuries occur significantly more often — up to 15 times as frequently — among victims of IPV than accident victims.45 A study of women’s injuries resulting from IPV and other assaults found that non-IPV assaults typically cause a single injury, whereas the median number of injuries for IPV assaults was 3.55 Traumatic Brain Injuries Because more than 80% of women treated for IPV injuries have facial and head trauma, it is very likely that a large proportion of these patients have sustained some degree of TBI. TBI has been described as “one of the most serious, prevalent and often undiagnosed results” of IPV.21 However, few suspected IPV victims are screened for brain injuries or neuropsychological effects.56 Like domestic violence, TBI is a dramatically under-reported type of injury; some studies suggest that as many as 85% of TBI cases go undiagnosed.57 Transient loss of consciousness and amnesia occurring with skull fracture or brain lesion that is confirmed by computed tomography (CT) or MR imaging is a common form of TBI called concussion.58 The severity of TBI can be assessed by the presence of concussion symptoms such as drowsiness, mood disorders, anxiety, seizures, chronic headache, blurred vision, nausea, insomnia, dizziness, memory lapses, concentration and attention deficits and sensitivity to noise or light.58 Delayed recall and amnesic or “blank” memories of events causing injury are signs of concussion, which is indicative of moderate TBI. African-American 140 IPV victims with clinical evidence of head injury may be at particular risk because of a greater severity of the violence reported for this population.21 Pediatric Patterns of Injury Pediatric head injuries resulting from physical abuse appear to have significantly worse outcomes than accidental head trauma, with near-universal CT- or MR-detectable brain atrophy and cerebral ischemia in 50% of abuse-related TBI cases.59 Subdural hematomas and meningeal bleeding are common results of physical assaults on infants and young children.60,61 Bone fractures are one of the most common findings in child abuse victims, following bruises and brain contusions.62 Multiple pediatric bone fractures, particularly when different rates of healing are evident, and any bone fractures in children with burn injuries, are suggestive of child abuse, and these findings should result in screening and skeletal fracture surveys.63,64 Multiple rib fractures are relatively rare in adult IPV victims, but such findings are a red flag for shaking, kicking or punching assaults on children (see Figure 1).63 However, rib fractures are less indicative of assault among children from France and other countries in which kinesitherapy is widely practiced because chest compression used in kinesitherapy is known to sometimes cause rib fractures.64,65 Multiple rib fractures that exhibit different stages of repair and healing are suggestive of a pattern of domestic violence, whether the patient is a child or an adult, male or female.63 (Sternal fractures may not be as rare among children as believed because of the difficulty of detection on standard chest radiographs, and they are not alone strongly indicative of abuse.66 Screening Consistent active screening is necessary to detect most cases of domestic violence.6 It is widely agreed that women with unwitnessed injuries to the head, neck or face — or who have multiple injuries — and children who have multiple bone fractures should be screened or assessed for domestic violence victimization.45 Numerous health care professional organizations recommend IPV screening, including the American Medical Association, American Nursing Association and American Congress of Obstetricians and Gynecologists.6 Many — but not most — hospitals have policies to screen for suspected domestic violence, but fewer have developed the cultural and linguistic resources or November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING Figure 1. Multiple rib fractures in different stages of healing in an infant victim of child abuse. Red and green arrows indicate rib fractures sustained at different points in time. U.S. National Institutes of Health. Public-domain U.S. government figure available at: http://commons.wikimedia.org/wiki/File:Fractured_ribs. jpg. Accessed September 9, 2010. domestic violence expertise to assist victims.67 Detected cases are sometimes referred to other institutions, such as battered women’s shelters, counseling services or social service agencies outside the heath care setting. Very frequently, even disclosed or confirmed cases of domestic violence victimization are not properly documented or referred to appropriate treatment or social services.6 Well-intentioned victim profiling by health care workers tends to emphasize patients’ age, ethnicity, income level and educational level — an approach that may lead to underscreening and underdetection of white, middleaged and middle- or high-income women.6 Numerous health care screening tools have been proposed to aid in identifying probable cases of IPV victimization among trauma patients, but few have been developed for languages other than English or Spanish; and few exist specifically to identify elder abuse victims.68 These instruments are reviewed in this section. However, it should be kept in mind that most studies have not directly assessed the validity of screening instruments or studied the efficacy of health care screening for domestic violence in reducing the frequency or severity of that violence.67,68 Instead, most studies use endpoints such as referral to social services, shelters or law enforcement.68 Current interventions include victim (battered women’s and children’s) shelters; confidential mail drop services or mail forwarding services operated by some Secretary of State offices to help abused women hide their current physical location; court-issued restraining orders preventing perpetrator contact with victims; prosecution and/or treatment and counseling for perpetrators; marital counseling and therapy; and preventive monitoring (eg, home visits by social services agency personnel).3 Screening instruments are vulnerable to recall bias, and are therefore designed to capture information only about the patient’s experiences over the previous 12 months.69 The Partner Violence Screen questionnaire is the simplest screening tool, which requires approximately 20 seconds to administer orally.70,71 It consists of 3 yesor-no questions with 1 follow-up question: 1. Have you been hit, kicked, punched or otherwise hurt by somebody in the past year? If yes, by whom? (current relationship/previous relationship/other) 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is making you feel unsafe now? The Hurt Insulted Threatened or Screamed at (HITS) instrument has 4 questions. Each is answered on a 5-point scale from 1 (never) to 5 (frequently): 1. How often does your partner physically hurt you? 2. Insult or talk down to you? 3. Threaten you with harm? 4. Scream or curse at you? (HITS is available online at www.healthyplace.com /psychological-tests/domestic-violence-screening-test/.) The longer, 8-item Woman Abuse Screening Tool (WAST)72 asks: 1. In general, how would you describe your relationship? (a lot of tension/some tension/no tension) 2. Do you and your partner work out arguments with (great difficulty/some difficulty/no difficulty) 3. Do arguments ever result in your feeling put down or bad about yourself? (often/sometimes/never) 4. Do arguments ever result in hitting, kicking or pushing? (often/sometimes/never) RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 141 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE 5. Do you ever feel frightened by what your partner says or does? (often/sometimes/never) 6. Has your partner ever abused you physically? (often/sometimes/never) 7. Has your partner ever abused you emotionally? (often/sometimes/never) 8. Has your partner ever abused you sexually? (often/sometimes/never) A shorter version, called the short-WAST, asks only Questions 1 and 2 from the preceding list.71 Combining injury location data (head, neck and face involvement or other) with either the Partner Violence Screen or short-WAST questionnaires yielded similar proportions of respondents reporting IPV.71 Even longer instruments, such as the 30-question Composite Abuse Scale, also are available.73 Although studies have shown that these screening instruments result in women disclosing IPV histories, very few studies have extensively validated the instruments or compared their relative efficacy. One randomized trial undertaken by the McMaster Violence Against Women Research Group in Ontario, Canada, compared interview-based, computer-based and paper questionnaire-based screening of emergency department, family practice and women’s health clinic patients using 3 instruments in each group: the Partner Violence Screen, the WAST and the 30-item Composite Abuse Scale.69 No significant differences were found in the IPV prevalence indicated by the different instruments or presentation methods, although women in this study preferred computer and paper self-administered questionnaires over interviews.69 A separate study conducted in Tennessee reported that patients preferred interview-style screening and the WAST, and that the Partner Violence Screen was the least-preferred approach.74 Regional and individual variation in preferences may suggest that patients should be offered a choice: After a brief oral explanation of the health professional’s concerns, the patient could be asked whether she or he would prefer to complete a written questionnaire or to talk it over. Most studies indicate, however, that most women do not object to being asked about domestic violence and that most victims disclose their abuse when asked.6 Traumatic Brain Injury Screening Simple questions about the frequency and severity of blows to the face and head, and resulting memory lapses or losses of consciousness, can identify domestic violence victims who are at greatest risk of having suffered TBIs.57 142 The “HELPS” mnemonic screening instrument is a widely used TBI tool.75 It asks: 1. H: Have you ever been Hit on your Head or Hit your Head? 2. E: Were you ever seen in the Emergency room, hospital or by a doctor because of an injury to your head? 3. L: Did you ever Lose consciousness or experience a period of feeling dazed or confused because of an injury to your head? 4. P: Do you experience any of these Problems in your daily life since hitting your head? Headaches; dizziness; anxiety; depression; concentration difficulties; difficulty remembering; difficulty reading, writing or calculating; poor problem-solving; difficulty performing your job/ school work; changes in relationships with others; poor judgment (being fired from jobs, arrested, fights)? 5. S: Have you any significant Sicknesses? Affirmative answers to items 1 (H), either 2 (E) or 3 (L), and the presence of 2 or more problems from item 4 (P) represent a positive indication for TBI. A positive HELPS screening result is not sufficient to diagnose TBI, but it does indicate that further clinical and diagnostic imaging examination is warranted.57 A June 2010 search of the medical literature yielded no validation studies regarding the use of the HELPS instrument for domestic violence victims. In addition to the HELPS questionnaire for assessing whether TBI is likely, the Glasgow Coma Scale commonly is used to assess the severity of TBI. The Glasgow scale was designed to be used repeatedly over time to track patient cognitive recovery or decline.58 This scale ranks TBI severity by assessing a patient’s eye opening activity and motor and verbal responses to commands and conversations (see Table 1).58 Because TBI involves both focal and diffuse trauma to different brain tissues and regions, it results in diverse and complex neuropsychological and behavioral symptoms, which complicates diagnosis and care. When TBI is suspected, CT or MR brain imaging is indicated to identify life-threatening trauma and to document and characterize the number and severity of brain injuries.58 Screening for Infant and Child Abuse Older children may be asked how injuries were sustained but should not be closely questioned without a child psychiatrist or psychologist. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING Table 1 Glasgow Coma Scale Scoring58 Eye Opening (E) 1 = None 2 = In response to pain 3 = In response to speech 4 = Spontaneous Motor Response (M) 1 = None 2 = Extensor response 3 = Abnormal flexion 4 = Withdrawn 5 = Localized response 6 = Obeys Verbal Response (V) 1 = None 2 = Incomprehensible sounds 3 = Inappropriate words for conversation 4 = Confused conversation 5 = Oriented Note: Glasgow Coma Scale score = E + M + V; range of possible scores is 3 to 15. Diagnostic imaging plays an important role in screening infants and young children for domestic violence victimization. Infants and young children cannot describe their abuse, and symptoms such as vomiting, fever, lethargy, seizures or coma are nonspecific to assault and alone do not constitute strong indications for child abuse screening. But in the presence of head injuries or bruising of the face, neck, or chest — particularly when inconsistent with the presenting injury or the history of the injury as provided by the parent — these may indicate child abuse.64 Unexplained injuries, particularly head injuries, bone fractures, bruising of the neck or face, burns and delayed care seeking by parents are all suggestive of child abuse.64 Because no self-reporting instrument is available for suspected child abuse victims, a radiographic skeletal survey is undertaken to characterize the number, timing and severity of bone fractures, and CT or MR brain imaging is performed to screen for TBIs. Approach and Patient Preparation Health care visits represent a major opportunity to identify and intervene in patterns of domestic violence.6 But barriers to detection prevent the effective use of that opportunity, and all too often, health care encounters that should serve as gateways to intervention become just another barrier.6 Barriers to identifying abuse include victims’ fearfulness, inadequate training of health care workers to recognize or assess suspected cases, insufficient staffing and other resources at health care facilities, linguistic barriers, cultural barriers such as gender norms or cultural tolerance of domestic violence, and social isolation of the victim.6 The presence of the suspected abuser is another significant barrier to identification and intervention in suspected cases of IPV and domestic violence, and few hospitals have explicit policies to separate suspected victims of domestic violence from suspected abusers for screening purposes. Health care professionals are busy and frequently fail to screen, refer or report suspected cases of domestic violence. This is partly due to an underappreciation among many health care professionals and medical and nursing students for how pervasive domestic violence is. For example, a recent survey of orthopedic surgeons in Canada revealed that 80% believed fewer than 1% of women experience IPV.4 Surveys also have revealed that health care professionals commonly hold victim-blaming attitudes or a reluctance to risk offending suspected victims by asking about victimization.6 It is important that health care personnel exhibit empathy, respect and concern; create an environment of support and confidentiality; and avoid expressions, comments or gestures that may communicate judgment or indifference to a suspected victim of domestic violence. Health care workers should be prepared to explain the health impacts of abuse and the effects on child development, and to also explain local resources for intervention. Fear and shame are common among victims, and trust is integral to patients’ disclosure of abuse. A 2006 meta-analysis of data from 29 studies found that IPV victims’ priorities for health care encounters in which they disclose abuse include nonjudgmental responses.76 Demanding or interrogative approaches to obtaining disclosures likely will fail. Emphasis should be placed on educating and empowering suspected victims.77 A gentle and nonjudgmental approach will avoid making a patient feel interrogated or accused. If a patient seems to be covering up her or his abuser’s RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 143 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE conduct through false denial, direct accusation of lying may be counterproductive. Instead, a quick description of locally available (and linguistically appropriate) resources and a contact sheet or card with numbers for local resources, such as battered women’s shelters, can be offered to any suspected victim encountered in a health care setting. English-speaking IPV victims prefer self-completed written or computer screening questionnaires to faceto-face interviews.69 The presence of a translator for non-English speakers from some cultural backgrounds may complicate accurate completion of domestic violence screening instruments. Health care institutions’ linguistic and cultural competency policies should include the availability of translations for patientadministered tests and written materials such as information sheets, and translators to administer domestic violence screening instruments to victims who speak locally common minority languages. Reporting Suspected Abuse All suspected victims of abuse should be referred to local support resources, such as battered women’s and children’s shelters, social service agencies, law enforcement and counseling services. In addition to referral, many states require that specific types of suspected abuse also must be reported to state agencies and law enforcement. All states have laws mandating the reporting of child abuse to state agencies.20 However, 8 states do not require health care workers to report elder abuse: Colorado, Illinois, New Jersey, New York, North Dakota, South Dakota, Pennsylvania and Wisconsin.20 Mandatory reporting of IPV is even less common. A 2007 review found that only California, Colorado, Kentucky, Mississippi, Ohio and Texas have passed laws requiring physicians to report cases; only California requires physicians to report IPV with or without the victim’s consent.20 However, 42 states have mandatory reporting laws for assaults involving gunshot or knife attacks. Despite criminal penalties for failing to comply with domestic violence reporting laws (up to 6 months in jail and $1000 in fines), physicians frequently fail to report abuse.78 Some physicians express the perception that reporting requirements reduce physicians’ ability to determine what is best for their patients.78 Others have argued that reporting IPV cases when adult victims have not sought to report those cases themselves can do more harm than good; reporting and law enforcement 144 or social service agency contact can prompt violent episodes by perpetrators. Also, cohabitation, cultural expectations and the presence of children can lead to unintended consequences.79 Furthermore, it has been argued that mandatory reporting could well discourage IPV victims from speaking candidly with their physicians.79 Nurses also under-report domestic violence.80,81 Inadequate training has repeatedly been identified as a major factor in the failure of health care workers to comply with reporting laws.80,81 Hospice and palliative care workers are less likely than others to report suspected cases of elder abuse, or even to know the appropriate agencies to which such cases should be reported.82 Diagnostic Imaging Diagnostic imaging plays a crucially important role in assessing and characterizing injuries caused by domestic violence, particularly for children and elders who cannot disclose abuse orally. This section describes the roles of diagnostic imaging in characterizing child battering; TBI; and head, neck and facial assault injuries. Abdominal injuries are rare in domestic violence, although gastrointestinal imaging of severely neglected seniors may evidence life-threatening constipation with fecal compaction and blockage in the intestines, which is a common result of chronic dehydration and neglect. Skeletal Survey in Suspected Child Battering Because infants and young children cannot describe their abuse, screening is conducted as a diagnostic imaging skeletal survey for fracture histories rather than a questionnaire.64 Even severe behavioral signs of abuse such as seizures and coma are not specific to abuse. However, facial and chest bruising as well as a sudden increase in infant head circumference — when accompanied by other, nonspecific signs or the presence of skin burns or retinal hemorrhaging — are highly suggestive of physical assaults and represent clear and urgent indications for skeletal survey imaging.64 Retinal hemorrhage, traditionally diagnosed with a hand-held ophthalmoscope by an ophthalmologist or other clinician, is present in 85% of assault-related child head trauma cases.64 It also is visualized as focal hyperintensities within the eye globe on axial T1 MR images or as hypointense foci on axial T2 images.83 A skeletal survey consists of a series of radiographic images encompassing the entire skeleton.84 Radiography alone is sufficient for detecting most bone fractures, and CT, MR, scintigraphy and ultrasound November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING should be used only in follow-up examinations of specific anatomic regions as indicated by the radiographic skeletal survey. Imaging results are not considered in isolation. Rather, results are weighed alongside clinical histories, bruises, burns and patterns of injury. If radiographic images are equivocal or suggest no fractures, but clinical evidence supports suspicion of physical abuse of the infant or child, follow-up bone scintigraphy may be indicated.62,64 Scintigraphy appears to have increased sensitivity for rib, skull and possibly long bone shaft fractures. (A literature search on June 12, 2010 identified no meta-analyses comparing radiographic and scintigraphic skeletal surveys. However, a 2006 review identified some studies suggesting that scintigraphy is more sensitive for identifying bone fractures and other studies suggesting radiography is more sensitive; the authors concluded that neither modality is clearly superior in all cases.85) The American College of Radiology (ACR) has issued guidelines on skeletal surveys for child battering and other indications, including metabolic disorders and genetic syndromes. 84 According to the ACR guidelines, detailed skeletal surveys with centered views at the joints as well as brain imaging with CT or MR are indicated for any suspected child battering involving patients younger than 2 years. These imaging modalities are also indicated for any sibling of a suspected child abuse victim or other child living in the same household as the suspected victim who is younger than 2 years. 64,84 Skeletal surveys generally are not recommended for children aged 5 years and older. 64 These examinations should be interpreted by a pediatric radiologist whenever possible to avoid misinterpretation of artifacts, dysplasias or metabolic bone disease signs as indications of abuse. Incorrect interpretations that either miss real abuse or indicate abuse where there is none can have catastrophic effects on children’s well-being.84 MR imaging traditionally has been used to clarify CT findings on follow-up, but is increasingly used as a first-line abuse trauma imaging modality for specific examinations, such as identifying vein thrombosis in the brain.83 Because of concerns about the adverse health consequences of radiation exposure from radiography, some authors advocate the use of wholebody MR imaging for skeletal surveys. However, MR examinations are longer procedures, and immobilizing young children can be challenging. A recent study found that fluorine 18-labeled sodium fluoride positron emission tomography (PET) more sensitively visualizes skeletal fractures in abused children, particularly for rib fractures, than radiography.86 However, PET exhibited less sensitivity in detecting classic metaphyseal lesions (CMLs) at the joints of long bones (see Figure 2). Because CMLs are strongly indicative of child abuse, the authors recommended that PET remain a follow-up imaging modality for skeletal survey, rather than a first-line modality.86 Single-view “babygram” radiographs of the entire infant skeleton do not sensitively visualize many fractures and should not be used as a skeletal survey technique.64 Skeletal surveys involve relatively high-dose radiation exposures for children because of the following factors: (1) extensive radiography of different bone regions, (2) repeat imaging resulting from the need for very highquality images, and (3) the use of follow-up radiography to identify bone fractures and evidence of healing. Limited evidence suggests that CT may more sensitively identify rib fractures than does traditional chest radiography.87 However, CT is not recommended for initial skeletal survey screening because of its much higher average per-examination radiation dose and scant empiric support for its superiority in identifying abuse-indicative fractures. However, CT follow-up may be indicated to better characterize complex fractures in the spine, pelvis and scapula identified in radiographic surveys.64 In all radiologic imaging, the ALARA principle (as low as reasonably achievable) always should be applied to minimize child radiation doses. MR imaging is becoming the preferred imaging modality for assessing brain damage resulting from domestic violence. The ACR skeletal survey protocol calls for separate exposures with uniform image density to ensure maximum image sharpness.84 According to the ACR guidelines, appendicular bones — including the right and left humerus, forearms, hands, femurs, lower legs and feet — should be radiographed at least in the frontal projection. Additional images should be taken as needed to assess suspicious lesions in follow-up, including projections centering on joints: ■ Humerus: anteroposterior (AP) image. ■ Forearms: AP. ■ Hands: posteroanterior (PA) image. ■ Femur: AP. ■ Lower legs: AP. ■ Feet: AP. According to the ACR guidelines, many of the bones RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 145 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE ■ Lumbosacral spine: lateral image. ■ Cervical spine: AP and lateral images. ■ Pelvis: AP image. A final radiographic report should be included in the child’s medical record, describing precisely the sites and projections examined and the specific abnormalities or suspected abnormalities identified.84 Skeletal survey findings are either “typical” for child abuse, “equivocal,” or evidence “no radiographic injuries.” Strong indications of abuse should be explicitly stated as such in the report and communicated to the referring clinician as urgent findings.84 Radiologic reports should (1) describe the quality of the images and abnormalities detected; (2) exclude alterB A native explanations for abnormalities, such as skeletal dysplasias or metabolic bone diseases; and (3) explicitly state the level of suspicion for abuse based on imaging examinations.64 All states require referring physicians to report child abuse. As mentioned previously, equivocal or no-injury radiographic findings, in the presence of compelling clinical or other evidence of child abuse, can be confirmed using bone scintigraphy imaging. One hallmark of chronic child battering is the presence of bone fractures of varying age, as evidenced by different degrees of healing. Diagnostic imaging-based estimates of the age of fractures and brain injuries are inexact, but the presence of fractures and lesions with different degrees of repair is evidence of C multiple violent assaults on the child.64 Some authors recommend a repeat skeletal survey 10 to 15 days after initial imaging to allow Figure 2. Metaphyseal lesions at the distal ends of long bones are highly assessment of fracture healing.64 No change in indicative of physical abuse of infants. A, Fracture that would appear fractures suggests nontraumatic origins.64 as a metaphyseal radiolucency on a radiograph. B, Displacement or tipMultiple rib fractures in children who ping of metaphyseal fracture will frequently cause a “bucket-handle” or C, have no history of kinesitherapy exposure concave appearance on radiographs (arrows). Reprinted with permission and CMLs in infants are strongly indicative from Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in of assault-related child injuries.64 Assaultabused infants: a radiologic-histopathologic study. AJR Am J Roentgenol. 1986;146:900-902. associated CMLs are shearing injuries, sometimes called “corner fractures” or “bucketof the axial skeleton, in contrast, should be imaged using handle fractures” (see Figure 2).62 at least 2 projections, with additional images as needed in Long bone shaft fractures are increasingly likely to follow-up examinations: be caused by accidental trauma with increasing child ■ Skull: frontal and lateral images. age; however, in infants these fractures may indicate ■ Thorax: AP and lateral images, including ribs assault, particularly if the fracture is a transverse or and the thoracic and upper lumbar vertebrae. spiral fracture of the humerus or femur.62 146 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING In a similar way, skull fractures are more suggestive of abuse in younger children and infants than in older children. However, simple skull fractures are less likely to have been caused by assault than depressed or complex fractures (see Figure 3).62 The vast majority of pelvic fractures are due to motor vehicle trauma, but these findings are sometimes identified in sexually abused girls.62 Brain Imaging in Suspected Child Abuse Pediatric brain imaging also is indicated when physical assaults on infants and young children are suspected. Assault-associated head injuries typically involve multiple subdural hematomas at distant sites on the brain surface and hypoxic-ischemic brain lesions.64 Vigilant monitoring of changes in infant head circumference is vitally important in suspected cases of abuse-related head injury or TBI. Brain swelling causing sudden or marked increases in infant head circumference should be imaged to detect possible chronic subdural hematomas.64 CT is indicated when intracranial hemorrhage or rapid change in neurologic symptoms is suspected.64 Suspected abuse involving behavioral symptoms (eg, shaken baby syndrome) requires imaging with noncontrast CT, which can sensitively identify brain hemorrhage. Imaging of suspected abuse-related head trauma without neurologic or behavioral symptoms is indicated for children younger than 2 years.64 MR imaging sensitively visualizes brain contusions, hypoxic-ischemic injury and thrombi in brain veins.64 T1- and T2-weighted sequences and T2 gradient-echo sequences are used in abuse neuroimaging to identify regions of cell death or hemorrhage.64 A few functional MR (fMR) imaging studies suggest this might become a promising modality for assessing TBI- and PTSDrelated cognitive prognoses in the future.88 Chronic abuse-related brain trauma reliably causes CT- and MR-detectable cerebral atrophy due to regional brain cell death, although the true extent of cellular damage is not always clear from anatomic brain imaging.59 CT or MR brain images can detect major focal damage but cannot confirm that a patient is truly free from significant diffuse or cellular brain damage. Structural imaging rarely detects diffuse microscopic TBI that has not caused reductions in regional or wholebrain volume. Patients with seemingly normal brain CT images routinely suffer from TBI symptoms and can suffer lifethreatening microscopic bleeds.58 TBI evolves over time; images taken on the day of injury or presentation may Figure 3. Depressed skull fracture in an infant. U.S. National Institutes of Health. Public-domain U.S. government figure available at: http://commons.wikimedia.org/wiki/File:Skull_Fracture .jpg. Accessed September 9, 2010. not reveal the eventual extent of brain damage. Followup neuroimaging examinations are therefore necessary to accurately assess TBI. Brain Imaging in Adults TBI scanning is underutilized; it is rarely performed in IPV victims (even though head and face trauma is very common among IPV victims) or elder abuse victims. In addition to head CT and MR imaging to characterize maxillofacial bone fractures (eg, nasal, mandible, zygomatic or skull fractures), noncontrastenhanced CT and MR examinations should be performed because both modalities can sensitively visualize large brain contusions and bleeding. Diffuse cellular damage that can impair cognitive function is RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 147 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE detected on CT and MR as brain atrophy or volume loss over time.88 As with pediatric TBI, brain imaging may miss subtle but life-threatening lesions and should be followed up with subsequent imaging over a period of several weeks. Furthermore, neurodegenerative processes resulting from TBI may not be detectable using structural neuroimaging until months after injury; MR imaging several months after the injury better predicts long-term outcome than day-of-injury CT.58,88 CT is the imaging modality of choice for acute TBI assessment in emergency settings; it sensitively visualizes focal lesions and skull fractures with short acquisition times. Detecting skull fractures is crucial because their presence often indicates the presence of intracranial hematomas (see Figure 4). A fully conscious adult patient with no skull fracture has a likelihood of only 1 in 7866 for acute hematoma, whereas the risk of hematoma in a fully conscious patient with skull fracture is 1 in 45. 58 Among patients with altered consciousness, the risk of hematoma is 1 in 180 for patients without skull fracture and 1 in 5 for patients exhibiting skull fracture. 58 The most common CT rating scale for TBI is the Trauma Coma Databank, which involves 7 distinct categories. 89 The score reflects the severity of brain damage and establishes a baseline for comparison with future neuroimaging results. 89 The scale classifies TBI as: ■ Diffuse injury I: No visible intracranial pathology. ■ Diffuse injury II: Midbrain, midline cisterns shifted up to 5 mm or lesions or bone fragments are present, but no high- or mixed-density lesion exceeding 25 cc. ■ Diffuse injury III: Swelling within the midbrain, midline cisterns compressed or absent, but no high- or mixed-density lesion exceeding 25 cc. ■ Diffuse injury IV: Brain midline shift exceeds 5 mm, but no high- or mixed-density lesion exceeding 25 cc. ■ Evacuated mass lesion V: Lesion surgically evacuated. ■ Non-evacuated mass lesion VI: High- or mixeddensity lesion exceeding 25 cc, but has not been surgically removed. ■ Brainstem injury VII: Focal lesion on brainstem but no other lesions. MR imaging offers excellent anatomic detail with resolution superior to CT and is preferred over CT for long-term follow-up monitoring applications. Because 148 Figure 4. Computed tomography image of skull fracture– associated hematoma. Wiki Commons. http://commons.wiki media.org/wiki/File:Epidurales_Haematom.jpg. MR involves longer acquisition times and is incompatible with some life-support equipment, it is rarely used in emergency or acute care settings. Frequently, MR is used to monitor degenerative changes and changes in hemorrhage over time as well as to detect lesions contributing to TBI-associated seizures. MR images acquired more than 45 days after initial injury better detect the ultimate extent of brain damage from TBI than day-of-injury images.58 MR sensitively visualizes water and edema, white matter damage and generalized cerebral atrophy measured as ventriculomegaly (expansion of the brain’s cerebrospinal fluid-filled ventricles) as well as thinning of the corpus callosum, the thin wall of tissue dividing the brain’s left and right cerebral hemispheres.58,88 Traditional T1 MR is used to detect focal brain atrophy, whereas combined T1 and T2 MR is superior for detecting ventriculomegaly.90 White-matter abnormalities are visualized in MR imaging as hyperintensities, often at the same sites where tiny, dotlike hemorrhages were visualized in day-of-injury CT images.58,88 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING Strangulation Neck trauma from strangulation is a common and life-threatening form of IPV. Clinical signs include petechiae in the upper eyelid skin and hemorrhage in the whites of the eyes.52 The extent of internal neck injuries from strangulation assaults is not always evident in clinical examination of external anatomy. Approximately 10% of violent deaths in the United States each year involve strangulation, and many victims die without “a single visible mark to the neck.”52 Subcutaneous hemorrhage identified in MR examinations is frequently more extensive than external clinical examination suggests and sometimes correlates better with patient reports of painful areas than does external bruising.49 Clinical assessment involves evaluating petechial hemorrhage, pain, voice hoarseness and painful swallowing. Pulse oximetry using a fingertip transducer should be undertaken immediately, particularly if the patient has suspected mental status alterations indicative of hypoxemia.52 Pharyngoscopic or fiberoptic laryngobronchoscopic examinations of the upper airways usually are performed during initial evaluation of strangulation assaults, but these should be followed up with radiography and other diagnostic imaging examinations. 52 Chest radiography allows rapid detection of lung edema, pneumonia or aspiration. Nasal radiography is undertaken to determine whether coughed-up blood is from internal nasal fractures, and soft-tissue neck radiography allows evaluation of larynx fracture and tracheal hematomas.52 Cervical spine radiographic examinations allow evaluation of hyoid bone fracture, which is a signature injury from severe strangulation assault and a marker in autopsy of strangulation as a cause of death. (The hyoid, a horseshoe or U-shaped bone sitting above the larynx in the front of the neck, is frequently fractured by force to the front of the neck.) CT and MR imaging allow for (1) detailed crosssectional anatomic imaging of neck tissues and vertebrae and (2) TBI assessment for brain injuries incidentally sustained during the strangulation assault or resulting directly from the assault (eg, stroke [cerebral infarction]). Because carotid Doppler ultrasonography can confirm intact blood supply to the brain, this modality should be undertaken if there are signs of stroke.52 Carotid arterial dissection and thrombosis are associated with stroke and frequently may be missed in strangulation cases.91 Doppler ultrasonography visualizes thrombosis and dissection of the arteries. Subsequent CT scans in dissection-positive patients can reveal brain infarction foci near the cerebral arteries as hypodensities.91 Lymph node hemorrhage is frequently detected as hyperintense MR foci.49 Attempts have been made to differentiate life-threatening from non–life-threatening strangulation assaults using diagnostic imaging scoring systems.49,92 Studies using very small case sample sizes (eg, 41 patients92) suggested that MR-detected intramuscular hemorrhage or edema, intracutaneous and subcutaneous bleeding and lymph node hemorrhage all may indicate lifethreatening strangulation.92 However, these findings and scoring systems must be confirmed by additional studies before they are adopted in routine practice. Patients with both suspected child abuse and stroke symptoms should be evaluated for strangulation and arterial dissection; in addition, these patients should undergo neuroimaging examinations to confirm and characterize stroke.93 CT scans of the neck vertebrae and hyoid bone should be undertaken to identify bone fractures. Conclusion Domestic violence is a common but frequently undetected source of injury and death in the United States. All health care workers should be aware of the signs, symptoms and patterns of injuries associated with domestic violence, and all hospitals and health care facilities should have consistent policies in place regarding the detection, treatment, referral and reporting of such cases. Diagnostic imaging plays a crucial role in the detection, characterization and follow-up monitoring of the effects of domestic violence–related physical assaults. However, brain imaging and imaging of strangulation injuries are frequently not performed, which leaves potentially life-threatening injuries undetected and results in failure to document the extent and nature of injuries that could be used in legal interventions against perpetrators. It is the ethical responsibility of every health care worker to follow policies that will improve the identification of domestic violence victims and assist appropriate interventions. References 1. Kyriacou DN, Anglin D, Taliaferro E, et al. Risk factors for injury to women from domestic violence. New Engl J Med. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 149 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... DOMESTIC VIOLENCE 1999;341(25):1892-1898. 2. Ellsberg M, Jansen HAFM, Heise L, et al. 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Clarot F, Vaz E, Papin F, Proust B. Fatal and non-fatal bilateral delayed carotid artery dissection after manual strangulation. Forens Sci Int. 2005;149(2-3):143-150. 92.Christe A, Thoeny H, Ross S, et al. Life-threatening versus non-life-threatening manual strangulation: are there appropriate criteria for MR imaging of the neck? Eur Radiol. 2009;19(8):1882-1889. 93.Agner C, Weig SG. Arterial dissection and stroke following child abuse: report and review of the literature. Childs Nerv Syst. 2005;21(5):416-420. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING Bryant Furlow, BA, is a medical writer and health care journalist, and a regular contributor to Radiologic Technology, The Lancet Oncology and Oncology Nurse Advisor. Mr Furlow’s medical reporting received a first-place award for investigative journalism from the New Mexico Press Association and Associated Press Managing Editors, and his series on the effects of hospital budget cuts on rural ambulance response times was nominated for a public service journalism award. He is a member of the Association of Health Care Journalists, Society of Professional Journalists, and Investigative Reporters and Editors. Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail [email protected]. ©2010 by the American Society of Radiologic Technologists. Publisher: American Society of Radiologic Technologists, 15000 Central Ave SE, Albuquerque, NM 87123-3909. Circulation ActualAverage A. Total No. of Copies 137,553 131,131 B. Paid and/or Requested 1. Outside-County Mail Subscriptions 136,006 128,391 2. In-County Subscriptions 0 0 3. 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Stephanie Martinez, Communications Administrative Assistant Statement of Ownership, Management and Circulation as of 9-16-10 Radiologic Technology Publication No. 0033-8397 6 issues annually; bimonthly Price $7.03 per year, included in member dues RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 153 Directed Reading Continuing Education Quiz #10806-01 Expiration Date: Dec. 31, 2012* Approved for 2.0 Cat. A+ CE credits Domestic Violence To receive Category A+ continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Choose the answer that is most correct based on the text. Transfer your responses to the answer sheet on Page 160 and then follow the directions for submitting the answer sheet to the American Society of Radiologic Technologists. You also may take Directed Reading quizzes online at www.asrt.org. Effective October 1, 2002, new and reinstated members are ineligible to take DRs from journals published prior to their most recent join date unless they have purchased a back issue from ASRT. Your access to Directed Reading quizzes for Continuing Education credit is detemined by your area of interest. For access to other quizzes, go to www.asrt.org/store. *Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date. 1. More than _______ of women’s visits to emergency departments result from domestic violence. a.one-sixth b.one-third c.one-half d.two-thirds 4. Up to _______ % of reported IPV victims are female. a.75 b.80 c.85 d.90 2. The lifetime prevalence of intimate partner violence (IPV) for women in the United States varies from _______ % in Washington state to _______ % among Hispanic women in the southeastern U.S. a. 1.9; 35 b. 4.5; 35 c. 1.9; 70 d. 4.5; 70 5. Female victims between _______ and _______ years of age are at greatest risk of IPV. a. 16; 24 b. 20; 28 c. 24; 32 d. 28; 36 3. According to the National Crime Victimization Survey, at least _______ Americans are victimized by IPV each year. a. 167 000 b. 267 000 c. 367 000 d. 467 000 6. Rates of mutual or bidirectional IPV range up to _______ % among couples with any history of IPV. a.51 b.61 c.71 d.81 Continued on next page 154 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY Directed Reading Continuing Education Quiz 7. African American and American Indian IPV homicide rates are _______ and _______ per 100 000, respectively, compared with the national average of 0.8 per 100 000. a. 1.5; 2 b. 2.5; 3 c. 3.5; 4 d. 4.5; 5 8. Risk factors for domestic violence perpetration include the: 1. perpetrator’s low educational achievement. 2. perpetrator threatening abuse of pets. 3. victim’s disability or impairment. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2 and 3 9. In 80% of child abuse cases, the perpetrators are: a.babysitters. b. older siblings. c.parents. d. other relatives. 10. Unwitnessed _______ injuries are a significant indicator of domestic violence. a.abdominal b. head, face or neck c. upper and lower extremity d. hand and foot 11. Multiple injuries are _______ times as common among IPV victims as in accident victims. a.5 b.10 c.15 d.20 12. Up to _______ % of traumatic brain injuries (TBIs) go undiagnosed. a.55 b. 65 c.75 d.85 13. Multiple _______ fractures represent a red flag highly indicative of shaking, kicking or punching assaults on children. a.rib b.forearm c.foot d. simple skull 14. The simplest IPV screening questionnaire reviewed in this Directed Reading is the 3-item _______ questionnaire. a. Partner Violence Screen b.HELPS c. WAST d.HITS 15. Which of the following is used to assess the need for TBI evaluation? a. Partner Violence Screen b.HELPS c. WAST d.HITS 16. Which of the following are barriers to identifying domestic violence victimization in health care settings? 1. language barriers 2. inadequate training 3. insufficient staffing a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2 and 3 Continued on next page RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 155 Directed Reading Continuing Education Quiz 17. Reporting child abuse to state agencies is mandatory in all 50 states. a.true b.false 22. _______ states require referring physicians to report child abuse. a.Many b.All c.Few d.Some 18. If radiographs are equivocal but clinical evidence suggests physical abuse of a child, which follow-up examination may be indicated? a. magnetic resonance (MR) imaging b. repeat skeletal survey c.ultrasonography d. bone scintigraphy 19. Skeletal surveys generally are not recommended for children aged _______ years and older. a.2 b.3 c.4 d.5 20. Which imaging modality exhibits better sensitivity for visualizing rib fractures than a radiographic skeletal survey, but less sensitivity for detecting classic metaphyseal lesions? a.ultrasonography b. positron emission tomography (PET) c. computed tomography (CT) d. MR imaging 21. _______ may be indicated for characterizing complex fractures in the spine, pelvis and scapula. a.Radiography b.PET c.CT d.MR 23. Some researchers recommend follow-up skeletal surveys after an interval of _______ days to assess whether bone fractures are healing and therefore are likely due to trauma rather than metabolic disorders or other causes. a. 10 to 15 b. 15 to 20 c. 20 to 25 d. 25 to 30 24. The Trauma Coma Databank rating scale for TBI is used with which diagnostic neuroimaging modality? a.radiography b.PET c.CT d.MR 25. MR images acquired more than _______ days after initial injury better detect the ultimate extent of brain damage from TBI than day-of-injury images. a.35 b.45 c.55 d.65 26. Approximately _______ % of violent deaths in the United States each year involve strangulation. a.5 b.10 c.15 d.20 Continued on next page 156 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY Directed Reading Continuing Education Quiz 27. Clinical assessment for strangulation involves evaluating _______. a. lymph node edema b. petechial hemorrhage c. intramuscular hemorrhage d. subcutaneous hemorrhage 28. According to this Directed Reading, which imaging modality allows early detection of lung edema, internal nasal fractures, larynx fractures and tracheal hematomas caused by strangulation attacks? a.radiography b.PET c.CT d.MR 29. Which of the following bones is frequently fractured by force to the front of the neck? a. C2 vertebra (axis) b. C6 vertebra c.hyoid d.zygomatic 30. If there are signs of stroke, carotid Doppler ultrasonography can confirm intact blood supply to the brain. a.true b.false RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 157 Log on. Take Quiz. Score! Take Your Directed Reading Quizzes Online Anytime! www.asrt.org/myasrt It’s Easy To Start: Visit www.asrt.org/myasrt. Log in. Select My Directed Readings. Select the answer sheet. essentialeducation Printed answer sheets are now located after the quiz questions. These can be mailed to ASRT at the address on the answer sheet. ©2010 ASRT. All rights reserved. ✁ Carefully cut or tear here. CE ....................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . DIRECTED READING Diagnosis and Treatment Of Scaphoid Fractures Cynthia N Patrick, BS, R.T.(R) The scaphoid bone in the wrist is the most frequently fractured carpal bone. This Directed Reading discusses types of scaphoid fractures, issues of special concern (eg, the risk of avascular necrosis and delayed union or nonunion), steps involved in bone fracture healing and various imaging modalities used for scaphoid fracture diagnosis. Types of fracture management such as casting and surgical intervention are examined. Factors that can negatively influence bone healing, such as certain disease processes and tobacco use, are also investigated. This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your area of interest. For access to other quizzes, go to www.asrt.org /store. After completing this article, readers should be able to: n Describe the anatomy of the scaphoid bone and types of scaphoid fractures. n Identify the prevalence of scaphoid fractures by their anatomic location. n List and describe the 5 stages of fractured bone healing. n Explain how and why avascular necrosis can occur in scaphoid fractures. n List diagnostic modalities used for imaging scaphoid fractures. n Summarize treatments for optimal scaphoid fracture healing management. n List comorbidities that may contribute to suboptimal fracture healing. T he wrist joint is arguably the most complex joint in the body and comprises many bony articulations. Eight small carpal bones align in 2 rows, enabling great range of motion as well as hand strength and dexterity (see Figure 1).1 The scaphoid bone is the first in the proximal carpal row and articulates with 5 bones: the distal radius proximally, the trapezium and trapezoid distally and the capitate and lunate medially (see Figure 2).2 The scaphoid has a twisted and curved shape and spans 2 rows of carpal bones, which allows a hinge effect. The scaphoid has many vital ligamentous attachments, including the scapholunate interosseous ligament that links the scaphoid to the lunate, and the radioscapholunate ligament that connects the radius, scaphoid and lunate.3 The scaphoid is covered almost completely with articular cartilage, which enables complicated wrist movement. However, this structure leaves the scaphoid prone to suboptimal fracture RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 healing due to the anatomy of its vascular supply.4 The origin of the term scaphoid is Greek, which means shaped like a boat.3 Sometimes the scaphoid is referred to as the navicular,5 which becomes further complicated because both the wrist and ankle contain navicular bones: the carpal navicular and the tarsal navicular, respectively. The Latin term navicular also describes the boat or curved shape of these bones. The carpal navicular, the first of the 8 carpal bones forming the wrist, is most often referred to as the scaphoid bone in current medical literature. Because of its location and physiology, a fall on an outstretched hand can cause the scaphoid to fracture. The scaphoid can be palpated by locating the anatomic “snuffbox,” which is a hollow depression on the dorsomedial aspect of the wrist between the extensor pollicis brevis and abductor pollicis longus tendons (see Figure 3).6 The scaphoid is fed mainly by the volar scaphoid branch of the radial artery, which is located at the distal end of the 161 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures A of avascular necrosis (AVN).4 AVN is a condition in which reduced blood supply to an area of bone leads to osteonecrosis, or death of bone tissue. The scaphoid is especially vulnerable to AVN following a fracture because of the structure and location of its arterial supply. When arterioles are severed, part of the bone may become cut off from its blood supply. The specific anatomic location of a scaphoid fracture determines whether there is risk of damage to or loss of arterial blood supply.4 Scaphoid Fractures B The scaphoid is the most frequently fractured carpal bone, accounting for approximately 60% to 70% of all carpal fractures.3,7 Scaphoid fractures usually occur in patients aged 15 to 40 years,8 the majority of whom are active males between ages 15 and 29.9 Scaphoid fractures most often result from a fall onto an outstretched hand.4,7 This mechanism of injury often results in a Colles (distal radius) fracture in an elderly patient, or an epiphyseal displacement of the distal radius in a child.4 Perron et al described the fall on outstretched hand (FOOSH) injury as well as hyperextension at the wrist as the causative mechanism in approximately 97% of scaphoid injuries.7 The treatment method for a scaphoid fracture depends on the fracture’s stability and anatomic location.3,4 A displaced scaphoid fracture is present if there is 1 mm or more of displacement.3,4 A displaced scaphoid fracture is considered unstable and at risk for nonunion. Types of Scaphoid Fractures Scaphoid fractures are classified according to Figure 1. Posteroanterior radiographs of wrist bones: A. Unlabeled. 3 main regions of the bone: the proximal pole, B. Labeled. Reprinted with permission from Richardson M. University the waist and the distal pole or tubercle.10 They of Washington Radiology website. http://uwmsk.org/RadAnat are further classified in several ways.10,11 Filan /WristPA.html. and Herbert described 2 types of stable scaphoid fractures, A1 and A2, plus 4 types of unstable scaphoid (see Figure 4).6 Dorsal and volar branches of fractures, B1-B4, as follows10 : the anterior interosseous artery also supply blood to ■ A1 — fracture of the distal pole or tubercle. the scaphoid toward its distal end. Because of this vas■ A2 — incomplete waist fracture. cular pattern, the proximal one-third of the bone may ■ B1 — distal oblique fracture. not receive optimal blood circulation. ■ B2 — complete fracture of the waist. The shape and location of the scaphoid bone makes ■ B3 — proximal pole fracture. it prone to missed fracture on initial diagnosis, and its ■ B4 — fracture dislocation (see Figure 5). tenuous vascular supply presents additional challenges Gelberman described type B4 as a trans-scaphoidto timely healing because of a proclivity for development perilunate fracture dislocation of the carpus.11 Type C 162 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING Figure 2. The carpals and metacarpals: anteroposterior or pal- mar aspect. Reprinted with permission from Standring S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. Philadelphia, PA: Elsevier/Churchill Livingstone; 2009:862. fractures are delayed unions, but they are omitted from the classification because they do not form natural groups.10 Type D fractures are nonunions older than 6 weeks, and are subclassified as follows10 : ■ D1 — fibrous union (no deformity). ■ D2 — pseudarthrosis (early deformity). ■ D3 — sclerotic pseudarthrosis (advanced deformity). ■ D4 — avascular necrosis (fragmented proximal pole [see Figure 5]). Treatment recommendations vary based on the classification of the fracture and other factors. According to Filan and Herbert, all classifications except type A1 require surgical intervention.10 Haisman and coauthors stated that the majority (approximately 75%) of scaphoid fractures occur at the waist, with only approximately 20% occurring in the proximal third or pole of the scaphoid.3 The least common location is the distal third or pole of the scaphoid, including the tubercle.3,4,12 Skinner stated that “on average, middle third fractures heal in 6 to 12 weeks, distal third fractures in 4 to 8 weeks, and proximal third fractures in 12 to 20 weeks.”12 Figure 3. The anatomic snuffbox (arrow) and location of the scaphoid bone. A. Extensor pollicis brevis tendon. B. Abductor pollicis longus tendon. Reprinted from Hobbs DL. Carpal box and open cup radiography. Radiol Technol. 2006;77(5):345. Delayed healing and nonunion scaphoid fractures are often attributed to poor blood supply that leads to AVN. According to Nishihara, “a delayed union is considered to be present if there is no evidence of healing after 3 months. A fracture nonunion is defined as absence of evidence of healing at 6 months after injury.”4 Nonunion of scaphoid fractures is reported at rates ranging from 3% to 10% 4 and 5% to 25%.3 There are numerous sources of information regarding scaphoid fracture healing rates, and these data may vary widely because they reflect different fracture types and the presence of other factors that may affect bone healing. According to Haisman et al, “the factors associated with nonunion include fracture displacement of greater than 1 mm, proximal fracture, osteonecrosis, vertical oblique fracture, and smoking.”3 The complexities and possible complications of scaphoid fracture healing can be further explored after first establishing what constitutes the normal healing process for fractures. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 163 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures Figure 4. Arterial blood supply to the scaphoid bone. The wrist is positioned in ulnar deviation. A. Radial artery. B. Volar scaphoid branch. C. Anterior interosseous artery. Scaphoid waist fracture is observed. Reprinted from Hobbs D. Carpal box and open cup radiography. Radiol Technol. 2006;77(5):345-349. The Bone Healing Process Bone is a constantly changing and complex type of connective tissue. The human skeleton comprises both cancellous (dense) and spongy (less dense) bone tissue. To maintain homeostasis in healthy bone tissue, some bone cells (osteoclasts) are constantly breaking down bone matrix. Other cells (osteoblasts) rebuild bone matrix. Bone tissue is permeated with blood vessels, and long bones contain marrow that generates blood cells. Bone fracture healing is a multistep process that begins with the impact that causes the injury. Skinner described bone healing as a process with 5 stages: impact, inflammation, soft callus formation, hard callus formation and finally remodeling.12 Bone healing proceeds somewhat differently depending on whether a fracture is stable or unstable — that is, whether or not the fracture surfaces are held in place sufficiently to prevent motion relative to each other.13 Most scaphoid 164 fractures are treated with fixation to stabilize them.3,10 However, in some cases diagnosis and treatment may be delayed for weeks or months and the healing process may have already begun in unstable or suboptimal alignment. When a bone fractures, both bleeding and an inflammatory response occur at the site of the break. A hematoma forms and surrounds the fractured bone surfaces and the torn outer surface (periosteum); the hematoma occupies any voids, including the medullary canal. Bone cells (osteocytes) and other tissues within the bone, such as blood vessels and nerves, are physically disrupted in the immediate area of the fracture. The lack of vascular supply caused by the disruption of the blood vessels in the area of the fracture causes these tissues to die from lack of nutrients and oxygen. Necrotic material and the blood platelets in the hematoma release messenger chemicals called inflammatory mediators. The most obvious aspect of the inflammatory response is edema or swelling due to blood plasma building up in the area of injury. The body also responds by sending leukocytes, macrophages and lymphocytes to the affected area. These cells begin resorbing necrotic material and other debris at the fracture site. Leukocytes, macrophages, and lymphocytes also stimulate the body to begin the process of angiogenesis — the production of new blood vessels — to restore the blood supply to the affected region.13 Necrotic bone material is resorbed by osteoclasts. As the hematoma is resorbed, it is replaced by granulation tissue. Granulation tissue temporarily replaces lost tissue in a wound and helps enable vascular formation during the healing process. As the inflammatory response begins to subside and the newly forming blood vessels begin to resupply fresh blood to the fracture area, bone repair can begin. The first repair cells to arrive are fibroblasts and chondrocytes, which begin producing the new bone matrix, or soft callus. Fibroblasts produce fibrillar collagen, which is the main component (approximately 90%) of the organic portion of bone matrix. Chondrocytes produce cartilagenous proteins. Fibrillar collagen is a protein that forms helical strands of protein that become entangled with each other to produce a 3-D mesh called osteoid, which becomes the scaffold for the new bone. The new bone produced initially is called woven bone because of the resemblance of the entangled collagen fibers to woven cloth.13 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING inner part is called the soft callus and remains longer as fibrous and cartilaginous tissue before it too starts to mineralize. Essentially, the fracture callus proceeds to harden from the outside in, with peripheral areas mineralizing earlier and the central areas mineralizing later. The new bone material produced is woven bone, and it eventually fills in the space between the fracture surfaces and typically surrounds the fracture site on the exterior of the bone as well. When enough hard callus has formed to stabilize the fracture and prevent relative motion between the fracture surfaces, the healing has reached the stage called clinical union.13 The final stage of bone healing consists of remodeling. The woven bone material of the hard callus is weaker than the original lamellar bone material was. Remodeling is a complex process in which osteoclasts Figure 5. Modified staging system for scaphoid fractures. Type A fractures are not illustrated. slowly break down the woven Types B5 (comminuted) and C (delayed union) have been omitted from the classification bone, while at the same time because they did not form natural groups. Other researchers noted the questionable validity of osteoblasts replace the woven type C. Reprinted with permission from Filan SL, Herbert TJ. Herbert screw fixation of bone with lamellar bone. Over scaphoid fractures. J Bone Joint Surg [Br]. 1996;78-B(4):519-529. www.jbjs.org.uk/cgi time, the remodeled bone even/reprint/78-B/4/519.pdf. Accessed September 21, 2010. tually achieves normal strength and the hard callus that had formed exterior to the original At this stage, according to Weinstein and Buckwalter, bone is resorbed. This restores the bone to very close to the bone healing process will take one of 2 paths, its original shape before the break. depending on whether the fracture surfaces are stable or In the case of a fracture that is rigidly stabilized, the unstable.13 In the case of an unstable fracture, an assemrepair process is somewhat simpler.13 Considered at the blage of osteoid, cartilaginous tissue and fibrous tissue microscopic level, in a stabilized fracture there are some forms in and around the fracture site. This is called areas where the opposite fracture surfaces are in direct the fracture callus. Once the fracture callus has been contact, and other areas where there are microscopic formed, osteoblasts and cells from the periosteum begin gaps between the bone surfaces. In the areas of direct to produce osteocytes to occupy the fracture callus. contact, new lamellar bone can be formed directly, withOsteocytes promote mineralization of the bone by mediout the intermediate step of the fracture callus. New ating the production of calcium phosphate, which forms lamellar bone is formed by osteoclasts that first break the hard part of the bone. The outer area of the fracture down the interface where the 2 fracture surfaces are in mineralizes first and forms the hard callus, whereas the contact; this stage is followed by osteoblast production RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 165 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures of lamellar bone that connects both surfaces. New blood vessels then grow into the new bone matrix. In areas where there are gaps between the fracture surfaces too large for the osteoblasts to fill directly with new lamellar bone, woven bone is formed instead by the same process as described previously for the unstable case. These pockets of woven bone are later remodeled into lamellar bone much as if they had been part of a fracture callus. Although many factors can affect the timeline of individual healing, on average a bone fracture takes approximately 6 to 8 weeks to heal completely. After the initial injury, the inflammation stage lasts for several days. Once soft callus begins to be replaced with hard callus, the hard callus formation becomes visible on radiographs, usually within 2 to 3 weeks of injury. The final remodeling stage of bone healing can continue for several months after the majority of the healing process is complete. It is important to recognize that some scaphoid fractures are not diagnosed or treated until weeks or even months after the initial injury. Some patients may delay seeking treatment because they assume that they only have a sprained wrist, as there is often no deformity and sometimes little to no swelling present. Therefore, callus may already be forming at the fracture site by the time the patient seeks care; or, because of insufficient blood supply, a scaphoid nonunion may occur. Also, if a patient obtains medical care at the time of injury but for some reason the scaphoid fracture diagnosis is missed, he or she may not receive proper treatment or follow-up. Imaging Scaphoid Fractures Radiography Before a patient comes for initial radiographs, a clinician will have determined a suspicion of a wrist fracture based on the patient’s injury and examination. Tenderness in the anatomic snuffbox area (see Figure 3) 6 should cause a clinician to suspect that a scaphoid fracture may be present.3 Depending on the clinical setting, the clinician’s experience and the patient’s symptoms and presentation, either routine wrist radiographs or wrist radiographs with additional images of the scaphoid may be ordered. Clinicians also will consider whether referral to an orthopedic specialist and follow-up studies may be advisable, even if initial radiographic findings are negative. Haisman and colleagues suggested wrist immobilization and follow-up radiographs in 1 to 2 weeks for patients with anatomic snuffbox tenderness whose initial radiographic 166 findings are negative. If a scaphoid fracture is suspected but repeat radiographs fail to show a fracture, computed tomography (CT), magnetic resonance (MR) imaging or a bone scan should be performed.3 Brydie and Raby observed that scaphoid fractures can take up to 6 weeks to become evident on radiographs and highly recommended MR imaging for early definitive diagnosis of scaphoid fracture.14 Initial radiographic images of the wrist vary among facilities. Merrill’s Atlas of Radiographic Positioning and Procedures15 lists standard images of the wrist as posteroanterior (PA), lateral and PA oblique; it also describes several scaphoid images, including the PA with ulnar deviation and the PA axial or Stecher method, with the image receptor placed on a 20° angle sponge and the central ray directed perpendicular to the table.15 Frank et al also described the Rafert-Long method for scaphoid imaging. This method is a series of 4 images with the wrist in ulnar deviation. Four separate exposures are made with 0°, 10°, 20° and 30° cephalic tube angles. Scaphoid images are obtained to demonstrate the scaphoid without superimposition or overlap of bones around it. Another positioning resource used by RTs and students is Radiographic Procedures: A Pocket Index by Kirby and Cockbain.16 These authors explained that radiology departments have established protocols for the images to be obtained in cases of suspected scaphoid fracture. In many patients, scaphoid fractures are not apparent on radiographs taken immediately after a traumatic event. These patients typically require additional imaging 10 to 14 days after the injury.16 The authors described the most common series of images for suspected scaphoid fractures as the anterior oblique, posterior oblique, lateral and PA with ulnar deviation, plus an additional image, the PA with ulnar deviation and 45° angulation, with the central ray angled 45° toward the elbow.16 Hobbs described and illustrated the carpal box and open cup methods of nontraditional scaphoid radiography.6 These are both methods of obtaining magnified views of the scaphoid. Hobbs cited the finding of Toth et al17 that the carpal box magnified imaging technique is effective as a primary diagnostic tool in place of more expensive CT and MR scans.6 In addition to routine wrist views, Perron et al described a scaphoid view with a clenched fist and the wrist held in ulnar deviation.6 Malik et al cited the need for standardization of scaphoid imaging.18 Plain radiographs are the primary imaging modality for the initial diagnosis of November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING scaphoid fractures, but Malik and colleagues documented that a variety of images are taken by radiographers when they are asked to perform scaphoid imaging.18 They suggested that 5 specific images represent the most effective protocol: anterior oblique, posterior oblique, lateral, PA with ulnar deviation, and PA with ulnar deviation and 20° beam angle.18 The significance of how soon after the injury initial radiographs are taken must be considered. Breitenseher et al observed that immediately after injury up to 65% of scaphoid fractures remain radiographically occult.19 In a study by Memarsadeghi et al of 29 patients with initially negative findings on posttrauma conventional radiographs, 20 patients were found to have fractures of 1 or more bones on 6-week follow-up radiographs. Eleven (38%) of these fractures were scaphoid fractures, and 2 of these patients had additional fractures in other wrist bones.20 Three of the 11 patients with scaphoid fractures had evidence of trabecular involvement only, whereas the other 8 patients had evidence of cortical involvement. Fractures found in other patients included 6 distal radius fractures, 2 triquetral bone fractures and 2 lunate fractures. Memarsadeghi and associates recognized that their study was small and that their findings should be further explored and validated in future studies.20 Further research could raise awareness about the possibility of radiographically occult scaphoid fractures and what can be done to decrease the incidence of missed diagnosis of these fractures. CT and MR Both CT and MR imaging are used widely to diagnose scaphoid fractures. A broad array of research has been published detailing appropriate applications of CT and MR for imaging various types of scaphoid fractures. Ty et al found that CT scans were useful in diagnosing suspected scaphoid waist fractures in the emergency department (ED).21 They reported that unnecessary immobilization in cases of a suspected scaphoid waist fracture could be avoided by immediately performing a CT examination. They also noted that CT is a widely available modality in EDs, and the cost of the CT examination is less than that of MR imaging. In their studies “no fractures were missed or undertreated.”21 Memarsadeghi and associates compared multidetector CT and MR imaging in 29 patients who were suspected of having a scaphoid fracture but who had normal initial radiographs.20 MR imaging correctly identified and localized all 11 occult scaphoid fractures that were later verified on 6-week follow-up radiographs. This resulted in 100% sensitivity and 100% specificity for the detection of fractures. CT imaging depicted all 8 scaphoid fractures with cortical involvement, resulting in 100% sensitivity and 100% specificity for identifying cortical involvement.20 The authors concluded that “multidetector CT is a highly accurate method for detecting occult cortical scaphoid fractures and is superior to MR imaging for identifying cortical involvement, but CT appears inferior to MR for identifying solely trabecular injury. Thus a positive CT scan is diagnostic, while a negative CT scan may warrant further evaluation.”20 Brydie and Raby studied the use of MR imaging to assess clinically suspected scaphoid fractures when radiographic findings were normal.14 Their study included 195 patients who were scanned within 14 days of injury. MR demonstrated occult fractures in nearly two-fifths of the study group, with 37 scaphoid fractures representing about half of the injuries. Other findings included 28 distal radius fractures and 9 fractures of other carpal bones. Perhaps more significantly, the MR results changed the medical management for 92% of the study group, which led the authors to conclude that MR should be considered the gold standard for imaging these types of injuries.14 Previous smaller studies also demonstrated the effectiveness of MR in scaphoid fracture diagnosis.22 Other Imaging Techniques Nuclear medicine bone scanning also is used to diagnose scaphoid fractures,23,24 but not as widely as CT and MR. Although bone scans are highly sensitive in demonstrating the presence of a fracture, they are not as specific as MR.25 Many orthopedic specialists use both MR and CT, as well as radiography and bone scans, in the diagnosis and follow-up of scaphoid nonunions.3,26 Fluoroscopy is used routinely during surgical procedures for internal fixation of scaphoid fractures.26 Orthopedic specialists may prefer to use MR or CT imaging at various stages of their patients’ treatment, depending on the age, location and type of scaphoid fracture and the progress of the fracture healing. Treatment for Scaphoid Fractures Treatment approaches for scaphoid fractures vary, and may include the use of casting, open reduction internal fixation (ORIF) surgery and screw fixation, and the use of bone grafts to optimize healing. Surgical intervention for newly diagnosed fractures RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 167 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures differs from surgical approaches for patients with nonunions. Recommendations for the most effective treatment of scaphoid fractures vary and depend on the anatomic location of the fracture. Casting Cast immobilization is intended to facilitate the rigid stabilization of fracture fragments necessary for bone healing to occur. Many types of fractures respond well to treatment with cast immobilization. However, Haisman et al stated that casting for scaphoid fractures is best used only when there is not great concern over delayed union or nonunion (eg, distal pole/tubercle fractures, type A1).3 Haisman and associates also observed that the best method of cast immobilization is controversial, and studies have yielded conflicting results regarding the efficacy of immobilizing the elbow and thumb.3 Herbert observed the detrimental effects of long cast immobilization time on the joints of the wrist, hand and arm adjacent to the scaphoid. Herbert wrote that “ joints should move,”27 and he has decreased or eliminated the need for cast immobilization of scaphoid fractures with innovative improvements to ORIF techniques.10,27 Haisman and colleagues described the disadvantages of immobilization compared with surgery: …more frequent office visits to check that the cast fits properly, more frequent radiographs to check fracture alignment, potential skin breakdown, prolonged immobilization until complete healing has occurred, stiffness of immobilized joints, and even perhaps a longer time to healing. The immobilization period after surgery is shorter or even unnecessary.3 Surgical Intervention An orthopedic specialist’s decision to recommend surgical intervention for a scaphoid fracture depends on many variables, including the location of the fracture (see Figure 5),10 the age of the fracture and the presence of displacement. Surgery currently is recommended much earlier and more aggressively because of the historical prevalence of suboptimal healing of scaphoid fractures without surgery and the documentation of more rapid healing and better treatment outcomes when surgery is done early on.3,10,27 ORIF and Screw Fixation Timothy Herbert was an innovator in the specialty field of hand and wrist orthopedic surgery in England during the 1970s and has since been considered a 168 Figure 6. The Herbert screw bridges a scaphoid fracture. Reprinted with permission from the University of Washington, Department of Radiology Web Services. Musculoskeletal radiology: Orthopedic hardware. www.rad.washington.edu/academics /academic-sections/msk/teaching-materials/online-musculoskeletalradiology-book/orthopedic-hardware. Accessed September 3, 2010. world-renowned expert on scaphoid fractures.27 He invented the Herbert compression screw for fixation of scaphoid fractures (see Figure 6).28 Herbert saw the need for a hardware device that would compress the scaphoid fracture fragment surfaces together and hold them in better contact with each other. Before Herbert invented the compression screw, Kirschner wires (K-wires) were used for fixation of scaphoid fractures; however, these wires did not have the compressive effect that promotes optimal bone healing. The cannulated titanium Herbert screw became generally available in the United States in 1978.27 The term cannulated refers to the screw’s hollow central shaft, which allows accurate placement of the screw over a guidewire under fluoroscopic guidance. The Herbert screw also features multiple threading, which allows variable thread pitch November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING threading also may contribute to increased holding power. 28 Bone Grafting Filan and Herbert,10 as well as many other orthopedic surgeons, described the addition of bone grafting with the compression screw to facilitate healing of scaphoid nonunions. Jones and associates described ORIF techniques involving cannulated screw fixation and the use of autologous vascularized bone grafts harvested from the patient’s femur to facilitate bone healing at the scaphoid fracture site.29 These authors emphasized the significance of harvesting a wellvascularized piece of bone for the graft as well as careful protection via elevation of the vessels before making the bone cuts for the graft.29 Other Treatment Modalities Novicoff and associates30 studied the application of various treatment modalities for delayed or impaired bone healing. Induction of bone healing by chemical, biophysical and hormonal means is a rapidly growing area.30 Treatment options ranging from autogenous bone grafting, pulsed electrical and electromagnetic fields (bone stimulators), extracorFigure 7. Acutrak screw bridging a scaphoid fracture. Reprinted with perporeal shock wave therapy and parathyroid mission from the University of Washington, Department of Radiology Web hormone treatment were studied. The authors Services. Musculoskeletal radiology: Orthopedic hardware. www.rad.washing concluded that additional randomized clinical ton.edu/academics/academic-sections/msk/teaching-materials/online-muscu studies with strict inclusion and exclusion criteloskeletal-radiology-book/orthopedic-hardware. Accessed September 3, 2010. ria are needed to more accurately analyze each of these unique modalities for enhanced bone healing.30 Future studies will need to address 27 the feasibility and role of these modalities in fracture and is an improvement over single-threaded screws. repair. Additionally, the Herbert screw was innovative because of its headless design, which allows it to be implanted Impediments to Healing below the surface of the bone. Nonunion in Scaphoid Fractures The Acutrak screw (Acumed, Hillsboro, Oregon) Haisman and associates indicated that nonunion has later improved on the Herbert screw design (see occurred if there is no evidence of healing after 3 to 4 Figure 7).28 Orthopedic surgeons at the University of months of conservative treatment for a scaphoid fracture.3 Washington use the Acutrak screw for fixation of most There are several recognized causes of scaphoid nonscaphoid fractures treated surgically at their institution. union. One main cause is nondiscovery of the fracture The Acutrak screw has basic similarities to the Herbert on the patient’s initial presentation for diagnosis and screw in that it uses compression and variable thread treatment. Additionally, nonunion can occur as a result pitch to provide effective fixation of bone fragments, of incomplete immobilization of the scaphoid fracture. but the Acutrak screw also has threading along its entire Causes specific to the injury itself include fragment dislength. This feature allows engagement of bone material location severe enough to prevent union without surgical along the full length of the screw, better securing fracintervention and instability of one or more of the other ture fragments and bone graft pieces. The full-length RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 169 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures adjacent carpal bones. Finally, proximal scaphoid fractures present special healing challenges that may lead to nonunion. Approximately 20% of all scaphoid fractures occur at the proximal pole, where retrograde blood supply can be interrupted and thus may put the patient at risk for AVN.3 Awh observed that MR is of great value in diagnosing scaphoid fractures effectively.31 The resolution and specificity available with MR have made it a preferred imaging modality for diagnosis of scaphoid fractures as well as for evaluating possible AVN of the scaphoid. Typically, in patients with a scaphoid waist fracture and associated AVN of the scaphoid’s proximal pole, the necrotic bone regions appear with diffusely low signal intensity in both T1- and T2-weighted images. If the regions of concern show both high signal intensity in T1-weighted images and signs of edema on T2-weighted images, those findings may be considered an indication that the proximal pole of the scaphoid still has adequate vascularity.31 In cases of scaphoid nonunion, evaluation of proximal pole vascularity can be enhanced by use of intravenous paramagnetic contrast. The appropriate technique is to obtain fat-suppressed T1-weighted images immediately after administration of the contrast. The degree and rapidity of enhancement produced by the contrast in the region of interest indicate how well vascularized the region is. A viable proximal pole will show significant uptake of the contrast in the bloodstream, whereas a proximal pole with poor vascularity or AVN will show less uptake at an abnormally slow rate. Awh concluded that in cases of suspected AVN of the scaphoid, contrast-enhanced MR is the most accurate imaging modality for determining the vascular status of the proximal pole.31 Enhancement of the proximal pole also has been found to correlate with the presence of punctate bleeding at surgery; this enhancement is a positive indication of bone tissue vascularity and indicative of likely success for bone graft healing.31 Comorbidities The term comorbidity refers to a patient having 2 or more disease processes or conditions at the same time. Risk factors and disease processes that can negatively affect bone fracture healing include osteoporosis,32 nutritional deficiency, endocrinologic disorders,33 diabetes mellitus34,35 and use of tobacco.36 These risk factors and conditions affect bone healing in different ways, and the specific mechanisms by which they inhibit healing are not fully understood. Comorbidities 170 that can affect bone healing are relevant to all types of fractures, but some are of particular interest in relation to scaphoid fracture healing. The scaphoid is especially vulnerable to AVN following a fracture because of the location of its supplying arteries and the tendency of arterioles within the bone to be severed by a fracture, which leaves parts of the bone without a fresh blood supply. Any comorbid condition that restricts peripheral circulation generally will compound such vascular insufficiency; and in the case of scaphoid fractures, healing may be delayed or inhibited. Conditions that have a negative effect on peripheral circulation include tobacco use (whether by smoking or use of smokeless tobacco products) and diabetes mellitus. “It has been well documented that diabetes mellitus (DM), a systemic disease affecting 17 million Americans, causes increased healing time with a concomitant increase in delayed unions and nonunions. Unfortunately, the specific mechanism for the delayed fracture healing in patients with diabetes has yet to be elucidated.”37 Nevertheless, nicotine has been found to inhibit the activity of osteoblast cells, which are critical for the formation of new bone tissue.38 Vasoconstrictors are substances that cause the smooth muscle of blood vessels to contract and narrow, which can restrict blood flow. McKee et al stated that nicotine acts as a vasoconstrictor and has been found to inhibit angiogenic response and tissue differentiation essential to bone healing. Additionally, nicotine affects skeletal metabolism and adversely affects the function of osteoblasts.38 Dinah and Vickers found that the success rate for operative treatment to correct established nonunion of the scaphoid was 82.4% for nonsmokers, but only 40.0% for tobacco smokers.36 Compounds present in tobacco other than nicotine are likely involved in suppressing normal bone healing. In a 2006 animal study it was found that even nicotinefree tobacco caused reduced strength in healed fractures.39 Patients recovering from a scaphoid injury or undergoing surgical fracture repair should therefore not use any form of tobacco product or alternative nicotine delivery products such as dermal patches or chewing gum containing nicotine. In their investigation of the effects of cigarette smoking on the operative treatment of scaphoid nonunions, Dinah and Vickers cited wide variations in the rate of nonunion in scaphoid fractures, from between 5% to 12% to as high as 47%.36 They also cited several studies documenting good results of screw fixation with autologous bone graft, with postoperative union rates November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING of approximately 80% to 90%. Variable factors that can reduce the success rate of this type of surgery include but are not limited to AVN, osteoarthritis and smoking. Dinah and Vickers also explored the effects of smoking on the surgical repair outcome of the scaphoid. They concluded that there is a significant association between smoking and failure of operative treatment for scaphoid nonunion, with the nonunion rate being 3 times higher in smokers than nonsmokers.36 According to Brinker et al, fracture nonunion is a multifactorial phenomenon, including such variables as inadequate vascularity, cigarette smoking and malnutrition. The authors stated that they are not aware of any prior studies that documented a relationship between metabolic and endocrine abnormalities and fracture nonunion.33 They studied fracture healing in patients with vitamin D deficiency, hypothyroidism and many other disorders. In their examinations of 37 patients with nonunion of various bone fractures, they found that 31 suffered from at least one metabolic or endocrine abnormality. Sixty-eight percent of the nonunion cases involved vitamin D deficiency.33 Other conditions found included calcium imbalances, hypogonadism and other hormone disorders. Brinker et al concluded that further studies are needed to confirm the causal association of metabolic and endocrine abnormalities with fracture nonunion.33 Another possible factor contributing to nonunion is the use of nonsteroidal anti-inflammatory drugs (NSAIDS).40 In a study of femoral nonunion cases, Giannoudis et al found that the most significant predictor of nonunion was the patient’s use of NSAIDS; the authors suggested that the reported inhibitory effects of NSAIDS on osteoblasts were probably the explanation.40 Patients with osteoporosis who experience any fracture, including a scaphoid fracture, may experience slower than normal or suboptimal healing. However, the majority of scaphoid fracture patients are male, younger than 40 years or both. Hodgkinson et al found that the demographic group in which scaphoid fractures most commonly occurred is men and boys in the age range of 15 to 29 years old. 8 They found these patients had higher rates of nonunion than other groups and also required on average the longest time for the fracture to achieve union. These young male patients also spent longer periods as outpatients than other groups and missed more work because of their injuries and treatment. 8 Therefore, osteoporosis per se is not usually a primary concern regarding scaphoid fractures because the population most prone to osteoporosis is postmenopausal women. According to the National Osteoporosis Foundation, millions of Americans are at risk for osteoporosis. Men as well as women can suffer from osteoporosis. However, women account for 4 times as many cases of the disease than do men.41 Risk factors for osteopenia (low bone mineral density [BMD]) and osteoporosis include advancing age, female gender, white or Asian ethnicity, low body mass index and sedentary lifestyle, among other factors.32 According to World Health Organization 1994 statistics, the patient population with osteopenia included 54% of postmenopausal white women in the United States.32 The 1994 statistics also indicated that 30% of postmenopausal white women in the United States have osteoporosis. Patients with osteoporosis are most likely to experience vertebral, hip and distal radius fractures due to thinning of the bone in these areas.32 A distal radius or Colles fracture more frequently occurs rather than a scaphoid fracture after a FOOSH injury because of trabecular bone weakness in the distal radius of individuals with osteoporosis. Increased awareness and education about prevention and diagnosis combined with availability of BMD testing have recently allowed for more effective management of osteoporosis. Because osteoporosis is so prevalent, it is considered a major public health threat41 and is therefore relevant when wrist fractures are discussed. It is important for patients to be educated regarding the many factors that can influence bone fracture healing. A combination of factors, such as diabetes and heavy smoking, can have very negative effects on fracture healing. Physiology of Nonunion Vascularization Kulenovic stated that scaphoid nonunion develops in stages.42 First, zonal demineralization occurs around the fracture cleft, and then pseudocystic areas of resorption develop in both fragments. Next, there is progressive widening of the fracture cleft and formation of osteophytes, which results in a gap between the bone pieces. At this final stage, ischemia of the proximal fragment often occurs. Neovascularization, the development of new blood vessels in tissues with compromised circulation due to trauma or disease, can result if a vascularized bone graft is inserted into the nonunion gap. When vascularity is restored to the proximal pole of the scaphoid, such as in cases wherein vascularized bone grafts are employed, a successful outcome is typically visible on MR images. The RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 171 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures restored vascularization at the healing site can often be seen as a zonal marrow edema visible as low signal intensity in T1-weighted images and high signal intensity in T2-weighted images. Additionally, this region will sometimes show a visible border of bandlike sclerosis called the “double line sign,”43,44 which is considered to be an indication of increased osteoblastic activity (see Figure 8).42 Illustrative Cases Figure 8. Coronal T2 and T2 fat saturation magnetic resonance images demonstrating scaphoid fracture nonunion of the distal pole (distal oblique fracture, classification B1) and resulting osteonecrosis. “Double line sign” is seen in the proximal pole. Patient history: scaphoid fracture 2 years previously. Reprinted with permission from Kulenovic D. Osteonecrosis of the proximal fragment in scaphoid nonunion. www.mskcases.com. http://mskcases.com/index .php?module=article&view=104. Accessed June 19, 2010. 172 Scaphoid fractures are frequently overlooked in emergency departments, yet the consequences of a missed or delayed diagnosis can be significant — including long-term pain, loss of mobility and decreased function. This section presents 3 case studies from Perron and colleagues that describe the diagnosis and treatment of scaphoid fracture in an ED setting.7 Also presented are 3 case studies from Pandit and Wen45 that illustrate some of the complexities and challenges involved in diagnosing and treating scaphoid fractures. Case 17 : A 16-year-old boy fell on his outstretched left hand while skateboarding without wearing wrist guards; he then felt immediate pain in his left wrist. When the patient arrived at the ED, the staff observed that the wrist was mildly swollen and diffusely tender. The patient also experienced snuffbox tenderness and pain with axial compression along the length of the long axis of his right thumb. Pain limited his dorsiflexion and palmar flexion. PA and lateral radiographs were taken. The PA radiograph demonstrated a middle third scaphoid fracture with no displacement or angulation; the other images appeared normal. Initial treatment consisted of a longarm thumb spica splint. The patient was released and referred for an orthopedic appointment in 7 days. By that time, the swelling in the wrist had decreased, and he was placed in a long-arm thumb spica cast for 6 weeks. The patient was subsequently placed in a short-arm thumb spica cast for another 6 weeks. At 12 weeks, radiographs demonstrated union of the fracture. Two years following the injury, the patient felt no pain, and his range of motion was normal.7 Case 27 : A 44-year-old woman fell on her outstretched right hand while intoxicated. She suffered immediate pain and swelling in her right wrist, but had no other injuries. Diffuse wrist swelling was found on clinical examination in the ED. Tenderness was noted on the dorsal area of the radial side of the wrist and in the snuffbox area. PA and lateral radiographs were November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING taken. These images did not demonstrate any definite fracture of the scaphoid. However, because of the clinical findings, an additional scaphoid image of the wrist was taken. This allowed diagnosis of a subtle distal-third scaphoid fracture. Treatment consisted of a long-arm thumb spica splint. However, the patient did not go to the follow-up appointment. Two years later, the patient returned to the ED and reported continuing wrist pain and decreased range of motion. During her interview, she stated that she had removed the initial splint after only 24 hours. Repeat radiographs indicated advanced degeneration of the scaphoid. The patient was referred to orthopedic surgery and underwent a proximal row carpectomy to relieve her chronic pain. One year following this procedure, she stated that her residual pain was minimal.7 Case 37 : A 33-year-old man presented to the ED approximately 24 hours after a fall onto his outstretched right hand while playing softball. He complained of persistent right wrist pain. Clinical examination indicated snuffbox tenderness, and the patient’s range of motion was limited because of pain. Plain radiographs demFigure 9. Transverse fracture through waist of scaphoid occurring onstrated no fracture on PA and scaphoid views. 1 year previously. No displacement or avascular necrosis is evident. Because of the patient’s clinical examination Reprinted with permission from Pandit S, Wen D. Scaphoid fractures findings, he was placed in a short-arm thumb with unusual presentations: a case series. Cases J. 2009;2:7220. www .ncbi.nlm.nih.gov/pmc/articles/PMC2740206/pdf/1757-1626-0002spica splint and instructed to follow up with an 0000007220.pdf. Accessed September 2010. orthopedic specialist in 10 to 14 days. At that appointment, the patient again presented with radial-sided pain. Palpation of the waist of the scaphoid snuffbox tenderness and had repeat radiographs that via the snuffbox, and over the distal pole of the scaphoid demonstrated a middle-third scaphoid fracture. He on the palmar side, both failed to induce tenderness. was treated with a long-arm thumb spica cast for 6 Radiographs taken at this time showed a nondisplaced weeks, and then changed to a short-arm thumb spica transverse fracture through the waist of the scaphoid, cast for 5 more weeks. He was found to have good but no AVN was observed (see Figure 9).45 MR imaging radiographic union of the fracture at 11 weeks.7 showed the fracture but not AVN. Treatment consisted Case 445 : A 39-year-old woman presented at a clinic of 6 months of splinting with electromagnetic bone complaining of diffuse radial-sided wrist pain in her stimulation. This treatment did not result in complete right hand. Her injury had occurred 1 year previously, healing, but after 6 months only symptomatic treatment when she had been practicing mock combat with a was continued.45 medieval sword. While holding the sword, she hyperCase 545 : A 20-year-old, right-handed man presented pronated her wrist without any direct impact to her to the clinic 5 years after sustaining an injury to his left hand or the wrist itself. Radiographs taken shortly after wrist. The injury had occurred while he was playing the incident had apparently been negative, and she soccer. The soccer ball struck his left hand, forcing a palreceived only symptomatic treatment for the continumar flexion of his wrist. He immediately reported pain, ing diffuse radial-sided wrist pain. but radiographs at the time failed to show a fracture. When the patient was examined in the clinic 1 year His treatment was a removable splint that he wore for after the original injury, no swelling was visible, but a few weeks, which somewhat improved his symptoms. passive extension and flexion of the wrist caused her RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 173 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures However, he continued to suffer from intermittent radial wrist pain, which became progressively worse. Clinical examination of the wrist 5 years subsequent to the injury showed no swelling, but the patient’s range of motion was restricted in both flexion and extension. There was no tenderness noted at the waist of the scaphoid, but there was tenderness at the proximal pole of the scaphoid near the scapholunate junction. Radiographs taken at this time showed a nondisplaced transverse fracture in the proximal portion of the scaphoid. Additionally, the proximal fragment of the scaphoid showed sclerosis and lucency, which indicated the possibility of AVN. Treatment at this time was internal fixation with vascularized bone grafting, which resulted in adequate healing.45 Case 645 : A 16-year-old boy presented to the clinic 1 month after an injury causing right wrist pain. The injury had occurred while wrestling with a friend, but the patient could not recall any specific trauma other than his wrist and forearm being rolled on by his friend. He reported that he had not had any immediate pain at the time, but that a few minutes afterward he noticed severe diffuse pain in his right wrist, including the radial side, ulnar side, palmar side, and dorsal side. Clinical examination revealed diffuse swelling over the volar and middorsal areas of the wrist. The wrist was diffusely tender on the dorsoradial side, with tenderness noted at the waist of the scaphoid. Range of motion for the affected wrist was only slightly less than that of the opposite wrist, with minor discomfort at the extreme ranges. Radiographic images showed a minimally displaced transverse fracture at the junction of the distal and middle thirds of the scaphoid, and slight widening of the scapholunate interval (see Figure 10).45 Treatment consisted of internal fixation with bone grafting.45 Cases Summary Figure 10. Fracture through scaphoid located just distal to waist with mild displacement. Slight widening of the scapholunate interval is also noted. No AVN is evident. Reprinted with permission from Pandit S, Wen D. Scaphoid fractures with unusual presentations: a case series. Cases J. 2009;2:7220. www.ncbi .nlm.nih.gov/pmc/articles/PMC2740206/pdf/1757-1626-00020000007220.pdf. Accessed September 2010. Case studies are of significant value in demonstrating different types of scaphoid fractures and the diversity of injuries experienced by individuals. Taking into account each mechanism of injury, the diagnostic workup of each case, what type of treatment the patient underwent (including patient compliance) and the resulting outcomes can enable a deeper understanding of the intricacies of individual scaphoid fracture diagnosis and treatment. Pandit and Wen45 reminded us that historically, diagnosis and treatment of scaphoid fractures has always been difficult. Even with current medical imaging technology, effective diagnosis of a scaphoid fracture at the time of the patient’s initial presentation remains a challenge to clinicians. The classic signs of scaphoid fracture, such as tenderness in the anatomic snuffbox, are still valuable guides. Likewise, patient reports regarding the mechanism of injury — particularly a fall on an outstretched hand — can provide an important clue. However, many cases remain in which these classic symptoms and signs are not present, but the patient has nevertheless suffered a scaphoid fracture.45 174 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CE ... DIRECTED READING Conclusion It is important for radiographers and radiology assistants to continue to expand their foundational knowledge to more fully understand the complexities of the many disorders, injuries and diagnoses they are involved with as part of the diagnostic team. Focusing on one anatomic area such as the scaphoid bone and then subsequently exploring a variety of case studies can help radiographers expand and renew their knowledge and expertise. There is abundant literature about scaphoid fractures, and research in this specialty area of orthopedics is ongoing. For radiographers, it is especially important to consider and practice effective diagnostic radiographic techniques and to be well informed about scaphoid fracture management because of the high percentage of these fractures that require surgical intervention to heal successfully. Radiographers who have a deeper understanding of the complexities of scaphoid fractures can facilitate better care for their patients from initial diagnosis through treatment, and therefore can contribute directly to the overarching goal of optimal fracture healing. References 1. Richardson M. Wrist PA views. University of Washington Radiology website. http://uwmsk.org/RadAnat/WristPA .html. 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The value of radiographs and bone scintigraphy in suspected scaphoid fracture. J Hand Surgery Br. 1993;18:403-406. 25.Fowler C, Sullivan B, Williams L, McCarthy G, Savage R, Palmer A. A comparison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid waist fracture. Skeletal Radiol. 1998;27:683-687. 26.Slade J, Dodds S. Minimally invasive management of scaphoid nonunions. Clin Orthop. 2006;445:108-119. 27. Timothy Herbert interview. Maîtrise Orthopédique. 2001(105). www.maitrise-orthop.com/corpusmaitri/interview/105 _herbert/herbertus.shtml. Accessed June 26, 2010. 28.University of Washington, Department of Radiology Web Services. Musculoskeletal radiology: orthopedic hardware. www.rad.washington.edu/academics/academicsections/msk/teaching-materials/online-musculoskel etal-radiology-book/orthopedic-hardware. Accessed September 3, 2010. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 175 .CE . . . . . . . . . . . . . . . . . . . . . . . . . . ....................................................................... SCaphoid fractures 29.Jones D, Heinz Burger A, Bishop T, Shin A. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse: surgical technique. J Bone Joint Surg. 2009;91:169-183. 30.Novicoff W, Manaswi A, Hogan M, Brubaker S, Mihalko W, Saleh K. Critical analysis of the evidence for current technologies in bone-healing and repair. J Bone Joint Surg. 2008;90:85-91. 31. Awh M. Scaphoid fracture. MRI Web Clinic 2006. www .radsource.us/clinic/0604. Accessed April 8, 2010. 32.Siaw E, Vanderford V. Osteoporosis and bone mineral density. Radiol Technol. 2001;72(4):383-386. 33.Brinker M, O’Connor D, Monla Y, Earthman T. Metabolic and endocrine abnormalities in patients with nonunions. Curr Orthopaedic Practice. 2007;19(4):430-442. 34.Segalman K, Clark G. Un-united fractures of the distal radius: a report of 12 cases. J Hand Surg. 1998;23A:914-919. 35.Wukich D, Kline A. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am. 2008;90:15701578. 36.Dinah A, Vickers R. Smoking increases failure rate of operation for established non-union of the scaphoid bone. Int Orthop. 2007;31:503-505. 37. Lin S. Impaired bone healing in patients with diabetes mellitus. The University of Medicine and Dentistry in New Jersey Research. 2004:5(4). www.umdnj.edu/research/publica tions/fall04/11_bone_healing.htm. Accessed September 3, 2010. 38.McKee M, DiPasquale D, Wild L, Stephen D, Kreder H, Schemitsch E. The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction. J Orthop Trauma. 2003;17:663-667. 39.Skott M, Andreassen T, Ulrich-Vinther M, et al. Tobacco extract but not nicotine impairs the mechanical strength of fracture healing in rats. J Orthop Res. 2006;24:1472-1479. 40.Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, De Boer P. Nonunion of the femoral diaphysis: The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surgery Br. 2000;82B(5):655-658. 41. National Osteoporosis Foundation. www.nof.org. Accessed July 7, 2010. 42.Kulenovic D. Osteonecrosis of the proximal fragment in scaphoid nonunion. www.mskcases.com http://mskcases .com/index.php?module=article&view=104. Accessed June 19, 2010. 43.Zurlo J. The double line sign. Radiology. 1999;212(2):541-542. 44.Saini A, Saifuddin A. MRI of osteonecrosis. Clin Radiol. 2004:59(12):1079-1093. 45.Pandit S, Wen DY. Scaphoid fractures with unusual presentations: a case series. Cases J. 2009;2:7220. http://casesjournal .com/content/2/1/7220. Accessed June 12, 2010. 176 Cynthia N Patrick, BS, R.T.(R), is a graduate student at the Warner School of Education and Human Development at the University of Rochester in Rochester, NY. She is an adjunct instructor for the Health Professions Department at Monroe Community College in Rochester, NY, and a full-time instructor at Everest Institute in Rochester, NY. Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail [email protected]. ©2010 by the American Society of Radiologic Technologists. Errata There was an error in the article titled “Factors Related to Radiation Safety Practices in California,” which appeared in the July/August 2010 issue. Table 6, question 7 on Page 542 should have indicated that best practice for C-arm set up is never to place the x-ray tube above the image intensifier tube. The images on the September/October 2010 Patient Page on stereotactic breast biopsy were incorrectly oriented. Our thanks to readers who called the error to our attention. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY Directed Reading Continuing Education Quiz #10806-02 Expiration Date: Dec. 31, 2012* Approved for 1.5 Cat. A+ CE credits Diagnosis and Treatment Of Scaphoid Fractures To receive Category A+ continuing education credit for this Directed Reading, read the preceding article and circle the correct response to each statement. Choose the answer that is most correct based on the text. Transfer your responses to the answer sheet on Page 182 and then follow the directions for submitting the answer sheet to the American Society of Radiologic Technologists. You also may take Directed Reading quizzes online at www.asrt.org. Effective October 1, 2002, new and reinstated members are ineligible to take DRs from journals published prior to their most recent join date unless they have purchased a back issue from ASRT. Your access to Directed Reading quizzes for Continuing Education credit is detemined by your area of interest. For access to other quizzes, go to www.asrt.org/store. *Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date. 1. Which of the following bones does not articulate with the scaphoid? a.capitate b.lunate c.hamate d.trapezoid 4. Which of the following is not a region of the scaphoid bone? a. proximal pole b. styloid process c.waist d. distal pole 2. Because of its vascular pattern, the _______ of the scaphoid may not receive optimal blood circulation. a. proximal one-third b. distal one-third c. distal radius d. lateral tubercle 5. Delayed union scaphoid fractures are classified as type _______. a.A1 b.B3 c.C d.D 3. The term osteonecrosis means _______. a. bone tissue regeneration b. narrowing of a joint space c. death of bone tissue d. revascularization of bone 6. A scaphoid fracture is said to have a delayed union if there is no evidence of healing _______ months after injury. a.2 b.3 c.6 d.9 Continued on next page RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 177 Directed Reading Continuing Education Quiz 7. A scaphoid fracture is said to have a nonunion if there is no evidence of healing _______ months after injury. a.2 b.3 c.4 d.6 12. The majority of the organic part of bone matrix consists of _______. a. fibrillar collagen b. calcium phosphate c. cartilaginous proteins d.osteoclasts 13. Calcium phosphate mineralizes from the outer area of a fracture first, forming _______. a. lamellar bone b. hard callus c. trabecular bone d. soft callus 8. One reported range for nonunion of scaphoid fractures is: a. 1% to 3%. b. 3% to 10%. c. 20% to 30%. d. 25% to 40%. 9. Skinner’s 5 stages of bone healing are _______. a. impact, inflammation, hard callus formation, soft callus formation, remodeling b. impact, inflammation, soft callus formation, hard callus formation, remodeling c. impact, soft callus formation, inflammation, remodeling, hard callus formation d. impact, soft callus formation, hard callus formation, remodeling, angiogenesis 10. The formation of new blood vessels is called _______. a.angiogenesis b.osteogenesis c.hematogenesis d.pathogenesis 11. Cells that resorb necrotic bone material are called _______. a.osteoblasts b.osteoclasts c.osteocytes d.chondrocytes 14. During the remodeling phase of normal fracture healing, woven bone is replaced by _______. a.leukocytes b.lymphocytes c. granulation tissue d. lamellar bone 15. For the PA axial or Stecher view of the scaphoid, the image receptor is placed _______. a. on a 45° angle sponge b. perpendicular to the central ray c. on a 20° angle sponge d. 72 in from the tube 16. Malik and colleagues suggested that the most effective protocol for radiography of suspected scaphoid fractures includes all of the following images except _______. a. posteroanterior with ulnar deviation b.lateral c. anteroposterior with ulnar deviation d. anterior oblique Continued on next page 178 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY Directed Reading Continuing Education Quiz 17. In the study by Brydie and Raby, magnetic resonance (MR) results changed the medical management for _______% of the study group, leading the researchers to conclude that MR should be considered the gold standard for imaging these types of injuries. a.63 b.72 c.82 d.92 18. According to Haisman et al, which of the following is not a disadvantage of immobilization compared with surgery? a. potential for skin breakdown b. need for more frequent radiographs to check alignment c. higher likelihood of avascular necrosis d. joint stiffness 19. Compression screws enable shorter healing times for scaphoid fractures because they _______. a. enable rapid remodeling of bone b. compress the bone fragments together to optimize surface contact c. allow for less revascularization d. leave some space between the fracture fragments and the bone graft 20. The main advantage of using cannulated screws for bone fixation is that they _______. a. have a hollow central shaft that enables accurate insertion over a guidewire under fluoroscopic guidance b. are solid and not hollow c. are made of stainless steel d. do not compress bone fragments together 21. The term comorbidity refers to _______. a. an individual who cannot recover from a disease b. a condition that can lead to a sudden stroke c. a patient who dies because of complications d. a patient who has 2 or more disease processes or conditions at the same time 22. According to this Directed Reading, all of the following are comorbid conditions that delay healing of scaphoid fractures except _______. a.osteoporosis b. aortic stenosis c. diabetes mellitus d. tobacco use 23. Nicotine acts as a _______. a.vasoconstrictor b. promoter of osteoblast cell function c. promoter of angiogenesis d.vasodilator 24. The term neovascularization means _______. a. undesirable development of new blood vessels b. a decrease in blood flow c. lack of new vascular development in tissue where circulation has been impaired by disease or trauma d. development of new blood vessels in tissue where circulation has been impaired by disease or trauma. 25. The “double line sign” seen on an MR image is best described as an indication of _______. a.infection b. increased osteoblastic activity c. avascular necrosis d. decreased osteoblastic activity RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 179 ✁ Carefully cut or tear here. ........................................................................................................... TEACHING TECHNIQUES Group Project: A New Online Tool Lynda N Donathan, MS, R.T.(R)(M)(CT)(MR), is assistant professor of imaging sciences at Morehead State University in Morehead, Kentucky. Misty Hanks is an instructional designer at Morehead State University. “Teaching Techniques” discusses issues of concern to educators. The primary focus of the column is innovative and interesting approaches to teaching. Comments and suggestions should be sent to [email protected]. Many radiologic science educators are experienced with online teaching. However, some of them struggle to understand the many paths that can be taken to create meaningful online assignments and how to grade them. In an editorial, Jeffrey Legg, PhD, R.T.(R) (CT)(QM), described the inertia we must all overcome to keep our teaching fresh and engaging.1 Dr Legg admitted that he rarely challenges himself to make his courses more learner-centric or engaging. I found myself in the same teaching rut a few years ago and sought the help of an instructional designer. Working with this designer helped me improve my course, and it was relatively painless! The group project described here has been tested and proven in many semesters of online teaching and is the result of continuous improvement and several instructional design sessions. I hope my experience will help you. Why a Group Project? There are those in the radiologic sciences who say courses should not or cannot be taught online because it is impossible to duplicate the interaction that occurs in a face-to-face classroom.2 Adding a group project like the one described here increases the interactivity of an online class. Group projects mandate student interaction, thereby cultivating engagement with diverse students, developing their skills in conflict management and providing them with experience in giving and receiving constructive feedback.3 It is important for students in the imaging sciences to share knowledge and real-world experiences. This group project encourages active learning and fosters a sense of community. An often overlooked benefit of group projects is that they allow instructors to step out of lecture mode and into the role of “guide on the side.” In describing a similar group project structure for students in the United Kingdom, Leese stressed that the online group project is RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 not about increasing technology use just to include new tools but instead about moving “from a teacher-led delivery to student-centered learning.”4 Online teaching shifts instructors from content experts to context experts.2 Whether you are new to online teaching or you just want to add a new tool to your toolbox, the group project is a great option you can apply immediately to your online classroom. There are many reasons for using a group project: to incorporate creative and critical thinking, to increase student engagement, to add interest to the course and to remove the instructor from center stage. How Does an Online Group Project Work? The instructor divides students into groups of 5 or fewer members. Each group has the following tools: group discussion board, group e-mail and file exchange. While groups occasionally try to exchange telephone numbers, this practice is discouraged. There are no shared files of group work conducted by telephone, whereas work conducted in the course management system is recorded and available to the instructor for grading. Each group is assigned a topic from the textbook and a deadline to be prepared to conduct the class discussion. I give the students a detailed description of the requirements. These requirements include the following: create a summary of the topic, develop meaningful discussion questions and lead the class discussion on the assigned topic. Each group of students researches its assigned topic and posts a summary in the class discussion board. My students often choose to summarize topics with a PowerPoint presentation (Microsoft Corporation, Redmond, Washington). The summary also can be a video, Web page, document, podcast or other media that suits the content area. Each group also must lead an online discussion by developing pertinent 183 ........................................................................................................... TEACHING TECHNIQUES questions and facilitating participation of the entire class. The summary, quality of discussion questions and facilitation of class discussion are a portion of the total grade. The remaining portion of the grade is a combination of individual and team work. Components of a Group Project Grading Rubric I developed my own rubric to grade this assignment. It allows me to assess up to 5 students’ group work at one time using one grading sheet for the entire group. The group project grading rubric includes 5 components: research, topic summary, discussion board, team work and individual work. Students receive full credit if: ■ Research is from a reliable source and includes appropriate content. ■ Topic summaries are complete, posted to the class discussion board and written in a student-friendly manner. ■ Discussion board questions are posted, and team members lead the discussion. ■ All team members participate, work together as a group and meet the project deadline. ■ Each individual team member completes his or her portion of the work. The research, topic summary and discussion board make up 75% of the grade; team work is 15% of the grade; and individual contribution is 10% of the grade. Conclusion This online group project is based on the experiences of an imaging science faculty member and an instructional designer. Collaboration with an instructional designer is a great way to develop a new tool. Input from a design expert and continuous improvement are essential to the success of online courses and programs. Think in terms of baby steps, and capitalize on our discoveries. ◆ References 1. Legg J. Learning new tricks. Radiologic Science & Education. 2009;14(1):1. 2. Martino S, Odle T. New instructional technology. Radiol Technol. 2008:80(1):67-74. 3. Gross Davis B. Collaborative learning: group work and study teams. http://teaching.berkeley.edu/bgd/collaborative.html. Accessed March 4, 2010. 4. Leese M. Out of class — out of mind? The use of a virtual learning environment to encourage student engagement in out of class activities. British Journal of Educational Technology. 2009;40(1):73. 184 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... MY PERSPECTIVE Building the Body of Knowledge Laura Aaron, PhD, R.T.(R)(M)(QM); Sarah Baker, EdD, R.T.(R), FASRT; Julie Gill, PhD, R.T.(R)(QM); Melissa Jackowski, EdD, R.T.(R) (M); James Johnston, PhD, R.T.(R)(CV); Nina Kowalczyk, PhD, R.T.(R) (CT)(QM), FASRT; Jeffrey Legg, PhD, R.T.(R)(CT) (QM); Tricia Leggett, DHEd, R.T.(R)(QM); Kim Metcalf, EdD, R.T.(R) (T); Diane Scutt, PhD; and Bettye Wilson, MEd, R.T.(R)(CT), RDMS, FASRT, are members and former members of the Editorial Review Board for Radiologic Technology. “My Perspective” features guest editorials on topics in the radiologic sciences. Opinions expressed by writers do not necessarily reflect those of the ASRT. Those interested in writing an editorial should e-mail [email protected]. Each of us is a part of the radiologic science profession. A profession is an occupational group that possesses a specific set of skills and knowledge base. Individuals who are members of a profession continue to learn as the profession evolves, perform professional responsibilities competently and conscientiously and add to the profession’s body of knowledge.1 It is widely accepted that a unique body of knowledge that is created and supported by research in a specific discipline is an essential component of professional identity. To build the body of knowledge within a profession, publication is needed. All professions benefit from the publication of peer-reviewed articles, and peer review is an accepted method to advance professional knowledge. Radiologic Science Research One problem that faces the radiologic science profession is the limited research foundation. Anyone who has ever had to search the radiologic science literature for a class, clinical problem or any other reason can attest to the limited amount of available information. There are many issues we face in daily practice on which there is little or no research we can consult for answers. In fact, most of the knowledge used to inform our profession in the United States is built on research conducted by physicians, physicists, nurses and other allied health professionals rather than radiologic technologists. There is some research that has been conducted internationally; however, more often we must look to other professions to answer our questions. This may present problems because it may not fit our particular circumstances. The challenge of scientific inquiry in allied health professions was identified in the late 1980s by the Institute of Medicine and the National Commission on Allied Health. Although other allied health professions have met this challenge in terms of research and publication, it appears RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 that the radiation sciences lag behind many other professions. Considering that scholarship is core to improving clinical practice, why are we not meeting this challenge? Perhaps looking at our profession from an international perspective will provide some valuable information. The United Kingdom and Australia have purposely focused on developing a culture that embraces research and writing in the radiation sciences. Entry-level radiography education was elevated to the baccalaureate level in the UK in the early 1990s, helping radiation science professionals acquire research and writing skills. Following the Research Assessment Exercise in 2001 conducted by the Higher Education Funding Council (UK), the College of Radiographers2 and Scutt3 reported on fundamental evidence of a positive attitudinal change and commitment to scholarly activities by radiography professionals. So what barriers exist in the United States that prevent us from making similar advancement? Are the issues educational, motivational, institutional, professional, or a combination of these? What is the next step in moving toward the goal of developing a professional culture in which scholarship is esteemed and valued? Increasing the Body of Knowledge We all have responsibilities in our life that can range from family and personal to professional obligations. The question is, “Who has the responsibility to build the body of knowledge?” The answer is: To improve, grow and legitimize our profession, it is essential that we expand our body of knowledge. The radiologic science profession has developed and evolved sufficiently from other disciplines. While research from other professions may be helpful, it does not solve our problems or answer our discipline-specific questions. We have grown 185 ........................................................................................................... MY PERSPECTIVE enough as a profession Table 1 that it is time for us to Education Level of ARRT-Registered Technologists take this step forward. Level Year The education level of technologists regis1999 2004 2009 tered by the American No. (%) No. (%) No. (%) Registry of Radiologic High school or high school + RT certificate 54 510 (26.7) 51 414 (22.4) 20 336 (7.2) Technologists (ARRT) has fluctuated during Certificate 25 202 (12.4) 28 093 (12.3) 56 924 (20.0) the past 10 years (see Associate degree 87 117 (42.7) 104 352 (45.5) 141 298 (50.0) Table 1). Changes Baccalaureate degree 30 071 (14.8) 37 305 (16.3) 53 464 (18.9) have occurred at every education level. Figure Master’s degree 4599 (2.3) 5779 (2.5) 8075 (2.9) 1 shows the percent of 271 (0.1) 351 (0.2) 450 (0.2) technologists with asso- Doctoral degree (PhD) Doctoral degree (MD) 335 (0.2) 366 (0.2) 465 (0.2) ciate, bachelor’s, and master’s and higher Other 1751 (0.9) 1564 (0.7) 1959 (0.7) degrees. Gains in all Total 203 856 229 224 282 971 categories have been Source: American Registry of Radiologic Technologists. made. When examining the percentage of ARRT-registered technologists who hold a master’s with the best methods, then we are doing a great disdegree or higher, there have been some increases. While service to our patients and the general public. Research these changes have been subtle, it should still hold true evidence needs to be used in our profession. Conducting that our published research should be increasing as well. and publishing research initiates critical analysis, leading As the entry-level standard for the profession increases, to further research and advancements in the profession. the responsibility for radiologic science professionals to Research yields organized information that can be put conduct research and grow the profession increases as well. All of us have a professional obligation to help expand our body of knowledge. However, many may not feel their research skills are adequate to address this task. And, those who have had adequate research training may not have the motivation to publish. So, how can we as a profession increase our contributions to the body of knowledge? Obviously, this process in any profession is evolutionary, but we have enough time for members of this profession to embrace research. The scope of things that are not yet known within and about the radiologic sciences is infinite because our profession can be considered fairly young compared with medicine and nursing. The advancement of technological changes is significantly faster than original research being completed. Why is this such a crucial issue? If the pracFigure 1. Percentage of technologists with associate, bachelor’s and master’s and higher degrees. Source: American Registry of Radiologic Technologists, 2010. titioners in our profession cannot perform 186 November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... into action (many times, immediately). This action usually manifests itself as making a sound decision. Often, incorrect or bad decisions are made because people are not patient enough to either conduct or wait for others to conduct research that will provide the evidence needed for a sound decision. In the radiologic sciences, making sound decisions is imperative to provide the best patient care possible. We have a professional obligation, so it follows that taking control of areas where one is expert is fundamental to moving the research agenda forward. Publishing the results of research can be considered a moral obligation, and writing is critical to the process. Writing for publication does not come easily to all, but there is no doubt that practice makes perfect, and the editorial process can go a long way in aiding this. Also, collaboration with other radiologic science professionals can facilitate the process. Many radiologic science professionals believe that the level of respect that the profession receives is not adequate or fair. To be seen and treated as a professional, each of us has a responsibility to act as a professional. One way to act as a professional is to add to our body of knowledge through publication. As radiologic science professionals, each of us should be learning every day. As we strive to create diagnostic images and provide quality patient care, we often find ways to do our job better or more efficiently. It is important that we share these thoughts with other professionals through publishing so our colleagues within the profession as well as patients can benefit. Likewise, it is also important for us all to become better consumers of knowledge. As aware consumers, we may better understand and analyze the information confronting us from research articles, our own institutions and manufacturers, for example. We also may become more aware of the objectivity and quality — or lack thereof — of the information with which we build upon and base our decisions. All of us can add to and better comprehend the body of knowledge, whether we are students, clinicians, educators or managers. It is time for us to embrace this responsibility and meet this challenge for the sake of our profession. ◆ Radiography. 2002;8:195-200. 3. Scutt D. The Research Assessment Exercise (RAE) 2001 revisited; the University of Liverpool UoA11 experience. Radiography. 2004;10:127-130. References 1. Cant R, Higgs J. Professional socialization. In: Higgs J, Edwards H, eds. Educating Beginning Practitioners: Challenges for Health Professional Education. Woburn, MA: ButterworthHeinemann; 1999:46-51. 2. College of Radiographers. Research, radiography, and the RAE: Lessons from the 2001 research assessment exercise. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 187 ........................................................................................................... WRITING & RESEARCH Qualitative Research Methods James Johnston, PhD, R.T.(R)(CV), is associate professor of radiologic sciences and director of interdisciplinary education for the College of Health Sciences and Human Services at Midwestern State University in Wichita Falls, Texas. He also is vice chairman of the Editorial Review Board for Radiologic Technology. “Writing & Research” discusses issues of concern to writers and researchers and is written by members of the Editorial Review Board. Comments and suggestions should be sent to [email protected]. 188 In general, research is a planned course of action with the goal of understanding a phenomenon or finding answers to research questions. There are 2 broad types of research: quantitative and qualitative. Quantitative research may be more familiar and uses numerical data collection processes, research designs and statistical procedures. It is based on the assumptions that social facts have an objective reality, variables can be identified and relationships measured. Quantitative research seeks generalizability and causal explanations. Qualitative research, on the other hand, uses strategies to gather data and seeks to ensure objective analysis of subjective meanings. It is based on the assumptions that reality is socially constructed, and variables are complex and difficult to measure. Qualitative research seeks contextualization and interpretation. Both types of research certainly have a place and value in increasing human knowledge. There are some major differences between quantitative and qualitative research. The role of the researcher in qualitative methods is quite different in that he or she serves as the data collection instrument. To gain the desired insight and understanding to answer the “why” questions, the researcher often is directly involved with the informants (called subjects in quantitative studies) or environment of the study itself. This can pose quite a challenge for the researcher, who must remain objective and unbiased in collecting data. In addition, researchers must be well trained and well versed in qualitative methods. The qualitative approach also seems opposite of quantitative research in that it ends with hypotheses and grounded theory. That is, once the data are collected, the researcher analyzes them, looking for patterns, meanings and explanations that are grounded in the data but lead to hypotheses that explain what was observed. Finally, the write-up of purely qualitative studies is also different. It takes on a narrative form and is often quite lengthy. But there are also more concise qualitative studies. In fact, mixed methods designs (using both quantitative and qualitative elements) are becoming increasingly popular in health care disciplines. The following is a brief description of 4 common qualitative research designs. Ethnography An ethnographic study is anthropological research whereby the researcher seeks to learn about the culture of a society by immersing himself or herself in that society and directly participating in it. In this way, the researcher hopes to “see” things through the eyes of the members of that culture and understand from their perspective. Such studies take place over a period of time. The researcher develops a rapport within the culture, identifies informants and takes copious notes along the way. He or she works to develop understanding of the people and influences of the environment in which they live through longterm observations. These studies are not about making improvements in a society but understanding it. Case Studies Case studies can be either quantitative or qualitative. In the qualitative method, they are studies of “cases” in their reallife context using multiple sources of data collection. They tend to be narrow, focused investigations that are explanatory, exploratory or descriptive in nature. They can involve single cases or multiple cases (one subject or several subjects). The cases are selected based on characteristics that reflect the research focus or interests. Each case remains separate, and multiple data collection methods are used to gather information from each case, such as a review of records, interviews, observations, etc. Because case studies generate a large amount of November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... data from multiple sources, systematic organization of the data is critical. At the conclusion of data collection, the researcher examines the raw data, deliberately using many interpretations to find links between the research cases and the original research questions. A report of findings then is written. The researcher presents conclusions supported by sufficient evidence so that the reader may draw similar conclusions independent of the researcher. Participant Observation As the name implies, participant observation is a method of research in which the researcher participates directly in the events and/or environment being studied. The researcher may be covert or overt about his or her real reason for taking part in the events or environment being studied. This raises ethical issues that must be addressed during an institutional review board approval process. The researcher also should be sensitive to the subjects and have a good understanding of the language and environment. Otherwise, the differences he or she introduces into the environment could change the setting and the outcomes. Because of the nature of this type of research it creates a “role play” dynamic for the researcher. As such, the researcher must consider how he or she appears and his or her purpose for being there. This method also requires copious notes (another consideration for the “role”) and good organization. Disciplined note processing, coding and categorizing are critical. As with the other methods of qualitative research, a lengthy narrative of the results is written that interprets the data from an insider’s perspective. data from each interview are then analyzed, interpreted and reported in a detailed narrative form. Conclusion Qualitative research can provide valuable insight and meaning in many areas of study. It also can be quite challenging to conduct. Much of the quality, reliability and validity of the study will depend on the knowledge, planning and skill of the researcher. He or she often will serve as the data collection instrument and as such must be disciplined and well versed in the method. With the ever-increasing complexity of health care services, qualitative research may provide valuable meaning and help decipher key issues. ◆ Interviewing Interviewing as a qualitative method is a process of gathering in-depth information about a research question from an informant. It is based on a set of interview questions that address the research question or questions. The interview can be conducted in either a structured or unstructured format. In the structured format, each informant is asked the same questions in the same order without elaboration or explanation. The unstructured format also asks the same questions but allows for a more conversational tone and the freedom to elaborate and ask follow-up questions. The researcher decides which format to use during the planning stage and sticks with it throughout the interviews. The researcher must be adept at conducting and guiding the interview while at the same time taking detailed and accurate notes of the informant’s responses. The RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 189 ........................................................................................................... TECHNICAL QUERY To See the Unseen Krys Geissler, MEd, R.T.(R)(M), is a former radiography instructor at the University of Alabama at Birmingham. “Technical Query” is a troubleshooting column that covers image acquisition and processing. The Problem The screening chest radiograph remains the standard general survey film for initial diagnosis of pathology of the chest, lungs and thorax region. However, many forms of pathology can present similar to normal variants in a chest radiograph. Optimal exposure factors and a well-positioned patient can reduce the possibility of inaccurate findings. However, other modalities, such as computed tomography (CT), are used to confirm the presence, size or progression of pathology. A 61-year-old woman recently developed an acute sinus infection, productive cough and shortness of breath. The chest radiographs did not reveal any significant findings except for some mild chronic obstructive pulmonary disease thought to be related to her 20-year smoking history (see Figures 1 and 2). Her symptoms worsened during the next 10 days despite the use of antibiotic therapy for an upper respiratory infection. The patient sought the opinion of a specialist in pulmonary medicine, who ordered a CT scan of the chest/thorax after a clinical examination and review of her chest radiographs. What did the CT scan reveal that is not evident in the chest radiographs? The Answer In the chest radiographs, the pathology is concealed because of a loss of lung expansion in the right upper lobe and unclear areas in Figure 1. Posteroanterior chest radiograph. the shadow of the mediastinum. Because the patient’s symptoms did not improve significantly, a CT of the chest was ordered 10 weeks later. The CT scan with contrast revealed a 9- x 10-cm mass in the right lower lobe, posterior segment (see Figure 3). The lung mass most likely 190 Figure 2. Lateral chest radiograph. represented a bronchogenic carcinoma, with hilar adenopathy and/or paratracheal involvement indicated by the widened mediastinum. A detailed patient history revealed that she had a persistent cough, a 15-pound weight loss and symptoms of chronic bronchitis for the past 9 months. The areas of concern were examined further with CT-guided tissue biopsy to establish a diagnosis and plan for treatment that would definitely exceed another round of ◆ antibiotic therapy. Thanks to Sue Weaver of Leeds, Alabama, for her contributions to “Technical Query.” Figure 3. Sectional CT scan. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... LITERATURE REVIEW Quality for Technologists Literature Review features contributions from volunteer writers from the radiologic sciences, reviewing the latest in publications and communication materials produced for the profession. Suggestions and questions should be sent to [email protected]. QUALITY MANAGEMENT IN THE IMAGING SCIENCES. 4th ed. Papp J. 2010. 532 pgs. Mosby Elsevier. www.us.elsevierhealth .com. $59.95. Quality Management in the Imaging Sciences, 4th edition, by Jeffrey Papp, PhD, R.T.(R) (QM), is a valuable training tool for entrylevel radiologic technologists as well as an excellent resource for veteran professionals pursuing postprimary certification in quality management. The introductory chapter gives a good historical perspective on the origins of quality management (QM) in the radiologic sciences and the state of QM in the 21st century. It makes the distinction between quality assurance and quality assessment and provides concise definitions for the many acronyms and terms used in QM programs. Terminology new to the 4th edition includes key quality characteristics and key process variables. Identifying and analyzing problems and specific quality improvement processes are thoroughly covered, providing a good foundation for subsequent chapters. An overview of statistical terms and graphics helps readers present data. The graphics use radiography examples that correlate well with real-life scenarios. The equipment detailed in the 4th edition is very similar to the 3rd edition, although the material has been reorganized. For example, chapter 3, Film/ Screen Image Receptors, Darkrooms and Viewing Conditions, covers much of the same information as the chapter titled Film Darkrooms in the 3rd edition, but then moves on to film/screen RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 image receptor information previously found in chapter 8. Grid information included in chapter 3 of the previous edition has been moved to chapter 7. It was surprising to see 2 chapters devoted to film processing and processor quality control. While the American Registry of Radiologic Technologists continues to include content on processors and processing, the amount of coverage in the text seems disproportionate to current practice. A technologist in an imaging department with a chemical processor should be aware of the need for processor quality control. However, most departments contract a processor maintenance company to perform cleaning and preventive inspections. The opening paragraph of chapter 6 acknowledges the digital revolution in diagnostic imaging. It is interesting that this statement is made in a chapter devoted to silver recovery. Practicing radiographers in a clinic using film should be aware of the justification for silver recovery and the regulations governing the process. However, the text includes a whole chapter with detailed information about recovery methods. Perhaps information about silver recovery could be consolidated and included with processor quality control in subsequent editions. The quality control chapters reinforce information radiography students learn in physics and image analysis by providing concise information about x-ray generators, ancillary and fluoroscopic equipment. Equipment testing procedures and the tools needed to perform the tests are included. The required specifications are listed at the end of each procedure. This provides technologists with all the information needed to implement a QC program. The 4th edition contains expanded coverage of QC for digital systems. Because this technology is so vendor specific, there is no universal QC program; however, the program recommended by 191 ........................................................................................................... LITERATURE REVIEW the American Association of Physicists in Medicine is outlined, and there are suggestions for basic QC procedures common to all systems. Many of the artifacts described in the outcomes assessment of radiographic images relate to processing, handling and storage. Again, these topics are less relevant in modern imaging departments. It seems likely that more emphasis will be placed on computed and digital radiography artifacts in future editions. The final 5 chapters of the text are modality specific, detailing quality management for mammography, computed tomography, magnetic resonance imaging, ultrasonography and nuclear medicine. Mammography quality standards are very specific, and this is the longest chapter in the book. The Mammography Quality Standards Act has updated the standards, and these revisions are included. The remaining modality chapters are not as detailed as the mammography chapter, but provide a good overview of procedures. The online resources that accompany the book have been upgraded in this edition. PowerPoint presentations are available as an instructors’ resource. The slides include salient points from each chapter. However, some chapters’ slides are mostly text, with the images available for downloading in a separate location. The slides are editable, so most instructors are likely to import these into the PowerPoint presentations. The 165-question practice tests are a valuable resource for technologists pursuing postprimary certification in quality management. This publication provides very detailed information on specific equipment tolerances. In some areas, there may be more detail than is warranted. Nevertheless, this book exposes radiologic technology students to the information they need to build a solid understanding of quality management. Additionally, this text would be a valuable addition to imaging departments for use as a reference when QM questions arise. Amy Freshley-Lebkuecher, MS, R.T.(R)(T) Associate Professor Radiologic Technology Clinical Coordinator Austin Peay State University Clarksville, Tennessee 192 CT OF THE AIRWAYS. Boiselle PM, Lynch DA, eds. 2009 (paperback edition). 408 pgs. Humana Press. www.humanapress.com. $99. The purpose of this book is to explore the fascinating world of imaging of the airways. It was written by physicians for physicians, primarily radiologists and pneumologists. With state-of-the-art CT equipment, images of entire airways can be created in a few minutes. CT has established itself as the pre-eminent noninvasive imaging modality for assessing functional airway abnormalities. This textbook contains new information in 4 sections. First, the introduction is an up-to-date review of the anatomy, physiology and pathology of the airways and CT imaging methods for the chest and lungs. Next, in the section titled Large Airways, the reader learns about CT imaging of tracheal disorders in children and adults. Third, under the heading Small Airways, many lung diseases are considered, such as bronchiolitis, asthma and smoking-related smallairway and interstitial lung disease. The fourth section, Pediatric Airway Disorders, covers large-airway pediatric disease and emerging techniques in CT that are not standard practice. This textbook was a collaborative effort by many prominent physicians from around the world, and is of particular use to radiologists. For the CT technologist, the last chapter, Imaging Overview, is of great interest. The figures and images in this textbook are of high quality, as is the paper, which turns easily in the hand. I would recommend this book for use in any radiology department. Anna F Hess, C.R.T. Napa, California November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... RE: REGISTRY Compare and Contrast: ASRT, ARRT Jerry Reid, PhD, is the regular contributing columnist for “RE: Registry,” which addresses issues concerning the American Registry of Radiologic Technologists. Dr Reid is executive director of the Registry. Questions or comments may be sent to his attention at the ARRT, 1255 Northland Drive, St Paul, MN 55120-1155. Individuals sometimes confuse the American Society of Radiologic Technologists (ASRT) and the American Registry of Radiologic Technologists (ARRT). Sometimes even those who recognize them as separate organizations confuse their functions. This confusion is easy to understand given the shared interests and historical connections between the 2 organizations, and considering their acronyms differ by only one letter. Although the organizations work closely together, they are separate and distinct entities with different roles. Comparing and contrasting the organizations on several factors highlight some of the ways that they are different and some of the ways they are alike. Historical Roots ASRT was founded in 1920 by a group of 13 technologists and Ed C Jerman for the purpose of forming a professional membership society for the growing number of technologists. Mr Jerman was elected as the first president of the society. That same year, a committee of the Radiological Society of North America (RSNA) recommended the establishment of a certification mechanism for identifying technologists who met standards of education, experience and ethics. RSNA invited the American Roentgen Ray Society to join this effort. The Registry was launched in 1922. Ed C Jerman was appointed as the examiner for the Registry. Clearly, the cross-pollination between the 2 organizations started from the outset. This is just the first instance of a luminary in the profession serving as an important connection between the organizations. The founding of the professional society and the certification agency as separate organizations, while not entirely unique, is not always the case in other professions. Frequently, the certification organization is founded by the professional society and may actually be a component of the society. This model RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 creates challenges in maintaining separation of purposes. In fact, the bodies that accredit certification organizations, such as the National Commission for Certifying Agencies, require a firewall to avoid undue influence over the decision making for certification by the professional society and prevent conflicts of interests. Incorporation as separate legal entities is the most effective way to achieve this separation. Mission and Vision The ASRT’s mission is to “to advance the medical imaging and radiation therapy profession and to enhance the quality of patient care.” ARRT’s mission is to “promote high standards of patient care by recognizing qualified individuals in medical imaging, interventional procedures, and radiation therapy.” The inclusion of the patient in the missions of both organizations highlights a major commonality in purpose. ASRT’s vision states that it “will be the premier professional association for the medical imaging and radiation therapy community through education, advocacy and research.” ARRT’s vision states that it “will be the premier organization for credentialing healthcare technology professionals in medical imaging, interventional procedures and radiation therapy.” Combining the information in the missions with information from the visions points out a difference. The difference lies in how patients are served. ASRT focuses on enhancing the profession by “education, advocacy and research,” whereas ARRT enhances the profession by setting and administrating standards for the qualifications of individuals in the profession. Members and Registrants ASRT has approximately 137 000 members. The ARRT bylaws establish that ARRT has only 9 members — the 9 trustees. The roughly 300 000 R.T.s are registrants as opposed to members. This 193 ........................................................................................................... RE: REGISTRY distinction is not a “distinction without a difference,” but in fact has important consequences regarding how the governance mechanism is created and how policies are set. productively, it provided funding to the ASRT Education and Research Foundation to produce the Online Digital Imaging Academy. This illustrates how ARRT can support education without directly providing it. Governance Geography The ASRT Bylaws establish that the governance for the organization will be through a House of Delegates and a Board of Directors. Voting members of the ASRT elect representatives to the House and to the Board. The bylaws of the ARRT establish its governing body as the 9-member board of trustees. ARRT trustees are appointed to the board by the ASRT and the American College of Radiology (ACR). All ARRT policies are established by the board of trustees. Policy Creation ASRT members vote for representatives who in turn set ASRT policies. ARRT policy, on the other hand, is set by the ARRT board of trustees. ARRT’s proposed policies are published for public comment, and the board carefully considers the comments received. However, the board ultimately sets the policy based upon its judgment of how best to achieve the organization’s mission. Initial Education ASRT develops national curricula for radiography and radiation therapy education. ARRT establishes educational standards for certification as a “higher order” standard. That is, ARRT requires that candidates for certification complete an accredited educational program and requires that graduates of the program complete a nationally recognized curriculum such as that developed by ASRT. ARRT representatives participate in ASRT’s curriculum development and revision process, and ASRT representatives participate in ARRT’s certification standards development and revision process. Continuing Education ASRT both provides continuing education (CE) activities and evaluates CE as one of ARRT’s Recognized Continuing Education Evaluation Mechanisms. ARRT does not provide any type of educational activities because it is generally viewed as a conflict of interest for a certification organization to both set the requirements for certification and to provide the education. ARRT certainly has a stake in high-quality education. For example, when ARRT saw the need for better education in digital imaging so that it could be examined more 194 ASRT’s headquarters is located in Albuquerque, New Mexico. ASRT made a deliberate decision to relocate from Chicago to Albuquerque in 1983 for a number of business reasons. ARRT headquarters has been in St. Paul, Minnesota, since the 1920s. ARRT’s location was determined by historical happenstance. The Registry was initially staffed by the editor of the RSNA’s journal, Radiology, which was based in Omaha, Nebraska. When responsibility for publishing Radiology was moved to J.R. Bruce Publishing in St. Paul, the Registry operations came with it. Although the ARRT has considered relocation several times during its history, the nature of ARRT’s work is such that a central location is more important than any other business factors. Being centrally located is an advantage given the large number of consultants who meet at the ARRT office twice a year to develop examinations. Staff ASRT has a staff of approximately 110 to serve its 137 000 members. ARRT has a staff of about 65 to serve its 300 000 registrants. The staff-to-member and staff-to-registrant ratios reflect the different purposes of the organizations. ASRT, as a professional membership organization, has a broad scope of activities ranging from peer-reviewed journals, advocacy campaigns, education and other membership-related offerings. As with all certification organizations, ARRT has a much narrower range of activities that fall within its mission compared with professional membership societies. ARRT’s laser-like focus on determining and applying standards of qualification allows it to carry out its work with a smaller staff. Disciplines Covered Both ASRT and ARRT include the full range of medical imaging and radiation therapy in their scopes of interest. Both organizations serve as umbrella groups under which all technologists, regardless of discipline, are served. Conclusion The factors compared and contrasted here represent only a sampling of the many that could be used November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... to illustrate how ASRT and ARRT are both alike and different. The 2 organizations are connected across time by common interests and individuals serving those interests. Even this “RE: Registry” column illustrates that connection: The tradition of including a column by the ARRT in the professional society’s Journal goes back to 1933, when The X-ray Technician, forerunner of Radiologic Technology, began including a section listing newly ARRT-certified individuals and, later, news from the Registry. ◆ RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 195 ........................................................................................................... STUDENT SCOPE Dose Reduction in CT Elizabeth Hemme, AAS, R.T.(R), is a student in the Radiation Science Technology baccalaureate degree program at the University of Cincinnati’s Raymond Walters College in Ohio. She is employed by Mercy Health Partners as a staff radiographer. Computed tomography (CT) has gained immense popularity as a diagnostic tool since its introduction in the 1970s. Because of its widespread and ever-growing use, the exposure to radiation from CT scans has become an important issue. CT scans offer a much higher ionizing dose of radiation than do other methods of imaging. For example, a typical chest CT scan has an effective dose of between 5 and 7 mSv, which would be equivalent to about 2 years of natural background radiation. A typical chest radiograph has an effective dose of only 0.02 mSv, comparable to only 10 days of natural background radiation.1 Although it is evident that the radiation dose received is considerably more for CT than for radiography, the dose received from one diagnostic CT is still within acceptable limits of exposure. Although CT examinations make up only 12% of all diagnostic radiology examinations, they contribute more than 45% of the population’s medical radiation exposure,2 and this percentage is only expected to rise. When performing any radiologic imaging study, keeping patients’ dose as low as reasonably achievable (ALARA) is an ethical issue that always should be taken into consideration. For this reason, much research has been done to develop ways to reduce dose during CT scans. Literature Review In 2007, approximately 62 million CT scans were performed in the United States alone.3 Four million of those examinations were on children. The most effective dose reduction tool is to decrease the number of CT studies prescribed overall. To avoid needless procedures, the physician must thoroughly review the risks vs the benefits on an individual patient basis. When a CT scan is warranted by medical necessity, the associated risk is small compared with the diagnostic information obtained. Brenner hypothesized that 196 about one-third of all exams performed were not justified by medical need.3 If Brenner was correct in his assumption, more than 20 million adults and 1 million children are needlessly exposed to radiation each year.3 When CT is absolutely necessary, optimization of dose and scan protocols should be the priority, in keeping with ALARA principles. “The principle of optimization should be applied on an individual basis so as to achieve image quality sufficient to provide diagnosis with the minimum dose to the patient. Intuition suggests that it would be reasonable to expect to use more radiation to get a satisfactory image with larger and less with smaller patients and vice versa.”4 The International Atomic Energy Agency conducted a study to prove just that. The agency also suggested that the diagnostic information offered by a CT scan was not affected by increasing technique (thereby increasing dose), but resulted in images with less noise and fewer streak artifacts. It also assessed changes in dose while employing different scanning techniques and noted different techniques that vendors offered on equipment.4 Shrimpton and associates suggested many ways to minimize the patient’s exposure to radiation, including the use of automatic exposure control (AEC), altering tube current and using noise reduction filters. They also suggested employing equipment that indicated patient dose after completion of the examination. This would allow the actual patient dose to be compared to the estimated dose for the examination.5 Blatant overexposure would be monitored and eliminated during future examinations. In addition, Shrimpton et al emphasized that applying lead shielding devices whenever possible greatly reduces patient dose during CT procedures. Lead shielding is an obvious option in reducing the amount of scatter radiation that reaches the patient. Sudheendra conducted a study in 2006 that tested November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ........................................................................................................... the difference in radiation exposure when not using a shield, using a single or double layer of 180° shielding and using a single or double layer of 360° shielding.6 Scans were done for the head, chest, abdomen and pelvis using a different method of shielding for each test. Although the reduction in scatter radiation was different for each organ and test, a reduction was seen in all cases when a lead shield was used. This is a simple and economical method of dose reduction that could be easily adopted by facilities worldwide. Many companies have capitalized on this aspect of dose reduction by producing lead shields to ensure that critical organs not intended to be scanned are protected. One such company, RadPad, has shields designed to protect the brain, thyroid, chest and abdominal areas.7 Machines with AEC systems eliminate much of the radiation dose produced by CT scanners that do not have AEC technology. With AEC, the technique is adjusted according to the patient’s body habitus (height, width, depth). McCollough and associates wrote, “AEC systems in which the tube current is modulated along the x-, y-, and z-axes and in which the acceptable level of image noise is varied according to patient size, anatomic region and diagnostic task can provide significant levels of dose reduction with minimal operator intervention.”8 As a result, these authors speculated that AEC systems eventually will become mandatory and easily available. Along with optimizing scan protocol, using shielding and considering the justification for the examination, Mozumdar suggested further education of consumers.9 Without formal education, a patient may not be aware of the fact that an abdominal CT scan is equivalent to 500 chest radiographs and more than 3 years of natural background radiation.1 Education empowers patients and allows them to form opinions on their own regarding diagnostic tests. Requiring that all CT scans be ordered by an experienced radiologist instead of a general physician also would help justify examinations and eliminate unnecessary tests. If the radiologist were the one to prescribe an imaging study, magnetic resonance (MR) imaging or ultrasonography might be chosen in lieu of a CT scan. This would eliminate radiation dose altogether. Although there are definite disadvantages to Mozumdar’s suggestions, the benefit of less radiation exposure is immense.9 On February 25, 2010, the Medical Imaging and Technology Alliance (MITA) publicized that CT equipment manufacturers would begin installing new radiation dose safeguards.10 One such safeguard is an alert when the recommended radiation dose is surpassed for a particular scan. The dose limits will be specific per examination and established by the facility. MITA also stated that these same manufacturers are working to set maximum dose limits on the equipment so unnecessary radiation is impossible. A spokesperson for the organization wrote that, “This feature is designed to prevent the use of hazardous levels of radiation that could lead to burns, hair loss or other injuries.”10 The upgrades should be implemented this year on new equipment and can even be offered as a software upgrade for existing scanners. Manufacturers worldwide are taking proactive roles in decreasing patient dose during diagnostic examinations. For example, Philips, a leading equipment manufacturer, acknowledges that dose reduction and maintenance are among its top priorities. Consequently, Philips employs DoseWise Radiation Management, which is a set of techniques, programs and practices based on the ALARA principle.11 DoseWise Radiation Management is always implemented during new equipment design and development. Philips’ most recent application is iDose, which “enables up to an 80% reduction in dose while maintaining diagnostic image quality and fast reconstruction times. iDose overcomes limitations, such as image noise, of conventional filtered back projection (FBP) reconstruction.”11 Palacio believes that advanced visualization (AV) also may play a role in lowering radiation dose during radiology studies. AV systems may be able to reduce the noise in images and produce higher-quality images at lower dose to the patient. He quoted Robert Taylor, PhD, president and chief executive officer of TeraRecon, a leading medical equipment manufacturer: If you look at the way CT data is processed, the data is always managed with advanced visualization — we derive stenosis, vessel diameter or bone quality and these solutions, the quality of these algorithms, directly impact the dose needed to achieve a viable clinical workup. Our software is designed to make the algorithms and the advanced tools work even if it is a noisy low-dose image.12 Implementing new technology and software definitely will allow facilities and technologists to reduce dose with no additional effort on their part. Implications Reducing patient exposure in CT is extremely important. All imaging technologists should strive to provide quality images using the lowest amount RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 197 ........................................................................................................... STUDENT SCOPE of radiation possible. Because dose from CT scans is greater than for all other imaging modalities, minimizing dose is especially crucial for this modality. The National Council on Radiation Protection and Measurements (NCRP) establishes policies and procedures regarding radiation exposure based on ALARA principles. A spokesperson for the NCRP stated, “The primary goal is to keep radiation exposure of the individual well below a level at which adverse effects are likely to be observed during the individual’s lifetime. Another objective is to minimize the incidence of genetic effects.”13 It is the ethical responsibility of each technologist to follow this instruction, whether by confirming scans ordered, using optimal protocol and AEC, or using various lead shields. By employing such dose-reduction techniques, technologists can help to minimize or eliminate the occurrence of deterministic, stochastic and even genetic responses. Not only is ALARA important for the patient’s benefit, it also is significant from a risk management standpoint. The litigious society in which we live does not accept mistakes, no matter the situation. A lawsuit regarding radiation overexposure not only would compromise the facility in which the technologist is employed but also could jeopardize the career of the technologist. Conclusion CT imaging is a very important aspect of modern medical technology. These scans quickly and easily aid in visualization and diagnosis of pathologies that might otherwise be missed. Although CT scans can be very beneficial, the patient exposure during a scan is far greater than exposures from other imaging modalities. A typical chest CT scan provides 73 times the amount of effective dose than a standard 2-view chest radiograph.1 Although a significant amount of radiation, this exposure is acceptable in any life-threatening situation. Lee, Brenner, Shrimpton, Sudheendra, Palacio, Taylor, McCollough and many others set out to prove that there are relatively easy ways to reduce radiation dose during CT examinations. Not only does the ordering physician have a responsibility to ensure that the examination is medically necessary, the technologist also needs to be conscientious about reducing dose by using optimal technique factors, AEC and filtration. Manufacturers are altering CT equipment, placing a greater emphasis on reducing radiation exposure to the patient and producing shielding devices fitted to specific anatomic areas. Education of the patient and 198 continuing education of radiology professionals will improve decision making and raise awareness about the risks involved. ◆ References 1. Radiological Society of North America Inc. Safety in medical imaging procedures. http://radiologyinfo.org/en /safety/index.cfin?pg=sfty_xray#3. Accessed January 28, 2010. 2. Lee K. Radiation safety: radiation dosimetry and CT dose reduction techniques. In: Budoff MJ, Shinbane JS, eds. Handbook of Cardiovascular CT. New York, NY: Springer; 2008:1-14. 3. Brenner D, Hall E. Computed tomography — an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. 4. International Atomic Energy Agency. Dose reduction in CT while maintaining diagnostic confidence: a feasibility /demonstration study. www.pub.iaea.org/ MTCD/publica tions/PDF/te_1621_web.pdf. Accessed February 18, 2010. 5. Shrimpton PC, Hillier MC, Lewis MA, Dunn M. National survey of doses from CT in the UK: 2003. Br J Radiol. 2006;79(948):968-980. 6. Sudheendra D. Diagnostic and interventional CT shielding: a dramatic decrease in scattered radiation for patients. http://radpad.com/Images/SIR2006-181.pdf. Accessed January 25, 2010. 7. RadPad Scatter Protection. www.radpad.com/pg2CT.html. Accessed May 22, 2010. 8. McCollough CH, Bruesewitz MR, Kofler JM Jr. CT dose reduction and dose management tools: overview of available options. RadioGraphics. 2006;26(2):503-512. 9. Mozumdar B. The control of radiation exposure from CT scans. The Internet Journal of Radiology. 2003;3. www .ispub.com/journal/the_internet_journal_of _radiology/. Accessed January 5, 2010. 10. HealthImaging.com. CT vendors to install rad dose safeguards; ACR calls for mandatory accreditation. www .healthimaging.com /index. php? option=com_articles& view=article&id=20891:ct-vendors-to-install-rad-dose-safeguards-acr-calls-for-mandatory-accreditation. Published February 26, 2010. Accessed April 11, 2010. 11. Higher Expectations, Lower Dose: Philips CT iDose Iterative Reconstructive Technique. Philips Healthcare website. www.healthcare.philips.com /asset. aspx?alt=&p=http://www.healthcare.philips .com/pwc_hc/main/products/ct/products/iDose /brochure/452296259621_CTiDose_LR.pdf. Published March 2010. Accessed July 2, 2010. 12. Palacio M. Technology trends: advanced visualization. Appl Radiol. 2010;39:27. 13. Gurley LT, Callaway WJ. Introduction to Radiologic Technology. 6th ed. St. Louis, MO: Mosby; 2006. November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY ......................................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . PATIENT PAGE Contrast Agents This patient education page provides general information concerning the radiologic sciences. The ASRT suggests that you consult your physician for specific information concerning your imaging exam and medical condition. Health care professionals may reproduce these pages for noncommercial educational purposes. Reproduction for other reasons is subject to ASRT approval. Although bones show up clearly on x-ray images, some other organs and tissues do not. Contrast agents, also known as contrast media, often are used during medical imaging examinations to highlight specific parts of the body and make them easier to see. Contrast agents can be used with many types of imaging examinations, including x-ray exams, computed tomography scans and magnetic resonance imaging. Contrast agents are administered in different ways: Some are given as a drink, others are injected or delivered through an intravenous line or an enema. After the examination, some contrast agents are harmlessly absorbed by the body; others are excreted through urine or bowel movements. Contrast agents are not dyes; they do not permanently discolor internal organs. Instead, they temporarily change the way x-rays or other imaging tools interact with your body. If the exam your physician requested for you requires a contrast agent, a radiologic technologist will explain how it is used before the An x-ray film showing the large intestine filled with exam begins. Radiologic barium, a common contrast agent. technologists are skilled health professionals who have specialized education in the safe use of contrast agents as well as in radiation protection, radiographic positioning and procedures. The technologist will answer any questions you have about the examiFor more information, nation or the contrast agent. contact the American Society Some contrast agents carry a small of Radiologic Technologists, risk of allergic reaction, so it is impor15000 Central Ave SE, tant to tell the radiologic technologist Albuquerque, NM who will perform your examination if 87123-3909, you have any type of allergy. Also, if you or visit us online at notice any unusual or uncomfortable www.asrt.org. RADIOLOGIC TECHNOLOGY November/December 2010, Vol. 82/No. 2 symptoms during the examination, be sure to tell the technologist. It is his or her job to make you as comfortable as possible while obtaining the best image possible. One of the most commonly used contrast agents is barium sulfate. Barium blocks the passage of x-rays, so barium-filled organs stand out better on x-ray exams. For an examination of the esophagus or stomach, patients are asked to drink a mixture of barium sulfate and water, sometimes with vanilla or fruit flavoring added. This mixture usually is thick and white. For an examination of the rectum or colon, barium is administered rectally through an enema tube. After the exam is finished, you can go to the bathroom and expel the barium. It is a good idea to increase your fluid intake after the exam to help remove the contrast from your body. Your bowel movements may be white for a few days. Contrast agents containing iodine are used to image the urinary tract, blood vessels, spleen, liver and bile duct. Iodine contrast agents are clear liquids and usually are injected. Patients who are allergic to iodine should not receive this type of contrast agent. Nonionic contrast may be available. Be sure to tell the technologist which medications you are taking and your current medical conditions before the exam begins. Some conditions and medications make the use of iodine contrast agents riskier. You may notice side effects associated with the use of iodine-containing contrast agents. These include a feeling of warmth or flushing, a metallic taste in the mouth, light headedness, nausea, itching and hives. Usually, these symptoms are mild and disappear quickly. However, it is a good idea to tell the radiologic technologist if you experience any of them. In extremely rare instances, these side effects can be serious. The technologist will monitor you carefully for signs of side effects. ◆ 203 Español . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . En ................ PATIENT PAGE Medios de Contraste Esta página educacional del paciente provée información general en cuanto a la ciencia radiológica. ASRT sugiere que usted consulte con su doctor para obtener información específica concerniente a su examen de imagen y condiciones medicas. Los profesionales del cuidado de la salud pueden reproducir estas páginas para ser usadas sin recibir lucro económico. La reproducción de estos documentos para ser usadas para otros objetivos necesita la autorización del ASRT. Para más información, contáctese con la Sociedad Americana de Tecnólogos Radiológicos, 15000 Central Ave SE, Albuquerque, NM 871233909, o visítenos en la web electrónica: www.asrt.org. 204 Aunque los huesos aparecen claramente en las imágenes de rayos-X, algunos órganos o tejidos no. Los agentes de contraste, también conocidos como medios de contraste, a menudo se utilizan durante los exámenes médicos de estudios de imagen para resaltar partes específicas del cuerpo y hacerlas más fáciles de ver. Los medios de contraste pueden utilizarse con muchos tipos de exámenes de imagen, incluyendo rayos-X, tomografía axial computerizada y resonancia magnética nuclear. Los medios de contraste se administran de diferentes formas. Algunos son administrados como una bebida, otros son inyectados o administrados a través de una vía intravenosa o un enema. Después del examen, algunos medios de contraste son absorbido por el cuerpo sin causar daños; otros son excretados en la orina o en las heces. Los medios de contraste no son tintes; no manchan de forma permanente los órganos internos. Estos cambian temporalmente la forma en que los rayosX u otras herraamientas de estudios de imagen interactúan con su cuerpo. Si el examen que su médico solicitó para usted requiere un medio de contraste, un tecnólogo radiológico le explicará como se utiliza antes de empezar el examen. Los tecnólogos radiológicos son profesionales especializados de la salud que tienen una educación especializada en el uso seguro de medios de contraste así como también en protección radiológica, posicionamiento radiográfico y procedimientos. El tecnólogo le responderá cualquier pregunta que tenga sobre el examen o el medio de contraste. Algunos medios de contraste llevan un pequeño riesgo de reacción alérgica, así que es importante comunicarle al tecnólogo radiológico, quien realizará su examen, si usted tiene algún tipo de alergia. También, si usted siente cualquier síntoma inusual o de malestar durante el examen, asegúrese de comunicárselo al tecnólogo; es su trabajo hacerle sentir tan cómodo como sea posible mientras se obtiene la mejor imagen posible. Uno de los medios de contraste más utilizados normalmente es el sulfato de bario. El bario bloquea el paso de los rayos-X, de forma que los órganos llenos con bario salen mejor en los exámenes de rayos-X. Para un examen del esófago o del estómago, se pide a los pacientes que beban una mezcla de sulfato de bario y agua, al que se le ha añadido algunas veces esencia de vainilla o de fruta. Esta mezcla normalmente es espesa y blanca. Para un examen del recto o el color, se administra bario por vía rectal a través de un enema. Después de haber terminado el examen, usted puede ir al baño y expulsar el bario. Es una buena idea aumentar su ingestacion de líquidos después del examen para ayudar a eliminar el medio de contraste de su cuerpo. Sus deposiciones o heces pueden ser blancas durante unos cuantos días. Los medios de contraste que contienen yodo se utilizan para obtener imágenes del, el tracto urinario, los vasos sanguíneos, el bazo, el hígado y las vías biliares. Los medios de contraste con yodo son líquidos transparentes y normalmente son inyectados. Los pacientes que son alérgicos al yodo no deben recibir este tipo de medio de contraste. Asegúrese de comunicar al tecnólogo los medicamentos que está tomando y sus condiciones médicas actuales antes de comenzar el examen. Algunas condiciones y medicamentos pueden hacer el uso de los medios de contraste con yodo más riesgoso. Usted puede que sienta los efectos secundarios asociados con el uso de los medios de contraste que contienen yodo. Estos incluyen un sentimiento de calor o sofoco, un saber metálico en la boca, mareos, náuseas, picor y ronchas. Normalmente, estos síntomas son leves y desaparecen rápidamente. Sin embargo, es una buena idea comunicarle al tecnólogo radiológico si usted experimenta cualquiera de ellos. En casos extremadamente raros, estos efectos secundarios pueden ser graves. El tecnólogo le monitorizará atentamente por la aparición de signos de efectos secundarios. ◆ November/December 2010, Vol. 82/No. 2 RADIOLOGIC TECHNOLOGY Physicians, Medical Physicists and Radiologic Technologists — TAKE THE PLEDGE TO IMAGE WISELY ™ Image Wisely,™ a campaign to build awareness and engage participation in adult radiation optimization, is sponsored by the American College of Radiology, Radiological Society of North America, American Society of Radiologic Technologists, and American Association of Physicists in Medicine. It is an initiative of the ACR/RSNA Joint Task Force on Adult Radiation Protection. BE SURE TO VISIT IMAGEWISELY.org NEW website featuring in-depth information on adult radiation dose safety for imaging physicians, medical physicists, radiologic technologists, referring practitioners, equipment manufacturers and patients. Website highlights: • Journal articles and white papers from leading contributors • Image Wisely™ pledge form • Patient Medical Imaging Record • Patient primer on radiation benefits and risks • Vendor equipment data Be among the first to Image Wisely™ Stop by any of these booths at RSNA to learn more and take the pledge: • ACR booth #2809 • ASRT booth #605 • AAPM booth #400 • Radiologyinfo.org RSNA services area