AKA RWJMS StudentPACS 2 wk Elective
Salil Soman, MD, MS
Radiology Resident, UMDNJ RWJMS
Spring 2009
Welcome
 Welcome to the Robert Wood Johnson Medical School
Department of Radiology Interactive Radiology
Elective – Student PACS.
 We look forward to having you rotate with us!
See One, Do One, Teach One
 On this rotation students are introduced to a selection
of disease entities represented in imaging studies.
 They then independently re-review the cases at PACS
workstations and select images that best visualize the
disease for presentation in SPACS modules.
 They also research the disease process and create a
series of questions which convey pertinent facts about
the presentation, diagnosis, and management of that
entity.
 Their final modules are then added to the Student
PACS web site as tutorial modules.
Finding A Needle In a Hay Stack
 Aside from the act of recognizing a identifying a
finding on a single image, radiologists often have to
search through a series of images (from tens to
thousands per study) to find the pertinent findings
 These modules seek to simulate this process of
searching not only on a single 2D image, but through a
series of them.
First Steps
• Get registered for the elective through registrar
• Complete Our Online form prior to first day of
rotation (As early as possible after officially being
registered for the rotation)
• Make an appointment to meet with a supervising
resident on the first day of rotation
• If you own them, bring your laptop and USB drive to
the first day meeting (not required)
Expectations
 Self Directed Work
 Goal Oriented Reference Searches
 Delivery of Final Products by decided guidelines
 Usually completion of 6 to 7 modules by end of
rotation
 Usually submission of first draft of all modules by
Monday of second week.
About The Web Site
http://rwjradiology.umdnj.edu under “Educational Material”
section
• StudentPacs subsection:
– http://www2.umdnj.edu/radpweb/SPACS2/index.html
• Site Highlights
– About the project
– Current Staff
– Instruction manuals
– Example modules
– Modules of previous rotation students
– Rotation registration form.
About SPACS Flash Modules
• Created by RWJMS Alumni and Radiology Dept Faculty & Residents
• The SPACS module is a Macromedia Flash™ animation that presents
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serial images, like those from a CT or MRI study, in a simulated PACS
interface.
It allows medical students and residents to experience the human body
like they would at the expensive PACS workstations from any computer.
Users can flip through images, zoom in, and pan around to follow
structures through slices of images at their own pace.
Pre-defined areas of interest, which we call "findings“, can be selected
by the user, prompting the program to ask a set of questions.
Because the modules are created in Flash, they are inherently easy to
distribute, either over the web or other means. File sizes relatively small
and the compatibility is nearly universal.
Process Overview
• Select and Review Cases
• Acquire Relevant Images and Reports with NO PATIENT
INFORMATION
• Create Tutorials Via Software
• Send first draft to supervising resident
– (html and swf files only) via email
• Revise and expand as apropriate
• Review tutorials with an attending radiologist.
• Turn in final products
– (.swf /.html /.fla files, txt of report with no patient
information, all used source jpg’s, word doc of all text used in
modules, your title, description, difficulty rating, radlex
keywords, html code for upload)
Typical 2 week Elective
Student Register
for elective,
complete online
registration form,
and review online
introduction prior
to elective
Students Shadow
attending
Radiologists in
main department
and collect cases
of interest for
creating tutorials
Students oriented
by supervising
Radiology
Resident
Students research
medical topics
related to case,
and then create
SPACs Module
Students
independently review
cases in PACS,
output images that
optimally represent
findings, w NO
personal health
information
Student reviews
edited modules
with attending
radiologist in main
department and
gets final edit
recommendation
First draft
flash file
emailed to
reviewing
resident, who
provides
feedback.
Student selects
Radlex
keywords, and
labeled case
made available
on elective web
site.
Getting Cases
 Review study with Faculty Radiologist or Radiology
Resident
 During this session write down Accession Number
(will allow you to look up case later to acquire images
and report)
 Focus questions and note taking on clinical aspects of
cases (including all pertinent aspects of radiology)
Case History
• Try to collect the information the radiologist had
available to best simulate experience of reading the
case
• Requisitions (often scanned in as a series in study)
• In Clinical History portion of current report or
available prior reports
– May often be information clinician provided when
directly consulting radiologist reading the study
What to Get
 From Supervisor
 Accession Number
 Pertinent Available Hx (Simulate actual experience)
 From PACS computer (on your own)
 JPG’s windowed as you wish with NO patient
information
 Create a txt file of report with NO patient information
Background About CT
 Algorithms
 Bony vs Soft Tissue
 Leverage Multislice Scanner
 Slice Thickness
 Reformats
 Window and Level
 Different settings highlight different structures
Selecting Images
 Choosing Series
 Different Algorithms
 Different Recons
 Minimize Number of Images
 Images to best convey information
 Optimal windowing
Information Relevant to Radiology
Radiology Relevant Information
NAME THE TYPE OF STUDY (for out of the
ordinary cases)
2. DESCRIBE FINDINGS; USE “BUZZ” WORDS IF
DIAGNOSIS IS CERTAIN
3. OFFER DIFFERENTIALS IF ANY
4. DISCUSS MANAGEMENT, ESPECIALLY CASES
THAT REQUIRE EMERGENT ATTENTION
1.
Your File Structure
• Create a folder titled with your name
• Within that folder create subfolder for each of your modules
titled with the module name, containing:
– A folder with all of the source jpeg images you used
– when creating a new module, tell software to save it into the folder
created for that module, which will make .fla file
– When you publish your project, it should create .html and .swf files
in the module’s folder
– A word document with all of the text you entered into the software
for each finding, answer, etc
•
use for spell checking and later for indexing the modules for search
– The text file with your html for the module (see later slide)
– A word document which lists what image numbers your findings are
on, and which contains your title, description and radlex keywords.
Flash 8 Professional
Student PACS extension
Using the Student PACS extension
Using the Extension in Flash I
• Create a new module with extension panel
• Name and save the file as described on the “Your File
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Structure” slide.
Direct the subsequent dialogue box to the location of
your jpeg images
Create hot spots on your images
For each hotspot create findings and questions
MAKE SURE THE “In Order” option IS SELECTED
Using the Extension in Flash II
• At the end of EVERY explanation should be a reference
• At the end of the last question for each finding, add
text as a new paragraph after the reference for the
explanation of the last question giving the user a
CLUE that they go look for another finding (for all
explanations except the LAST finding).
• Choose the close or save option from the SPACS panel
once you are done working on the module.
• When you are ready to view the module in a web
browser choose “Publish” from the SPACS menu on the
SPACS panel within flash.
If You Can’t Find the SPACS Panel
 Open Flash Professional
 Create a new blank document
 Then look under the “Windows” drop down menu,
choose the “Other Panels” option and StudentPACS
should be an option under the subsequent menu.
Versioning
• When you create a module, all of your work gets save
as a “.fla” file.
• We recommend keeping a copy of the last working
version of each .fla file when making changes
– (so you can go back to the older file that worked in case
something goes wrong with your changes)
– This should be done manually from the computer using
the copy command (not using Save As from within
flash)
About References
• EVERY answer in the module, regardless how
fundamental needs to have a reference (textbook,
journal article, web site less preferable) including at
least a chapter number, though page number is
preferred.
• All references should be in standard MLA format.
• If you find it helpful, UMDNJ provides a free copy of
EndNote to all UMDNJ students
(http://www.umdnj.edu/librweb)
Search Tools / Resources
• Google / Google Scholar / Yottalook (Google tailored for
Radiology by RSNA)
– http://www.yottalook.com/
• Pub Med
– http://www.ncbi.nlm.nih.gov/pubmed/
• UMDNJ Library Digital Resources (Radiology and Other
Textbooks, E Journals)
– http://www.umdnj.edu/librweb
• Evidence Based Radiology
– http://evidencebasedradiology.net/
• Free Large file email Transfer Web Service
– e.g. http://yousendit.com
The Development Process
• Once you have created your first draft of your first module,
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select the “Publish” option from the SPACS menu on the
SPACS panel.
This will result in a .html and a .swf file being created in
your folder for your module.
Email your supervising resident the .html and .swf files for
your first module along with a list of on what image
number in your .swf each finding is on.
This will require you to look at the html file in a web
browser to get the image numbers.
You may need a send file service like “yousendit.com” to
send the swf and html files.
• (yousendit allows you to send files up to 100 MB for free).
Radlex Classification
 Ontology created by RSNA for classifying radiological
entities, similar to the SNOMed and MESH ontologies
which are used in indices like PubMed
 Radlex Term browser at http://radlex.org
 Terms help make modules discoverable via searches
 Each module should have radlex terms identified.
Choosing RadLEX terms
 Highlighted structures are (i.e. internal carotid
artery, small bowel, pancreas)
 Body part imaged
 Imaging modality used / type of study
 Teaching points (i.e. pneumatosis coli,
pancreatitis, aspergillosis)
 Radiographic signs (i.e. signet ring sign)
 Miscellaneous terms introduced through
questions
Choosing Difficulty Ratings
 Overall tutorial difficulty
 Difficulty of imaging findings
 Difficulty of questions
Add Final Author Information
 In the final version of each module as it’s own
paragraph after the patient history please list the
author, supervising resident and editors.
HTML Code for Web Site I
 Create a copy of the following code for each of your
modules with the following information filled in:
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9.
Name of Module
Date of final submission
Description
Radlex Terms
Your name as Author
Supervising Resident
Editors
Image numbers on which each of the findings are present (e.g.
Finding 1: images 2-7, Finding 2: Image 4-5)
Difficulty Ratings: overall difficulty, findings difficulty and
questions difficulty (rate as easy/medium/difficult)
HTML Code for Web Site II
NOTE : EVERYTHING IN BOLD BELOW SHOULD BE REPLACED WITH THE INFO FOR YOUR
MODULES
COPY THE TEXT BELOW INTO A TEXT FILE FOR EACH MODULE AND EDIT ACCORDINLY.
<!-- Start Post -->
<div class="post">
<div class="date">
<span class="month">Oct</span>
<span class="day">9</span>
<span class="year">2008</span>
</div> <p><span class="title style1">
<a href="http://www2.umdnj.edu/radpweb/SPACS/Elective_Cases/Lauren%20Kovacs/bowel/AbdominalPain2.html"
target="case"> [ Bacteremia and abdominal pain ]</a></span>
76 year old male with bacteremia and abdominal pain with history of clostridium difficile colitis.<BR>
<span class="title">Author:</span> Lauren Kovacs, MS III</span><BR>
<span class="title">Resident Supervisor:</span> Salil Soman, MD, MS<BR>
<span class="title">Editors:</span> A. Masand, MS III, S.Soman, MD, MS, JK Amorosa, MD<BR>
<span class="title">Radlex Terms:</span> pneumatosis coli (air in the bowel wall), causes: bowel perforation, ischemic
bowel disease, blunt abdominal trauma; clostridium difficile; pneumoperitoneum; upper GI barium study; CT
Abdomen/Pelvis without contrast
<BR><span class="title">Clues:</span> Finding 1: images 1-5, Finding 2: images 7-9, Finding 3: images 4-5
<BR><span class="title">Difficulty:</span><b>Overall</B> Easy, <b>Findings:</B> Easy, <b>Questions:</B> Medium</p></div>
<!-- End Post -->
Final Products
(ALL WITHOUT ANY PATIENT INFORMATION!)
 Source JPG’s
 Report of Case
 Word Document with ALL text entered into the case (use this to do
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your spell checking)
A title, brief description and difficulty rating of each module (has 3
parts – overall, findings, and questions)
.fla source file
.html and .swf files
File with image numbers of findings (e.g. finding 1: slices 1-3)
Radlex terms of module
HTML Code for each module in a text file
On Last Day of Rotation
• Copy the folder you created titled with your name
(which contains all your final materials for each of
your modules) to the C:\studentPACS directory on the
computer in MEB 405
• Turn in a CD (or DVD) of this folder with your name
and rotation dates written on it to the department
elective coordinator (Mary Ellen Hobler) in Radiology
Department Office in MEB
– If necessary, you can create this disc using the CD or
DVD burners on the computer in MEB 405.
Again, Welcome to
the Rotation
We look forward to having
you rotate with us.