Christiane Nyhsen, MD

May I congratulate the authors and editors of the article about use of imaging in the detection of drug mules and body stuffers (February/March 2008, page 36). I found the article very interesting, and there is no doubt about the technical advances CT is making, in particular in problem-solving.

One issuethat of radiationhas, however, not been addressed sufficiently, in my opinion. A CT scan of the abdomen and pelvis carries a significant radiation exposure. The concerned patients will often be young and/or potentially need a repeat scan. These points should not be overlooked.

In the case of a medical emergency, the radiation dose is justified due to the potential adverse outcome if no direct action is taken. Indications of "screening for drugs" and "to aid legal prosecution," on the other hand, should be disputed. 

Imagine the hypothetical case of a 19-year-old asymptomatic female traveler who is suspected of carrying drugs. Is it ethical to subject her to a CT scan of the abdomen/pelvis? What happens if she turns out to be in the early stages of pregnancy, which cannot always be excluded? What would happen if she were found to be innocent? Would she be within her rights to seek compensation? Could she sue the police if she were to develop bowel cancer 15 to 20 years later?

Such cases raise very important questions from ethical, medicolegal, and radiation protection points of view. As radiologists, we are gatekeepers of radiation use, and we should not forget this important role. Therefore, we may choose not to use CT to its full potential but seek alternatives with less risk attached, even if they are more tedious and the pictures not quite as "pretty." Ultrasound and MRI were mentioned in the article. Maybe they should be used first. 

Dr. Christiane Nyhsen is a consultant radiologist, City Hospitals Sunderland, U.K., and chair, Radiology Trainees Forum. Dr. Nyhsen is also a member of DI Europe's Editorial Advisory Board.

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Many outstanding radiology teaching resources are now available on the Internet. The huge number of such Web sites is increasing on an almost daily basis.

These sites are a valuable and inexpensive tool for radiology trainees. Also, they provide an opportunity for experienced radiologists to refresh knowledge of areas not frequently used in daily practice, or as a means of continuous medical education (CME). Some sites can even award CME points.

Books are no longer the exclusive source of information about interesting case studies or revision aids. As this selection of Web sites shows, it is perfectly possible to keep up to date in radiology by surfing the Internet.

eMedicine Clinical Knowledge Base (WebMD)


This site contains up-to-date and well-structured clinical background information for a wide variety of pathologies. It is ideal for a comprehensive overview of diseases, whether commonplace or rare, straightforward or complex. Cancer staging classifications are presented well. The site is not primarily written for radiologists, but does contain a radiology section. Not all pages contain representative example images. Registration (free) is required for full access to site content. CME courses are offered.


This encyclopedia is for medical professionals only. Registration is required to access content, but this is free of charge and can be completed quickly. The site has an efficient search engine. When entering a specific keyword, a selection of medical articles will appear as well as representative images in multiple modalities and references to textbooks. It is an encyclopedia that can be accessed by, for example, trainees on-call.

Anatomy Atlases (Michael P. D'Alessandro, M.D.)


All the anatomy you will ever need is here. The content spans beautifully reproduced and translated drawings dating back to 1841 through to photographic illustrations of cross-sectional anatomical specimens and the most colorful histology slides.

EURORAD (European Association of Radiology)


The EAR's e-learning initiative contains a selection of high quality cases. Access to all content in the online teaching database is free. To access initial cases, registration is not needed, but it is required for submission of a new case. The site has an efficient search tool, and cases can be selected by entering a keyword or by subspecialty. All cases contain a clinical history, images, and discussion. They can be read in English, French, or Spanish.

MedPix medical image database (Uniformed Services University, Bethesda, Maryland)


The MedPix peer-reviewed teaching files and imaging atlas contain an extensive collection of images from a wide range of pathologies. You can search for a particular case or click on "hide diagnosis" to test yourself on a series of cases. Online category 1 CME and continuing nursing education (CNE) credits are available.

CT is us (Advanced Medical Imaging Laboratory, Johns Hopkins Medical Institutions, Baltimore, Maryland)


The many examples in this CT teaching file cover a range of diverse pathologies. Images are separated by anatomical systems. Users first view the images without knowing the diagnosis, which is an excellent way to test diagnostic confidence. The pictures are small, but the collection is huge. You will be hard-pressed to find another site wholly dedicated to CT that matches this.

Ultrasoundcases.info (Aloka/Taco Geertsma, M.D.)


Are you looking for a large collection of ultrasound cases? If so, this site should be ideal. Still images are loaded as well as cine loops. Some cases include correlation with other imaging modalities. It is well worth a visit.

BIRADS tutorial (Georg Pfarl, M.D., Thomas Helbich, M.D.)


This Web site on the American College of Radiology's Breast Imaging Reporting and Data System (BIRADS) has been designed for the Austrian Roentgen Society. It is an excellent site for residents getting started in mammography. More experienced radiologists can also use the site to test their knowledge or to search for good teaching examples.

Joint program in nuclear medicine teaching file (Harvard Medical School)


Click on "electronic learning resources" to find basic facts about fluorine-18F FDG PET/CT imaging and a PET/CT image atlas. This includes an excellent collection of normal PET/CT scans, and cases with abnormal tracer uptake due to benign causes or previous treatment. It is an ideal teaching site to appreciate that PET/CT has its own share of diagnostic challenges.

PET and PET/CT (S. Mark Taper Foundation Imaging Center)


This is a smaller Web site than the previous one, but it still contains a good list of indications for PET/CT in oncology. It also provides examples of pathology seen on PET and PET/CT. It is a good place to begin appreciating the main use of PET/CT in cancer imaging.

The radiology assistant (Dutch Radiology Society)


This new and expanding teaching Web site is a good example of how complex pathologies can be presented to junior trainees. It contains a variety of imaging-led overviews focusing on abdominal pathology, anatomical and pathological descriptions of the temporal bone, breast imaging, and musculoskeletal cases. We hope to see more sites like this in future.

www.thoracicrad.org/str99/education_main.htm


Sit back and listen to a wide variety of audio recordings or view slides from presentations given at the society's annual meetings. Sessions covering cardiac imaging as well as thoracic imaging are available free and without prior registration.

www2.rsna.org/search/rsnacustomsearch.cfm


Here you can find refresher courses and plenary and focus sessions with online presentations, as well as published "cases of the day" from previous annual meetings of the RSNA. The entire site is free to RSNA members; limited access is available for nonmembers. Trainee radiologists can apply for free RSNA membership. CME credits are available for members only.


If you were unable to get to last year's ECR or you missed a good session, register with the congress Web site and choose "EDIPS downloads" (ECR e-Learning) to receive key presentations from previous meetings. Videos are available as well as slides. Posters from ECR and other selected radiology meetings can be reviewed at "EPOS." What a great opportunity- and it's free!

International Society for Magnetic Resonance in Medicine


#Education
This Web site lists links to tutorials on MR physics and patient safety as well as MRI teaching files.


This "portal for radiology and imaging related sites" does not list as many sites as the ISMRM site, but it offers a brief review from the site's author and a star rating system.

RadiologyEducation.com (Michael P. D'Alessandro, M.D.)


This sizeable digital library of radiology education resources allows users to search for the best Web sites themselves. Links to radiology textbooks, radiological teaching files, anatomy atlases, and journals are also included. The site states as its goal to provide "a starting point for entry into radiology places of enlightenment, entertainment, and education on the Internet."

World Wide Web radiology sites (Med Nexus)


This site presents another long list of links to radiology teaching Web sites, but doesn't offer any description or evaluation of the sites' quality and/or usefulness.

DR. NYHSEN is a specialist radiology registrar at Newcastle-upon-Tyne, U.K. DR. ADRIAENSEN is a radiology resident based in Amersfoort, the Netherlands

Web sites provide boost for radiology training

The last decade spawned great changes throughout Europe affecting junior radiologists as well as those in many other specialties. New technical and subspecialty developments increase demands on junior radiologists but also create entirely new opportunities. 

The inclusion of more countries in the European Union offers many radiologists new possibilities to work abroad. The introduction of PACS also offers great potential. But other modern radiology trends, such as teleradiology and outsourcing, present concerns for radiology trainees. A survey by the Radiology Trainees Forum Board of radiology teaching centers from 30 European countries found that in 7% of centers, outsourcing impinges significantly on training and that in 13% of centers the training deficts are beginning to show. It is therefore very important that good quality training be integrated with outsourced modalities.

With all these changes it is important to understand the perspective of junior radiologists and to reassess training on a regular basis. That is why national and European junior representative forums are so important. The Royal College of Radiologists in the U.K., for example, includes junior representation on all important boards and committees. Radiology trainees are asked for their opinions on training and their comments are seriously considered.

European trainees are organized by the Radiology Trainees Forum (formerly the Junior Radiologists Forum) where all national representatives meet annually at the European Congress of Radiology general assembly. The assembly is open to all trainees wishing to attend and provides an opportunity to discuss training issues. 

At the ECR, the forum will present results from its recent survey on teleradiology and outsourcing, provide information on grants and fellowships throughout Europe, and discuss new initiatives such as exchange programs and workshops for radiology trainees. In addition, a program on Saturday, March 4 will highlight advances in ultrasound and an interactive session on near misses in radiology, in the Austria Center, from 16:00 to 17:30.

Trainee attendance at the ECR has risen sharply over the years with great support from the Investment in the Youth program. Investment in youth is important, as the quality of tomorrow's radiologists can only be as good as the teaching offered to radiology trainees today.

Dr. Nyhsen is vice chair of the European Radiology Trainees Forum Board.

The last decade spawned great changes throughout Europe affecting junior radiologists as well as those in many other specialties. New technical and subspecialty developments increase demands on junior radiologists but also create entirely new opportunities.

Christiane Nyhsen, MD

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Web sites provide boost for radiology training

ECR offers trainees opportunities to expand knowledge base