Search

Flexible learning addresses students' needs for more flexibility and autonomy in shaping their learning process, and is often realised through online technologies in a blended learning design. While higher education institutions are increasingly considering replacing classroom time and offering more blended learning, current research is limited regarding its effectiveness and modifying design factors. This study analysed a flexible study programme with 133 courses in a blended learning design in different disciplines over more than 4 years with a mixed-methods approach. In the analysed flexible study programme, classroom instruction time was reduced by 51% and replaced with an online learning environment in a blended learning format (N students = 278). Student achievement was compared to the conventional study format (N students = 1068). The estimated summary effect size for the 133 blended learning courses analysed was close to, but not significantly different from, zero (d = - 0.0562, p = 0.3684). Although overall effectiveness was equivalent to the conventional study format, considerable variance in the effect sizes between the courses was observed. Based on the relative effect sizes of the courses and data from detailed analyses and surveys, heterogeneity can be explained by differences in the implementation quality of the educational design factors. Our results indicate that when implementing flexible study programmes in a blended learning design, particular attention should be paid to the following educational design principles: adequate course structure and guidance for students, activating learning tasks, stimulating interaction and social presence of teachers, and timely feedback on learning process and outcomes.

Evidence-based research is becoming increasingly important in educational research. Calculation and test methods available in statistical software packages such as SPSS and STATA are widely used. To evaluate teaching innovations such as blended learning against classical classroom settings, for example, previous studies have mainly applied inference methods such as the t-test or variance analyses. The problem with these methods is that they test for the difference. A non-significant result does not automatically mean equivalence of the treatments examined, which is why we propose the use of equivalence testing. This paper introduces the equivalence test as complementary to the classical t-test and briefly discusses other approaches based on confidence intervals and Bayesian methods. As an example, the introduction of a blended learning format to a Bachelor's degree programme is used to demonstrate the procedure and discuss the results of conducting an equivalence test. By combining tests for difference and equivalence successfully, it was possible to arrive at more informative statistical statements: Whereas a t-test alone only produced results for three out of 22 courses, a t-test and an equivalence test in combination yielded statistically confirmed statements for 12 out of 22 courses.

Conducting a barriers analysis is an important first step when designing proenvironmental behavior change interventions. Yet, detailed information on common barriers to energy conservation campaigns remains unavailable. Using a pair of original surveys, we leverage the theory of planned behavior to report on the most important barriers for fourteen energy conservation behaviors common in university residences and offices. Our results provide key information for individuals designing community-based social marketing and other behavior change campaigns in an educational setting, particularly for energy conservation efforts. Results also provide guidance for the process of conducting effective barrier assessments. (Contains 2 tables and 1 figure.)

An Autism Diagnostic Interview (ADI-R) was conducted with parents of 11 children with early infantile autism and 16 with a language disorder, along with a standardized Autism Diagnostic Observation Schedule (ADOS-G). Ten children with autism were correctly classified on both measures. One child with a language disorder was falsely classified on the ADI-R. (Contains references.) (Author/CR)

Background: Advanced imaging techniques play a pivotal role in oncology. A large variety of computed tomography (CT) scanners, scan protocols, and acquisition techniques have led to a wide range in image quality and radiation exposure. This study aims at implementing verifiable oncological imaging by quality assurance and optimization (i-Violin) through harmonizing image quality and radiation dose across Europe., Methods: The 2‑year multicenter implementation study outlined here will focus on CT imaging of lung, stomach, and colorectal cancer and include imaging for four radiological indications: diagnosis, radiation therapy planning, staging, and follow-up. Therefore, 480 anonymized CT data sets of patients will be collected by the associated university hospitals and uploaded to a repository. Radiologists will determine key abdominopelvic structures for image quality assessment by consensus and subsequently adapt a previously developed lung CT tool for the objective evaluation of image quality. The quality metrics will be evaluated for their correlation with perceived image quality and the standardized optimization strategy will be disseminated across Europe., Results: The results of the outlined study will be used to obtain European reference data, to build teaching programs for the developed tools, and to create a culture of optimization in oncological CT imaging., Conclusion: The study protocol and rationale for i‑Violin, a European approach for standardization and harmonization of image quality and optimization of CT procedures in oncological imaging, is presented. Future results will be disseminated across all EU member states, and i‑Violin is thus expected to have a sustained impact on CT imaging for cancer patients across Europe., Competing Interests: Declarations. Conflict of interest: T. Jorg, M.C. Halfmann, L. Müller, F. Stoehr, P. Mildenberger, M. Hierath, G. Paulo, J. Santos, J. Damilakis, I. Kralik, B. Brkljacic, D. Cvetko, D. Kuhleji, H. Bosmans, D. Petrov, S. Foley, P. Toroi, J.P. McNulty and C. Hoeschen declare that they have no competing interests. i‑Violin will only deal with fully anonymized patient data, to avoid any ethical issues. However, each participating clinical site will inform their ethical review board. Ethics approvals will be obtained from the appropriate bodies prior to starting i‑Violin image collection activities according to the requirements of the respective institutions. The study will be performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The supplement containing this article is not sponsored by industry., (© 2024. The Author(s).)

Preoperative anemia in children is a significant clinical concern requiring precise diagnosis. Although traditional blood sample collection is effective, it poses challenges because of children's aversion and technical difficulties. Therefore, this study explores the suitability of noninvasive hemoglobin measurements in children during preoperative anesthesia consultation. Noninvasive hemoglobin measurement (SpHb®; Masimo) in children aged ≤ 17 years was performed during preoperative anesthesia consultation and compared with laboratory hemoglobin (labHb) levels. SpHb was measured in 62 children (median age: 6 years, standard deviation [SD] ± 5.3) without adverse effects but was unsuccessful in one child. The bias, limits of agreement, and root mean square error between SpHb and labHb were 0.3, -2.26- +2.8, and 1.3 g/dl, respectively. LabHb demonstrated a significant regression relationship with R 2 of 0.359. LabHb was associated with a negative effect on bias [- 0.443 (CI 95: - 0.591- - 0.153, P < 0.001)], i.e., SpHb tends to underestimate labHb for high labHb values. The retest reliability between two consecutive SpHb measurements was 0.727 (P < 0.001). Double measurement of SpHb, age, weight, sex, heart rate, and perfusion index had no significant effects on accuracy. Using SpHb, a specificity of 96.3% (95% confidence interval [CI 95]: 87.3%-99.5%) and a sensitivity of 57.1% (CI 95: 18.4%-90.1%) were observed. Based on adapted cut-off values for SpHb (age-dependent cut-off values plus 0.8 g/dl), a sensitivity of 100% (CI 95: 64.6%-100%) was achieved for the investigated study collective. SpHb measurement in children is a quick procedure. The accuracy of hemoglobin measurement is insufficient for the diagnosis of anemia. Thus, whether the calculated cut-off SpHb values of this study collective can be considered for anemia screening in pediatric patients undergoing preoperative anesthesia consultation should be confirmed. Trial registration number and date of registration: This prospective study was registered at ClinicalTrials.gov (NCT03586141)., (© 2024. The Author(s).)

Objective: Patients surviving acute pulmonary embolism (PE) necessitate long-term treatment and follow-up. However, the chronic economic impact of PE on European healthcare systems remains to be determined., Methods and Results: We calculated the direct cost of illness during the first year after discharge for the index PE, analyzing data from a multicentre prospective cohort study in Germany. Main and accompanying readmission diagnoses were used to calculate DRG-based hospital reimbursements; anticoagulation costs were estimated from the exact treatment duration and each drug's unique national identifier; and outpatient post-PE care costs from guidelines-recommended algorithms and national reimbursement catalogues. Of 1017 patients enrolled at 17 centres, 958 (94%) completed ≥ 3-month follow-up; of those, 24% were rehospitalized (0.34 [95% CI 0.30-0.39] readmissions per PE survivor). Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis of 837 patients with complete 12-month follow-up) cancer, but not recurrent PE, were independent cost predictors by hurdle gamma regression accounting for zero readmissions. Estimated rehospitalization cost was €1138 (95% CI 896-1420) per patient. Anticoagulation duration was 329 (IQR 142-365) days, with estimated average per-patient costs of €1050 (median 972; IQR 458-1197); costs of scheduled ambulatory follow-up visits amounted to €181. Total estimated direct per-patient costs during the first year after PE ranged from €2369 (primary analysis) to €2542 (sensitivity analysis)., Conclusions: By estimating per-patient costs and identifying cost drivers of post-PE care, our study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved cardiovascular prevention. (Trial registration number: DRKS00005939)., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Structured reporting (SR) not only offers advantages regarding report quality but, as an IT-based method, also the opportunity to aggregate and analyze large, highly structured datasets (data mining). In this study, a data mining algorithm was used to calculate epidemiological data and in-hospital prevalence statistics of pulmonary embolism (PE) by analyzing structured CT reports.All structured reports for PE CT scans from the last 5 years (n = 2790) were extracted from the SR database and analyzed. The prevalence of PE was calculated for the entire cohort and stratified by referral type and clinical referrer. Distributions of the manifestation of PEs (central, lobar, segmental, subsegmental, as well as left-sided, right-sided, bilateral) were calculated, and the occurrence of right heart strain was correlated with the manifestation.The prevalence of PE in the entire cohort was 24% (n = 678). The median age of PE patients was 71 years (IQR 58-80), and the sex distribution was 1.2/1 (M/F). Outpatients showed a lower prevalence of 23% compared to patients from regular wards (27%) and intensive care units (30%). Surgically referred patients had a higher prevalence than patients from internal medicine (34% vs. 22%). Patients with central and bilateral PEs had a significantly higher occurrence of right heart strain compared to patients with peripheral and unilateral embolisms.Data mining of structured reports is a simple method for obtaining prevalence statistics, epidemiological data, and the distribution of disease characteristics, as demonstrated by the PE use case. The generated data can be helpful for multiple purposes, such as for internal clinical quality assurance and scientific analyses. To benefit from this, consistent use of SR is required and is therefore recommended. · SR-based data mining allows simple epidemiologic analyses for PE.. · The prevalence of PE differs between outpatients and inpatients.. · Central and bilateral PEs have an increased risk of right heart strain.. · Jorg T, Halfmann MC, Graafen D et al. Structured reporting for efficient epidemiological and in-hospital prevalence analysis of pulmonary embolisms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2301-3349., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Introduction: Δ 9 -Tetrahydrocannabinol (THC) acts as an agonist at cannabinoid receptors. Its chronic intake affects many behaviors, including cognitive processes. The aims of this study in rats are to assess the chronic effects of THC on impulsivity and on regional brain glucose uptake. Materials and Methods: For the determination of "waiting impulsivity," a total of 20 male Lister Hooded rats were trained to perform a reaction time task, followed by a baseline test of impulsivity and baseline glucose uptake measurements with [ 18 F]-fluoro-2-deoxy-D-glucose and positron emission tomography (PET). Then, 10 rats each received 3 mg/kg THC or vehicle injected intraperitoneally daily for 21 days. Subsequently, a second behavioral test and PET measurements were performed, and blood THC concentrations were determined. Analyses of variance of brain regions of the impulsivity network with the parameter "standardized uptake value" regarding glucose uptake and correlation analyses of the collected parameters were carried out. Discussion: After chronic THC treatment, decreased glucose uptake ( p -values <0.05) was found in cingulate cortex, hippocampus, amygdala, thalamus, and cerebellar cortex, as compared with vehicle-treated rats. The number of correct no-go responses (increased waiting time) significantly increased ( p <0.05) in THC-treated rats. Furthermore, correct no-go responses correlated positively and strongly with the THC blood concentrations (Spearman's ρ =0.79, p <0.01). Conclusion: These findings reflect a specific reduction in impulsive behavior after chronic THC treatment, showing a functionally relevant influence of THC on "waiting impulsivity" with reduced selective glucose uptake at the same time.

Objectives: Artificial intelligence (AI) has tremendous potential to help radiologists in daily clinical routine. However, a seamless, standardized, and time-efficient way of integrating AI into the radiology workflow is often lacking. This constrains the full potential of this technology. To address this, we developed a new reporting pipeline that enables automated pre-population of structured reports with results provided by AI tools., Methods: Findings from a commercially available AI tool for chest X-ray pathology detection were sent to an IHE-MRRT-compliant structured reporting (SR) platform as DICOM SR elements and used to automatically pre-populate a chest X-ray SR template. Pre-populated AI results could be validated, altered, or deleted by radiologists accessing the SR template. We assessed the performance of this newly developed AI to SR pipeline by comparing reporting times and subjective report quality to reports created as free-text and conventional structured reports., Results: Chest X-ray reports with the new pipeline could be created in significantly less time than free-text reports and conventional structured reports (mean reporting times: 66.8 s vs. 85.6 s and 85.8 s, respectively; both p < 0.001). Reports created with the pipeline were rated significantly higher quality on a 5-point Likert scale than free-text reports (p < 0.001)., Conclusion: The AI to SR pipeline offers a standardized, time-efficient way to integrate AI-generated findings into the reporting workflow as parts of structured reports and has the potential to improve clinical AI integration and further increase synergy between AI and SR in the future., Critical Relevance Statement: With the AI-to-structured reporting pipeline, chest X-ray reports can be created in a standardized, time-efficient, and high-quality manner. The pipeline has the potential to improve AI integration into daily clinical routine, which may facilitate utilization of the benefits of AI to the fullest., Key Points: • A pipeline was developed for automated transfer of AI results into structured reports. • Pipeline chest X-ray reporting is faster than free-text or conventional structured reports. • Report quality was also rated higher for reports created with the pipeline. • The pipeline offers efficient, standardized AI integration into the clinical workflow., (© 2024. The Author(s).)

Purpose: Kidney volume is important in the management of renal diseases. Unfortunately, the currently available, semi-automated kidney volume determination is time-consuming and prone to errors. Recent advances in its automation are promising but mostly require contrast-enhanced computed tomography (CT) scans. This study aimed at establishing an automated estimation of kidney volume in non-contrast, low-dose CT scans of patients with suspected urolithiasis., Methods: The kidney segmentation process was automated with 2D Convolutional Neural Network (CNN) models trained on manually segmented 2D transverse images extracted from low-dose, unenhanced CT scans of 210 patients. The models' segmentation accuracy was assessed using Dice Similarity Coefficient (DSC), for the overlap with manually-generated masks on a set of images not used in the training. Next, the models were applied to 22 previously unseen cases to segment kidney regions. The volume of each kidney was calculated from the product of voxel number and their volume in each segmented mask. Kidney volume results were then validated against results semi-automatically obtained by radiologists., Results: The CNN-enabled kidney volume estimation took a mean of 32 s for both kidneys in a CT scan with an average of 1026 slices. The DSC was 0.91 and 0.86 and for left and right kidneys, respectively. Inter-rater variability had consistencies of ICC = 0.89 (right), 0.92 (left), and absolute agreements of ICC = 0.89 (right), 0.93 (left) between the CNN-enabled and semi-automated volume estimations., Conclusion: In our work, we demonstrated that CNN-enabled kidney volume estimation is feasible and highly reproducible in low-dose, non-enhanced CT scans. Automatic segmentation can thereby quantitatively enhance radiological reports., (© 2023. The Author(s).)

Purpose: To investigate the epidemiology and distribution of disease characteristics of urolithiasis by data mining structured radiology reports., Methods: The content of structured radiology reports of 2028 urolithiasis CTs was extracted from the department's structured reporting (SR) platform. The investigated cohort represented the full spectrum of a tertiary care center, including mostly symptomatic outpatients as well as inpatients. The prevalences of urolithiasis in general and of nephro- and ureterolithasis were calculated. The distributions of age, sex, calculus size, density and location, and the number of ureteral and renal calculi were calculated. For ureterolithiasis, the impact of calculus characteristics on the degree of possible obstructive uropathy was calculated., Results: The prevalence of urolithiasis in the investigated cohort was 72%. Of those patients, 25% had nephrolithiasis, 40% ureterolithiasis, and 35% combined nephro- and ureterolithiasis. The sex distribution was 2.3:1 (M:F). The median patient age was 50 years (IQR 36-62). The median number of calculi per patient was 1. The median size of calculi was 4 mm, and the median density was 734 HU. Of the patients who suffered from ureterolithiasis, 81% showed obstructive uropathy, with 2nd-degree uropathy being the most common. Calculus characteristics showed no impact on the degree of obstructive uropathy., Conclusion: SR-based data mining is a simple method by which to obtain epidemiologic data and distributions of disease characteristics, for the investigated cohort of urolithiasis patients. The added information can be useful for multiple purposes, such as clinical quality assurance, radiation protection, and scientific or economic investigations. To benefit from these, the consistent use of SR is mandatory. However, in clinical routine SR usage can be elaborate and requires radiologists to adapt., (© 2023. The Author(s).)

Background: Written medical examinations consist of multiple-choice questions and/or free-text answers. The latter require manual evaluation and rating, which is time-consuming and potentially error-prone. We tested whether natural language processing (NLP) can be used to automatically analyze free-text answers to support the review process., Methods: The European Board of Radiology of the European Society of Radiology provided representative datasets comprising sample questions, answer keys, participant answers, and reviewer markings from European Diploma in Radiology examinations. Three free-text questions with the highest number of corresponding answers were selected: Questions 1 and 2 were "unstructured" and required a typical free-text answer whereas question 3 was "structured" and offered a selection of predefined wordings/phrases for participants to use in their free-text answer. The NLP engine was designed using word lists, rule-based synonyms, and decision tree learning based on the answer keys and its performance tested against the gold standard of reviewer markings., Results: After implementing the NLP approach in Python, F1 scores were calculated as a measure of NLP performance: 0.26 (unstructured question 1, n = 96), 0.33 (unstructured question 2, n = 327), and 0.5 (more structured question, n = 111). The respective precision/recall values were 0.26/0.27, 0.4/0.32, and 0.62/0.55., Conclusion: This study showed the successful design of an NLP-based approach for automatic evaluation of free-text answers in the EDiR examination. Thus, as a future field of application, NLP could work as a decision-support system for reviewers and support the design of examinations being adjusted to the requirements of an automated, NLP-based review process., Clinical Relevance Statement: Natural language processing can be successfully used to automatically evaluate free-text answers, performing better with more structured question-answer formats. Furthermore, this study provides a baseline for further work applying, e.g., more elaborated NLP approaches/large language models., Key Points: • Free-text answers require manual evaluation, which is time-consuming and potentially error-prone. • We developed a simple NLP-based approach - requiring only minimal effort/modeling - to automatically analyze and mark free-text answers. • Our NLP engine has the potential to support the manual evaluation process. • NLP performance is better on a more structured question-answer format., (© 2023. European Society of Radiology (ESR).)

Stepped wedge cluster randomized trials (SWCRT) are increasingly used for the evaluation of complex interventions in health services research. They randomly allocate treatments to clusters that switch to intervention under investigation at variable time points without returning to control condition. The resulting unbalanced allocation over time periods and the uncertainty about the underlying correlation structures at cluster-level renders designing and analyzing SWCRTs a challenge. Adjusting for time trends is recommended, appropriate parameterizations depend on the particular context. For sample size calculation, the covariance structure and covariance parameters are usually assumed to be known. These assumptions greatly affect the influence single cluster-period cells have on the effect estimate. Thus, it is important to understand how cluster-period cells contribute to the treatment effect estimate. We therefore discuss two measures of cell influence. These are functions of the design characteristics and covariance structure only and can thus be calculated at the planning stage: the coefficient matrix as discussed by Matthews and Forbes and information content (IC) as introduced by Kasza and Forbes. The main result is a new formula for IC that is more general and computationally more efficient. The formula applies to any generalized least squares estimator, especially for any type of time trend adjustment or nonblock diagonal matrices. We further show a functional relationship between IC and the coefficient matrix. We give two examples that tie in with current literature. All discussed tools and methods are implemented in the R package SteppedPower., (© 2022 The Authors. Biometrical Journal published by Wiley-VCH GmbH.)

Background: Children are often treated off-label and are at a disadvantage in pharmacotherapy. The aim of this study was to implement and evaluate a quality assurance measure (PaedPharm) for pediatric pharmacotherapy whose purpose is to reduce medication-related hospitalizations among children and adolescents., Methods: PaedPharm consisted of the digital pediatric drug information system PaedAMIS, pediatric pharmaceutical quality circles (PaedZirk), and an adverse drug event (ADE) reporting system (PaedReport). The intervention was implemented in a cluster-randomized trial (DRKS 00013924) in 12 regions, with a pediatric and adolescent medicine clinic in each and a total of 152 surrounding private practitioners, in 6 sequences over 8 quarters. In addition to the proportion of ADE-related hospital admissions (primary endpoint), comprehensive process evaluation included other endpoints such as coverage, user acceptance, and relevance to practice., Results: 41 829 inpatient admissions were recorded, of which 5101 were patients of physicians who participated in our study. 4.1% of admissions were ADE-related under control conditions, and 3.1% under intervention conditions (95% CI: [2.3; 5.9] and [1.8; 4.5], respectively). A model-based comparison yielded an intervention effect of 0.73 (population-based odds ratio; [0.39; 1.37]; p = 0.33). PaedAMIS achieved moderate user acceptance and PaedZirk achieved high user acceptance., Conclusion: The introduction of PaedPharm was associated with a decrease in medication-related hospitalizations that did not reach statistical significance. The process evaluation revealed broad acceptance of the intervention in outpatient pediatrics and adolescent medicine.

Purpose: Accumulating evidence from epidemiological studies that pediatric computed tomography (CT) examinations can be associated with a small but non-zero excess risk for developing leukemia or brain tumor highlights the need to optimize doses of pediatric CT procedures. Mandatory dose reference levels (DRL) can support reduction of collective dose from CT imaging. Regular surveys of applied dose-related parameters are instrumental to decide when technological advances and optimized protocol design allow lower doses without sacrificing image quality. Our aim was to collect dosimetric data to support adapting current DRL to changing clinical practice., Method: Dosimetric data and technical scan parameters from common pediatric CT examinations were retrospectively collected directly from Picture Archiving and Communication Systems (PACS), Dose Management Systems (DMS), and Radiological Information Systems (RIS)., Results: We collected data from 17 institutions on 7746 CT series from the years 2016 to 2018 from examinations of the head, thorax, abdomen, cervical spine, temporal bone, paranasal sinuses and knee in patients below 18 years of age. Most of the age-stratified parameter distributions were lower than distributions from previously-analyzed data from before 2010. Most of the third quartiles were lower than German DRL at the time of the survey., Conclusions: Directly interfacing PACS, DMS, and RIS installations allows large-scale data collection but relies on high data-quality at the documentation stage. Data should be validated by expert knowledge or guided questionnaires. Observed clinical practice in pediatric CT imaging suggests lowering some DRL in Germany is reasonable., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: To evaluate the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years., Methods: We analysed the content of our image database from January 2016 to December 2022 and compared the numbers of structured reports and free-text reports. For the ten most common SR templates, usage proportions were calculated on a quarterly basis. Annual modality-specific SR usage was calculated for ultrasound, CT, and MRI. During the implementation process, we surveyed radiologists and clinical referring physicians concerning their views on reporting in radiology., Results: As of December 2022, our reporting platform contained more than 22,000 structured reports. Use of the ten most common SR templates increased markedly since their implementation, leading to a mean SR usage of 77% in Q4 2022. The highest percentages of SR usage were shown for trauma CT, focussed assessment with ultrasound for trauma (FAST), and prostate MRI: 97%, 95%, and 92%, respectively, in 2022. Overall modality-specific SR usage was 17% for ultrasound, 13% for CT, and 6% for MRI in 2022. Both radiologists and referring physicians were more satisfied with structured reports and rated SR better than free-text reporting (FTR) on various attributes., Conclusions: The increasing SR usage during the period under review and the positive attitude towards SR among both radiologists and clinical referrers show that SR can be successfully implemented. We therefore encourage others to take this step in order to benefit from the advantages of SR., Key Points: 1. Structured reporting usage increased markedly since its implementation at our institution in 2016. 2. Mean usage for the ten most popular structured reporting templates was 77% in 2022. 3. Both radiologists and referring physicians preferred structured reports over free-text reports. 4. Our data shows that structured reporting can be successfully implemented. 5. We strongly encourage others to implement structured reporting at their institutions., (© 2023. The Author(s).)

Background: Structured reporting (SR) is recommended in radiology, due to its advantages over free-text reporting (FTR). However, SR use is hindered by insufficient integration of speech recognition, which is well accepted among radiologists and commonly used for unstructured FTR. SR templates must be laboriously completed using a mouse and keyboard, which may explain why SR use remains limited in clinical routine, despite its advantages. Artificial intelligence and related fields, like natural language processing (NLP), offer enormous possibilities to facilitate the imaging workflow. Here, we aimed to use the potential of NLP to combine the advantages of SR and speech recognition., Results: We developed a reporting tool that uses NLP to automatically convert dictated free text into a structured report. The tool comprises a task-oriented dialogue system, which assists the radiologist by sending visual feedback if relevant findings are missed. The system was developed on top of several NLP components and speech recognition. It extracts structured content from dictated free text and uses it to complete an SR template in RadLex terms, which is displayed in its user interface. The tool was evaluated for reporting of urolithiasis CTs, as a use case. It was tested using fictitious text samples about urolithiasis, and 50 original reports of CTs from patients with urolithiasis. The NLP recognition worked well for both, with an F1 score of 0.98 (precision: 0.99; recall: 0.96) for the test with fictitious samples and an F1 score of 0.90 (precision: 0.96; recall: 0.83) for the test with original reports., Conclusion: Due to its unique ability to integrate speech into SR, this novel tool could represent a major contribution to the future of reporting., (© 2023. The Author(s).)

Background: To evaluate the relationship between pandemic events and dental emergency service frequentation. Utilization patterns in the scope of the COVID-19 pandemic were analyzed and considered in regard of seasonal parameters., Methods: All outpatients seeking treatment in a university hospital's dental emergency service were analyzed in the years 2019, 2019 and 2020 according to demographic data and emergencies were subdivided into "absolute" and "relative". The years 2018 and 2019 were used to compare COVID-19 and non-COVID-19 phases. Defined waves of the pandemic were compared with equivalent prior-year periods., Results: Our study includes 11,219 dental emergency patients over a period of three years with a slight surplus of male patients. Comparing the pre-COVID-19 years and 2020 as a year of pandemic, the total count of cases decreased by more than 25%. The share of absolute emergencies in 2020 was higher than in the years before (p &lt; 0.0001). The under-utilization during the waves was more pronounced during the first wave compared to the second waves., Conclusions: Additionally to the clear decrease by more than 25% in 2020, we found an inverse dependency of 7-day-incidence of COVID-19 and number of visits. This effect was more distinct for relative emergencies, while the number of patients with absolute emergencies remains rather constant. Probably, there is an acclimatization effect regarding the waves. Patients older than 60 years who suffered from relative emergencies showed an under-utilzation during 2020. During a pandemic such as COVID-19, the effect of under-utilization is more pronounced among elderly patients. However, a pandemic acclimatization effect seems to occur. This can be taken into account in the administration of this kind of circumstances in the future., (© 2022. The Author(s).)

Purpose: Photon-counting detector computed tomography (PCD-CT) has the potential to significantly improve CT imaging in many ways including, but not limited to, low-dose high-resolution CT (HRCT) of the lung. The aim of this study was to perform an intrapatient comparison of the radiation dose and image quality of PCD-CT compared with conventional energy-integrating detector CT (EID-CT)., Methods: A total of 32 consecutive patients with available PCD-CT and EID-CT HRCT scans were included in the final analysis. The CT dose index (CTDI vol ) was extracted from patient dose reports. Qualitative image analysis comprised the lung parenchyma and mediastinal structures and was assessed by 3 readers using a 5-point Likert scale. Quantitative image analysis included assessment of noise and signal-to-noise ratio in the lung parenchyma, trachea, aorta, muscle, and background., Results: The mean CTDI vol was 2.0 times higher in the conventional EID-CT scans (1.8±0.5 mGy) compared with PCD-CT (0.9±0.5 mGy, P <0.001). The overall image quality was rated significantly better by all 3 raters ( P <0.001) in the PCD-CT relative to the EID-CT. Quantitative analysis showed no significant differences in noise and signal-to-noise ratio in the lung parenchyma between PCD-CT and EID-CT., Conclusion: Compared with conventional EID-CT scans, PCD-CT demonstrated similar or better objective and subjective image quality at significantly reduced dose levels in an intrapatient comparison. These results and their effect on clinical decision-making should be further investigated in prospective studies., Competing Interests: J.O. is a Siemens employee. The remaining authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: In response to the COVID-19 pandemic, many researchers have developed artificial intelligence (AI) tools to differentiate COVID-19 pneumonia from other conditions in chest CT. However, in many cases, performance has not been clinically validated. The aim of this study was to evaluate the performance of commercial AI solutions in differentiating COVID-19 pneumonia from other lung conditions., Methods: Four commercial AI solutions were evaluated on a dual-center clinical dataset consisting of 500 CT studies; COVID-19 pneumonia was microbiologically proven in 50 of these. Sensitivity, specificity, positive and negative predictive values, and AUC were calculated. In a subgroup analysis, the performance of the AI solutions in differentiating COVID-19 pneumonia from other conditions was evaluated in CT studies with ground-glass opacities (GGOs)., Results: Sensitivity and specificity ranges were 62-96% and 31-80%, respectively. Negative and positive predictive values ranged between 82-99% and 19-25%, respectively. AUC was in the range 0.54-0.79. In CT studies with GGO, sensitivity remained unchanged. However, specificity was lower, and ranged between 15 and 53%. AUC for studies with GGO was in the range 0.54-0.69., Conclusions: This study highlights the variable specificity and low positive predictive value of AI solutions in diagnosing COVID-19 pneumonia in chest CT. However, one solution yielded acceptable values for sensitivity. Thus, with further improvement, commercial AI solutions currently under development have the potential to be integrated as alert tools in clinical routine workflow. Randomized trials are needed to assess the true benefits and also potential harms of the use of AI in image analysis., Key Points: • Commercial AI solutions achieved a sensitivity and specificity ranging from 62 to 96% and from 31 to 80%, respectively, in identifying patients suspicious for COVID-19 in a clinical dataset. • Sensitivity remained within the same range, while specificity was even lower in subgroup analysis of CT studies with ground-glass opacities, and interrater agreement between the commercial AI solutions was minimal to nonexistent. • Thus, commercial AI solutions have the potential to be integrated as alert tools for the detection of patients with lung changes suspicious for COVID-19 pneumonia in a clinical routine workflow, if further improvement is made., (© 2021. The Author(s).)

Objective: During the COVID-19 pandemic, the number of patients presenting in hospitals because of emergency conditions decreased. Radiology is thus confronted with the effects of the pandemic. The aim of this study was to use natural language processing (NLP) to automatically analyze the number and distribution of fractures during the pandemic and in the 5 years before the pandemic., Materials and Methods: We used a pre-trained commercially available NLP engine to automatically categorize 5397 radiological reports of radiographs (hand/wrist, elbow, shoulder, ankle, knee, pelvis/hip) within a 6-week period from March to April in 2015-2020 into "fracture affirmed" or "fracture not affirmed." The NLP engine achieved an F 1 score of 0.81 compared to human annotators., Results: In 2020, we found a significant decrease of fractures in general (p < 0.001); the average number of fractures in 2015-2019 was 295, whereas it was 233 in 2020. In children and adolescents (p < 0.001), and in adults up to 65 years (p = 0.006), significantly fewer fractures were reported in 2020. The number of fractures in the elderly did not change (p = 0.15). The number of hand/wrist fractures (p < 0.001) and fractures of the elbow (p < 0.001) was significantly lower in 2020 compared with the average in the years 2015-2019., Conclusion: NLP can be used to identify relevant changes in the number of pathologies as shown here for the use case fracture detection. This may trigger root cause analysis and enable automated real-time monitoring in radiology., (© 2021. The Author(s).)

Purpose: The model of end-stage liver disease (MELD) score has been shown to predict 3-month prognosis following transjugular intrahepatic portosystemic stent shunt (TIPS) in liver cirrhosis; however, that score was derived from a mixed cohort, including patients with refractory ascites and variceal bleeding. This study re-evaluates the role of the MELD score and focuses on differences between both groups of patients., Methods: A total of 301 patients (192 male and 109 female) received TIPS, 213 because of refractory ascites and 88 because of variceal bleeding. Univariate and multivariate Cox analyses were performed to identify predictors of mortality and area under the receiver operator characteristics (AUROC) were used to assess the prognostic capacity of the MELD score and of the results of predictors of the multivariate analyses., Results: In refractory ascites, age, bilirubin and albumin were independent predictors of mortality. In variceal bleeding, emergency TIPS during ongoing bleeding, concomitant grade III ascites, history of hepatic encephalopathy, spontaneous bacterial peritonitis, bilirubin and platelet count proved significant. AUROCs of the MELD score for 3-month survival yielded 0.543 and 0.836 for refractory ascites and variceal bleeding, respectively (P < 0.001). For 1-year survival, the respective AUROCs yielded 0.533 and 0.767 (P < 0.001). In contrast to MELD, the AUROCs based on the calculated risk scores of this study resulted in 0.660 and 0.876 for 3-month survival, and 0.665 and 0.835 for 1-year survival in patients with ascites and variceal bleeding, respectively., Conclusion: In refractory ascites, the prognostic capability of MELD is significantly inferior compared to variceal bleeding. The results of our multivariate analyses and AUROC calculations corroborate the impact of different prognostic variables in patients undergoing TIPS for ascites and variceal bleeding., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Clear-cell renal cell carcinoma (ccRCC) is common and associated with substantial mortality. TNM stage and histopathological grading have been the sole determinants of a patient's prognosis for decades and there are few prognostic biomarkers used in clinical routine. Management of ccRCC involves multiple disciplines such as urology, radiology, oncology, and pathology and each of these specialties generates highly complex medical data. Here, artificial intelligence (AI) could prove extremely powerful to extract meaningful information to benefit patients., Objective: In the study, we developed and evaluated a multimodal deep learning model (MMDLM) for prognosis prediction in ccRCC., Design Setting and Participants: Two mixed cohorts of non-metastatic and metastatic ccRCC patients were used: (1) The Cancer Genome Atlas cohort including 230 patients and (2) the Mainz cohort including 18 patients with ccRCC. For each of these patients, we trained the MMDLM on multiscale histopathological images, CT/MRI scans, and genomic data from whole exome sequencing., Outcome Measurements and Statistical Analysis: Outcome measurements included Harrell's concordance index (C-index) and also various performance parameters for predicting the 5-year survival status (5YSS). Different visualization techniques were used to make our model more transparent., Results: The MMDLM showed great performance in predicting the prognosis of ccRCC patients with a mean C-index of 0.7791 and a mean accuracy of 83.43%. Training on a combination of data from different sources yielded significantly better results compared to when only one source was used. Furthermore, the MMDLM's prediction was an independent prognostic factor outperforming other clinical parameters., Interpretation: Multimodal deep learning can contribute to prognosis prediction in ccRCC and potentially help to improve the clinical management of this disease., Patient Summary: An AI-based computer program can analyze various medical data (microscopic images, CT/MRI scans, and genomic data) simultaneously and thereby predict the survival time of patients with renal cancer., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Schulz, Woerl, Jungmann, Glasner, Stenzel, Strobl, Fernandez, Wagner, Haferkamp, Mildenberger, Roth and Foersch.)

Objective: With the initiative of the ACR International Economics Committee, a multinational survey was conducted to evaluate radiology residency programs around the world., Methods: A 31-question survey was developed. It included: economic issues, program size and length, resident's activities during daytime and call, academic aspects including syllabus and examinations. Data was tabulated using the forementioned thematic framework and was qualitatively analyzed., Results: Responses were received from all 17 countries that were invited to participate (France, Netherlands, Israel, UK, Russia, USA, Japan, India, Germany, Canada, Turkey, Croatia, Serbia, Italy, Ireland, Hungary, and Greece). Residency length varied between 2 and 5 years. The certificate of residency completion is provided by a local hospital [4/17 (23%)], University [6/17 (36%)], National Board [6/17 (36%)], and Ministry of Health [1/17 (6%)]. There was variability among the number of residency programs and residents per program ranging from 15 to 300 programs per nation with a 1-700 residents in each one respectively. Salaries varied significantly and ranged from 8000 to 75,000 USD equivalent. Exams are an integral part of training in all surveyed countries. Length of call varied between 5 and 26 h and the number of monthly calls ranged from 3 to 6. The future of radiology was judged as growing in [12/17 (70%)] countries and stagnant in [5/17 (30%)] countries., Discussion: Radiology residency programs worldwide have many similarities. The differences are in the structure of the residency programs. Stagnation and uncertainties need to be addressed to ensure the continued development of the next generation of radiologists., Summary Statement: There are many similarities in the academic aims and approach to education and training of radiology residency programs worldwide. The differences are in the structure of the residency programs and payments to individual residents., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to determine whether structured reports (SRs) reduce reporting time and/or increase the level of detail for trauma CT scans compared to free-text reports (FTRs)., Method: Eight radiology residents used SRs and FTRs to describe 14 whole-body CT scans of patients with polytrauma in a simulated emergency room setting. Each resident created both a brief report and a detailed report for each case using one of the two formats. We measured the time to complete the detailed reports and established a scoring system to objectively measure report completeness and the level of detail. Scoring sheets divided the CT findings into main and secondary criteria. Finally, the radiological residents completed a questionnaire on their opinions of the SRs and FTRs., Results: The detailed SRs were completed significantly faster than the detailed FTRs (mean 19 min vs. 25 min; p < 0.001). The maximum allowance of 25 min was used for 25% of SRs and 59% of FTRs. For brief reports, the SRs contained more secondary criteria than the FTRs (p = 0.001), but no significant differences were detected in main criteria. Study participants rated their own SRs as significantly more time-efficient, concise, and clearly structured compared to the FTRs. However, SRs and FTRs were rated similarly for quality, accuracy, and completeness., Conclusion: We found that SRs for whole-body trauma CT add clinical value compared to FTRs because SRs reduce reporting time and increase the level of detail for trauma CT scans., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Due to the outbreak of the coronavirus disease 2019 (COVID-19), it proved necessary to rapidly change medical education from on-site to online teaching. Thus, medical educators were forced to rethink the purpose of teaching and the best form of transmission of knowledge. In cooperation with the European Society of Radiology (ESR), we investigated the attitudes of radiologists in Europe and North America toward innovative online teaching concepts., Methods: In total, 224 radiologists from 31 different countries participated in our cross-sectional, web-based survey study. On a 7-point Likert scale, participants had to answer 27 questions about the online teaching situation before/during the pandemic, technical and social aspects of online teaching and the future role of online teaching in radiology., Results: An overwhelming majority stated that radiology is particularly well-suited for online teaching (91%), that online teaching should play a more prominent role after the pandemic (73%) and that lecturers should be familiar with online teaching techniques (89%). Difficulties include a higher workload in preparing online courses (59%), issues with motivating students to follow online courses (56%) and the risk of social isolation (71%). Before the pandemic, only 12% of teaching was provided online; for the future, our participants deemed a proportion of approximately 50% online teaching appropriate., Conclusion: Our participants are open-minded about online teaching in radiology. As the best way of transferring knowledge in medical education is still unclear, online teaching offers potential for innovation in radiology education. To support online teaching development, a structured, framework-based "online curriculum" should be established., (© 2021. The Author(s).)

Objectives: We investigated the attitudes of radiologists, information technology (IT) specialists, and industry representatives on artificial intelligence (AI) and its future impact on radiological work., Materials and Methods: During a national meeting for AI, eHealth, and IT infrastructure in 2019, we conducted a survey to obtain participants' attitudes. A total of 123 participants completed 28 items exploring AI usage in medicine. The Kruskal-Wallis test was used to identify differences between radiologists, IT specialists, and industry representatives., Results: The strongest agreement between all respondents occurred with the following: plausibility checks are important to understand the decisions of the AI (93% agreement), validation of AI algorithms is mandatory (91%), and medicine becomes more efficient in the age of AI (86%). In contrast, only 25% of the respondents had confidence in the AI results, and only 17% believed that medicine will become more human through the use of AI. The answers were significantly different between the three professions for four items: relevance for protocol selection in cross-sectional imaging (p = 0.034), medical societies should be involved in validation (p = 0.028), patients should be informed about the use of AI (p = 0.047), and AI should be part of medical education (p = 0.026)., Conclusion: Currently, a discrepancy exists between high expectations for the future role of AI and low confidence in the results. This attitude was similar across all three groups. The demand for plausibility checks and the need to prove the usefulness in randomized controlled studies indicate what is needed in future research., Competing Interests: Conflict of interest The authors of this paper declare no relationships with any companies whose products or services may be related to the subject matter of the article., (Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Non-invasive haemoglobin measurement using absolute values lacks the precision to be the sole basis for the treatment of pre-operative anaemia. However, it can possibly serve as a screening test, indexing 'anaemia' with high sensitivity when values remain under prespecified cut-off values. Based on previous data, non-invasive haemoglobin cut-off values (146 g.l -1 for women and 152 g.l -1 for men) detect true anaemia with 99% sensitivity. An index test with these prespecified cut-off values was verified by prospective measurement of non-invasive and invasive haemoglobin pre-operatively in elective surgical patients. In 809 patients, this showed an estimated sensitivity (95%CI) of 98.9% (94.1-99.9%) in women and 96.4% (91.0-99.0%) in men. This saved invasive blood tests in 9% of female and 28% of male patients. In female patients, a lower non-invasive haemoglobin cut-off value (138 g.l -1 ) would save 28% of invasive blood tests with a sensitivity of 95%. The target 99% sensitivity would be reached by non-invasive haemoglobin cut-off values of 152 g.l -1 in female and 162 g.l -1 in male patients, saving 3% and 9% of invasive blood tests, respectively. Bias and limits of agreement between non-invasive and laboratory haemoglobin levels were 2 and - 25 to 28 g.l -1 , respectively. Patient and measurement characteristics did not influence the agreement between non-invasive and laboratory haemoglobin levels. Although sensitivity was very high, the index test using prespecified cut-off values just failed to reach the target sensitivity to detect true anaemia. Nevertheless, with respect to blood-sparing effects, the use of the index test in men may be clinically useful, while an index test with a lower cut-off (132 g.l -1 ) could be more clinically appropriate in women., (© 2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

The European Directive 2013/59/Euratom requires member states of the European Union to ensure justification and optimisation of radiological procedures and store information on patient exposure for analysis and quality assurance. The EuroSafe Imaging campaign of the European Society of Radiology created a working group (WG) on "Dose Management" with the aim to provide European recommendations on the implementation of dose management systems (DMS) in clinical practice. The WG follows Action 4: "Promote dose management systems to establish local, national, and European diagnostic reference levels (DRL)" of the EuroSafe Imaging Call for Action 2018. DMS are designed for medical practitioners, radiographers, medical physics experts (MPE) and other health professionals involved in imaging to support their tasks and duties of radiation protection in accordance with local and national requirements. The WG analysed requirements and critical points when installing a DMS and classified the individual functions at different performance levels. KEY POINTS: • DMS are very helpful software tools for monitoring patient exposure, optimisation, compliance with DRLs and quality assurance. • DMS can help to fulfil dosimetric aspects of the European Directive 2013/59/Euratom. • The EuroSafe WG analyses DMS requirements and gives recommendations for users.

Background: To assess the prognostic implications of cardiac magnetic resonance imaging (CMR) in patients with clinical suspicion of myocardial infarction with non-obstructed coronary arteries (MINOCA)., Methods: A total of 145 patients (58 ± 15 years, 97 men) were retrospectively enrolled in this single-center, longitudinal observational study. All patients underwent CMR including cine, edema-sensitive, and late gadolinium enhancement acquisitions, within a median of 3 days after cardiac catheterization. Follow-up was performed by medical records chart review and phone interviews; the median follow-up time was 4.2 years. The primary endpoint was defined as a combination of death, stroke, new onset of congestive heart failure, recurrent hospitalization, or the need for an invasive cardiac procedure., Results: In 143 (98.6%) cases, CMR revealed the following cardiac pathologies: myocarditis (n = 48, 33.1%), structural cardiomyopathies (n = 40, 27.6%), "true" myocardial infarction (n = 22, 15.1%), hypertensive heart disease (n = 19, 13.1%), and Tako-Tsubo cardiomyopathy (n = 14, 9.7%). Only two patients (1.4%) had a normal CMR examination. There were significant prognostic differences between different etiologies, e.g. myocarditis and Tako-Tsubo cardiomyopathy had a more favorable prognosis then structural cardiomyopathies. Age, end-diastolic volume index and time-to-CMR showed significant association with the primary endpoint in multi-variate Cox regression., Conclusions: CMR performed early after the onset of clinical symptoms allows discrimination between acute myocardial injury from "true" MINOCA in patients presenting with chest pain and elevated cardiac biomarkers, thereby helping to identify the underlying pathology in suspected MINOCA and allowing risk stratification based on the established diagnosis. Furthermore, CMR parameters allow for improved prediction of adverse events compared to clinical and laboratory parameters., Competing Interests: Declaration of Competing Interest TE has received a speaker fee and travel support from Siemens Healthineers, AVS receives institutional research support and travel support from Siemens Healthineers and is consultant for Bayer and Elucid Bioimaging. UJS has received institutional research support and/or honoraria for speaking and consulting from Astellas, Bayer, Bracco, Elucid BioImaging, General Electric, Guerbet, HeartFlow Inc., and Siemens Healthineers. None of these companies supported this studies and none of the authors reports a conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: The aim of this study was to determine the status of radiology quality improvement programs in a variety of selected nations worldwide., Methods: A survey was developed by select members of the International Economics Committee of the American College of Radiology on quality programs and was distributed to committee members. Members responded on behalf of their country. The 51-question survey asked about 12 different quality initiatives which were grouped into 4 themes: departments, users, equipment, and outcomes. Respondents reported whether a designated type of quality initiative was used in their country and answered subsequent questions further characterizing it., Results: The response rate was 100% and represented Australia, Canada, China, England, France, Germany, India, Israel, Japan, the Netherlands, Russia, and the United States. The most frequently reported quality initiatives were imaging appropriateness (91.7%) and disease registries (91.7%), followed by key performance indicators (83.3%) and morbidity and mortality rounds (83.3%). Peer review, equipment accreditation, radiation dose monitoring, and structured reporting were reported by 75.0% of respondents, followed by 58.3% of respondents for quality audits and critical incident reporting. The least frequently reported initiatives included Lean/Kaizen exercises and physician performance assessments, implemented by 25.0% of respondents., Conclusion: There is considerable diversity in the quality programs used throughout the world, despite some influence by national and international organizations, from whom further guidance could increase uniformity and optimize patient care in radiology.

Purpose: The MEDIRAD project is about the effects of low radiation dose in the context of medical procedures. The goal of the work is to develop an informatics service that will provide the researchers of the MEDIRAD project with a platform to share acquired images, along with the associated dosimetric data pertaining to the radiation resulting from the procedure., Methods: The authors designed a system architecture to manage image data and dosimetric data in an integrated way. DICOM and non-DICOM data are stored in separated repositories, and the link between the two is provided through a semantic database, i.e., a database whose information schema in aligned with an ontology., Results: The system currently supports CT, PET, SPECT, and NM images as well as dose reports. Currently, two workflows for non-DICOM data generated from dosimetric calculations have been taken into account, one concerning Monte Carlo-based calculation of organ doses in Chest CT, and the other estimation of doses in nontarget organs in 131 I targeted radionuclide therapy of the thyroid., Conclusion: The system is currently deployed, thus providing access to image and related dosimetric data to all MEDIRAD users. The software was designed in such a way that it can be reused to support similar needs in other projects.

Structured reporting is a favorable and sustainable form of reporting in radiology. Among its advantages are better presentation, clearer nomenclature, and higher quality. By using MRRT-compliant templates, the content of the categorized items (e.g., select fields) can be automatically stored in a database, which allows further research and quality analytics based on established ontologies like RadLex® linked to the items. Additionally, it is relevant to provide free-text input for descriptions of findings and impressions in complex imaging studies or for the information included with the clinical referral. So far, however, this unstructured content cannot be categorized. We developed a solution to analyze and code these free-text parts of the templates in our MRRT-compliant reporting platform, using natural language processing (NLP) with RadLex® terms in addition to the already categorized items. The established hybrid reporting concept is working successfully. The NLP tool provides RadLex® codes with modifiers (affirmed, speculated, negated). Radiologists can confirm or reject codes provided by NLP before finalizing the structured report. Furthermore, users can suggest RadLex® codes from free text that is not correctly coded with NLP or can suggest to change the modifier. Analyzing free-text fields took 1.23 s on average. Hybrid reporting enables coding of free-text information in our MRRT-compliant templates and thus increases the amount of categorized data that can be stored in the database. This enhances the possibilities for further analyses, such as correlating clinical information with radiological findings or storing high-quality structured information for machine-learning approaches.

Objective: The majority of radiological reports are still written as free text and lack structure. Further evaluation of free-text reports is difficult to achieve without a great deal of manual effort, and is not possible in everyday clinical practice. This study aims to automatically capture clinical information and positive hit rates from narrative radiological reports of suspected urolithiasis using natural language processing (NLP)., Methods: Narrative reports of low dose computed tomography (CT) of the retroperitoneum from April 2016 to July 2018 (n = 1714) were analyzed using NLP. These free-text reports were automatically structured based on RadLex concepts. Manual feedback was used to test and train the NLP engine to further enhance the performance. The chi-squared test, phi coefficient, and logistic regression analysis were performed to determine the effect of clinical information on the positive hit rate of urolithiasis., Results: Urolithiasis was affirmed in 72 % of the reports; in 38 % at least one stone was described in the kidneys, and in 45 % at least one stone was described in the ureter. Clinical information, such as previous stone history and obstructive uropathy, showed a strong correlation with confirmed urolithiasis (p = 0.001). Previous stone history and the combination of obstructive uropathy and loin pain had the highest association with positive urolithiasis (p < 0.001)., Conclusion: Applying this NLP approach to already existing free-text reports allows the conversion of such reports into a structured form. This may be valuable for epidemiological studies, to evaluate the appropriateness of CT examinations, or to answer a variety of research questions., Competing Interests: Declaration of Competing Interest Benedikt Kämpgen is an employee of Empolis Information Management GmbH (Kaiserslautern, Germany). The other authors declare no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Hintergrund: In Sekundärdaten existieren oftmals unstrukturierte Freitexte. In dieser Arbeit wird ein Text-Mining-System validiert, um unstrukturierte medizinische Daten für Forschungszwecke zu extrahieren., Methoden: Aus einer radiologischen Klinik wurden aus 7102 CT-Befunden 1000 zufällig ausgewählt. Diese wurden von 2 Medizinern manuell in definierte Befundgruppen eingeteilt. Zur automatisierten Verschlagwortung und Klassifizierung wurde die Textanalyse-Software Averbis Extraction Platform (AEP) eingesetzt. Besonderheiten des Systems sind u. a. eine morphologische Analyse zur Zerlegung zusammengesetzter Wörter sowie die Erkennung von Nominalphrasen, Abkürzungen und negierten Aussagen. Anhand der extrahierten standardisierten Schlüsselwörter werden Befundberichte mithilfe maschineller Lernverfahren den vorgegebenen Befundgruppen zugeordnet. Zur Bewertung von Reliabilität und Validität des automatisierten Verfahrens werden die automatisierten und 2 unabhängige manuelle Klassifizierungen in mehreren Durchläufen auf Übereinstimmungen hin verglichen., Ergebnisse: Die manuelle Klassifizierung war zu zeitaufwendig. Bei der automatisierten Verschlagwortung stellte sich in unseren Daten die Klassifizierung nach ICD-10 als ungeeignet heraus. Ebenfalls zeigte sich, dass die Stichwortsuche keine verlässlichen Ergebnisse liefert. Computerunterstütztes Textmining in Kombination mit maschinellem Lernen führte zu verlässlichen Klassifizierungen. Die Inter-Rater-Reliabilität der beiden manuellen Klassifizierungen, sowie der maschinellen und der manuellen Klassifizierung war sehr hoch. Beide manuelle Klassifizierungen stimmten in 93% aller Befunde überein. Der Kappa-Koeffizient beträgt 0,89 [95% Konfidenzintervall (KI) 0,87-0,92]. Die automatische Klassifizierung stimmte in 86% aller Befunde mit der unabhängigen, zweiten manuellen Klassifizierung überein (Kappa-Koeffizient 0,79 [95% KI 0,75-0,81])., Diskussion: Die Klassifizierung der Software AEP war sehr gut. In unserer Studie folgte sie allerdings einem systematischen Muster. Die meisten falschen Zuordnungen finden sich in Befunden, die auf ein erhöhtes Krebsrisiko hinweisen. Die Freitextstruktur der Befunde lässt Bedenken hinsichtlich der Machbarkeit einer rein automatisierten Analyse aufkommen. Die Kombination aus menschlichem Intellekt und einer intelligenten, lernfähigen Software erscheint als zukunftsweisend, um unstrukturierte aber wichtige Textinformationen der Forschung zugänglich machen zu können., Competing Interests: Philipp Daumke is the CEO of the Averbis GmbH. The AEP was not provided free of Charge, however the second human classification was provided free of Charge. The Averbis GmbH was not involved in the Analysis and the judgement of the results of the different approaches. Besides that there are no conflicts of interest for any of the authors of this manuscript., (Eigentümer und Copyright ©Georg Thieme Verlag KG 2019.)

Aim: To develop a robust open-source method for fully automated extraction of total lung capacity (TLC) from computed tomography (CT) images and to demonstrate its integration into the clinical workflow., Materials and Methods: Using only open-source software, an algorithm was developed based on a region-growing method that does not require manual interaction. Lung volumes calculated from reconstructions with different kernels (TLC CT ) were assessed. To validate the algorithm calculations, the results were correlated to TLC measured by pulmonary function testing (TLC PFT ) in a subgroup of patients for which this information was available within 3 days of the CT examination., Results: A total of 288 patients were analysed retrospectively. Manual review revealed poor segmentation results in 13 (4.5%) patients. In the validation subgroup, the correlation between TLC CT and TLC PFT was r=0.87 (p<0.001). Measurements showed excellent agreement between the two reconstruction kernels with an intraclass correlation coefficient (ICC) of 0.99. Calculation of the volumes took an average of 5 seconds (standard deviation: 3.72 seconds). Integration of the algorithm into the departments of the PACS environment was successful. A DICOM-encapsulated PDF document with measurements and an overlay of the segmentation results was sent to the PACS to allow the radiologists to detect false measurements., Conclusions: The algorithm developed allows fast and fully automated calculation of lung volume without any additional input from the radiologist. The algorithm delivers excellent segmentation in >95% of cases with significant positive correlations between lung volume on CT and TLC on PFT., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

PURPOSE We aimed to evaluate the influence of irreversible image compression at varying levels on image post-processing algorithms (3D volume rendering of angiographs, computer-assisted detection of lung nodules, segmentation and volumetry of liver lesions, and automated evaluation of functional cardiac imaging) in computed tomography (CT). METHODS Uncompressed CT image data (30 angiographs of the lower limbs, 38 lung exams, 20 liver exams and 30 cardiac exams) were anonymized and subsequently compressed using the JPEG2000 algorithm with compression ratios of 8:1, 10:1, and 15:1. Volume renderings of CT angiographies obtained from compressed and uncompressed data were compared using objective and subjective measures. Computer-assisted detection of lung nodules was performed on compressed and uncompressed image data and compared with respect to diagnostic performance. Segmentation and volumetry of liver lesions as well as measurement of ejection fraction on cardiac studies was performed on compressed and uncompressed datasets; differences in measurements were analyzed. RESULTS No differences could be detected for the 3D volume renderings and no statistically significant differences in performance were found for the computer-assisted detection algorithm. Measurements in volumetry of liver lesions and functional cardiac imaging showed good to excellent reliability. CONCLUSION Irreversible image compression within the limits proposed by the European Society of Radiology has no significant influence on commonly used image post-processing algorithms in CT.

Background:  In order to reduce alcohol relapse after liver transplantation (LT), the German national guidelines for waiting-list maintenance and organ allocation demand a minimum 6-month period of alcohol abstinence pre-LT, confirmed by measuring urinary ethyl glucuronide (uEtG)., Methods:  Between January 2015 and June 2016, uEtG was measured at least once in 339 cirrhotic patients with an indication for LT at the University Medical Center Mainz. uEtG was measured with an enzyme-linked immunosorbent assay (ELISA) screening test (cutoff value: 500 µg/L). For uEtG values ≥ 500 µg/L, liquid chromatography-mass spectrometry (LC-MS/MS) was performed as a confirmatory assay. Data were collected prospectively in a transplant database., Results:  Of the 339 potential liver transplant candidates, uEtG was negative in 86.4 %. Most patients were male (64.3 %), with an average age of 56.42 ± 10.1 years. In the multivariate analysis, mean corpuscular volume (p = 0.001), urinary creatinine (p = 0.001), gamma-glutamyl transferase (p = 0.001), and hemoglobin (p = 0.003) were significantly associated with a positive uEtG test result. The sensitivity of the ELISA screening test was 100 % for uEtG values > 2000 µg/L, as confirmed by LC-MS/MS., Conclusion:  uEtG is an effective parameter to reveal alcohol consumption by patients on the waiting list for LT. The sensitivity of the ELISA is excellent for uEtG values > 2000 µg/L, for which LC-MS/MS confirmation could be omitted., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Data used for training of deep learning networks usually needs large amounts of accurate labels. These labels are usually extracted from reports using natural language processing or by time-consuming manual review. The aim of this study was therefore to develop and evaluate a workflow for using data from structured reports as labels to be used in a deep learning application., Materials and Methods: We included all plain anteriorposterior radiographs of the ankle for which structured reports were available. A workflow was designed and implemented where a script was used to automatically retrieve, convert, and anonymize the respective radiographs of cases where fractures were either present or absent from the institution's picture archiving and communication system (PACS). These images were then used to retrain a pretrained deep convolutional neural network. Finally, performance was evaluated on a set of previously unseen radiographs., Results: Once implemented and configured, completion of the whole workflow took under 1 h. A total of 157 structured reports were retrieved from the reporting platform. For all structured reports, corresponding radiographs were successfully retrieved from the PACS and fed into the training process. On an unseen validation subset, the model showed a satisfactory performance with an area under the curve of 0.850 (95% CI 0.634-1.000) for detection of fractures., Conclusion: We demonstrate that data obtained from structured reports written in clinical routine can be used to successfully train deep learning algorithms. This highlights the potential role of structured reporting for the future of radiology, especially in the context of deep learning.

Background : Recession and resection of rectus muscles for correction of strabismus in Thyroid Eye Disease (TED) is relatively unpopular as it is assumed to enhance the restriction of ocular ductions. Therefore, the purpose of this study was to compare ductions of recession only and recess/resect procedures. Methods : We retrospectively reviewed the charts of 119 patients who underwent strabismus surgery for TED from 1991 to 2015, of which 102 were included in the present study. Forty-six interventions were performed on horizontal, 56 on vertical rectus muscles; comprising 41 recess/resect surgeries for horizontal deviations, and 7 in patients with vertical strabismus. Ocular ductions and alignment were evaluated preoperatively and at 3 and 12 months postoperatively. Results : Both recessions as well as recess/resect procedures resulted in improved abduction and elevation, respectively. At the exam 3 months postoperatively, median abduction for the recession only group and the recess/resect group were 27.5° and 35°, respectively. The similar figures for elevation were 25° and 10°, respectively. Neither were statistically significant. No restricted adduction or depression was seen in the recess/resect surgeries groups with lateral or superior rectus resection. None of the patients showed unusual postoperative inflammation or conjunctival scarring. Conclusion : In this retrospective analysis, we found an equal effect on ocular ductions in patients with TED when comparing recess/resect eye muscle surgery to recess only procedures. In TED patients with large horizontal angle deviations and abduction deficit, medial rectus recession and lateral rectus resection surgery can be considered. Muscle resections in TED do not seem to have a clinically relevant risk to increase the restriction of ocular ductions but rather improve ductions in the restricted directions of gaze.

Background: The stepped-wedge design (SWD) of clinical trials has become very popular in recent years, particularly in health services research. Typically, study participants are randomly allotted in clusters to the different treatment options., Methods: The basic principles of the stepped wedge design and related statistical techniques are described here on the basis of pertinent publications retrieved by a selective search in PubMed and in the CIS statistical literature database., Results: In a typical SWD trial, the intervention is begun at a time point that varies from cluster to cluster. Until this time point is reached, all participants in the cluster belong to the control arm of the trial. Once the intervention is begun, it is continued with- out change until the end of the trial period. The starting time for the intervention in each cluster is determined by randomization. At the first time point of measurement, no intervention has yet begun in any cluster; at the last one, the intervention is in prog- ress in all clusters. The treatment effect can be optimally assessed under the assumption of an identical correlation at all time points. A method is available to calculate the power and the number of clusters that would be necessary in order to achieve statistical significance by the appropriate type of significance test. All of the statistical techniques presented here are based on the assumptions of a normal distribution of cluster means and of a constant intervention effect across all time points of measure- ment., Conclusion: The necessary statistical tools for the planning and evaluation of SWD trials now stand at our disposal. Such trials nevertheless are subject to major risks, as valid results can be obtained only if the far-reaching assumptions of the model are, in fact, justified.

Background:  The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine., Method:  In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license., Results:  The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians., Conclusion:  Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions., Key Points:   · Structured reports have numerous advantages over conventional narrative reports.. · The German Radiological Society is developing consensus-based and quality assured report templates.. · Report templates are provided at www.befundung.drg.de under a free license.. · Vendors are now encouraged to provide solutions for the implementation of structured reporting.., Citation Format: · Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2019; 191: 33 - 39., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: This paper studies the possibilities of an integrated IT-based workflow for epidemiological research in pulmonary embolism (PE) using freely available tools and structured reporting (SR)., Methods: We included a total of 521 consecutive cases which had been referred to the radiology department for CT pulmonary angiography with suspected PE. Free-text reports were transformed into structured reports using a freely available IHE Management of Radiology Report Templates-compliant reporting platform. D-dimer values were retrieved from the hospitals laboratory results system. All information was stored in the platform's database and visualized using freely available tools. For further analysis, we directly accessed the platform's database with an advanced analytics tool (RapidMiner)., Results: Results: We were able to develop an integrated workflow for epidemiological statistics from reports obtained in clinical routine. The report data allowed for automated calculation of epidemiological parameters. Prevalence of PE was 27.6%. The mean age in patients with and without PE did not differ (62.8 years and 62.0 years, respectively, p = 0.987). As expected, there was a significant difference in mean D-dimer values (10.13 and 3.12 mg l-1 fibrinogen equivalent units, respectively, p < 0.001)., Conclusion: SR can make data obtained from clinical routine more accessible. Designing practical workflows is feasible using freely available tools and allows for the calculation of epidemiological statistics on a near realtime basis. Therefore, radiologists should push for the implementation of SR in clinical routine. Summary sentence: Implementing practical workflows that allow for the calculation of epidemiological statistics using SR and freely available tools is easily feasible. Advances in knowledge: Theoretical benefits of SR have long been discussed, but practical implementation demonstrating those benefits has been lacking. Here, we present a first experience providing proof that SR will make data from clinical routine more accessible.

Background: Coronary artery bypass grafting (CABG) is still an important therapeutic approach in the treatment especially of advanced coronary artery disease. In this study, we elucidate the current role of multidetector computed tomography angiography (MD-CTA) in imaging patients after CABG surgery., Method: This study is based on recent reports in the literature (2007 - 2016) on imaging of CABG using 64-slice MD-CT scanners and beyond. We included 13 reports that compared ECG-gated MD-CTA with conventional invasive coronary angiography (ICA) as the reference standard for the assessment of graft patency and for the detection of > 50 % stenoses. These studies had to provide absolute values for true-positive, true-negative, false-positive and false-negative results or at least allow calculation of these numbers. In total, 1002 patients with 2521 bypass grafts were the basis for this review., Results and Conclusion: The sensitivity and specificity for the assessment of graft patency or the detection of > 50 % graft stenosis were 97.2 % and 97.5 %, respectively. The negative and positive predictive values were 93.6 % and 99 %, respectively. By using prospective ECG-gating and an increasing pitch factor, the radiation dose exposure declined to 2.4 mSv in the latest reports. ECG-gated MD-CTA provides a fast and reliable, noninvasive method for assessing patients after CABG. The most substantial benefit of the newest CT scanner generations is a remarkable reduction of radiation dose exposure while maintaining a still excellent diagnostic accuracy during recent years., Key Points: · MD-CTA using 64-slice MDCT scanners and beyond is a reliable, noninvasive method for evaluating CABGs.. · Technical advances such as prospective ECG-gating, iterative reconstruction algorithms and high-pitch scanning lead to a remarkable drop-down in radiation dose exposures as low as 2.4 mSv.. · Despite significant dose reductions, MD-CTA could maintain a high diagnostic accuracy in evaluating CABGs in recent years.., Citation Format: · Jungmann F, Emrich T, Mildenberger P et al. Multidetector Computed Tomography Angiography (MD-CTA) of Coronary Artery Bypass Grafts - Update 2017. Fortschr Röntgenstr 2018; 190: 237 - 249., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The positron emission tomography ligand [ 18 F]MK-9470 is an inverse agonist that binds reversibly and with high affinity to the cannabinoid type 1 receptor. Due to its slow brain kinetics, care is required in the definition of its dissociation rates from the receptor. The goal of this study was to investigate pharmacokinetic analysis methods using an arterial input function., Methods: Five Sprague-Dawley rats received injections of 13 to 25 MBq of [ 18 F]MK-9470 and were scanned over a period of 90 min. Arterial blood samples were collected throughout the scan. Data were analyzed using four different compartmental models: a reversible one-tissue model, reversible two tissue models with and without parameter constraints and an irreversible two-tissue model. The outcome values were goodness of fit measures (Akaike information criterion; standard error), pharmacokinetic modeling parameters (volume of distribution; irreversible uptake constant) and intersubject variability., Results: Goodness of fit measures indicated that the experimental data are more adequately described by a two-tissue model than a one-tissue model. Differences in mean Akaike information criterion values between all two-tissue models were < 5%. Mean standard errors of model parameters were lowest for the irreversible model (range: 1% to 6%). The irreversible model delivered plausible results for all animals that were less variable compared to results of the other two-tissue models., Conclusions: A reversible two-tissue model may not deliver stable results for all animals and regions within a 90-min microPET study protocol. Stable parameters for all animals and regions are obtained when an irreversible model is used. If the acquisition time of the experiment is limited, an irreversible model provides a consistent distribution of composite outcome parameters, suggesting its suitability for use in future studies., (© 2017 American Association of Physicists in Medicine.)

Purpose  To transfer the report sheet from the guidelines regarding the German Transplantation Act to a standards-compliant report template and to evaluate it in the clinical routine. Materials and Methods  The template was developed using the freely available software brackets.io. It was implemented in the clinical routine using a reporting platform developed in-house. Interfaces to the department RIS and PACS allowed for integration into the usual reporting workflow. The evaluation period was 70 days. Results  Developing the template for implementation of the guidelines was possible without any difficulties. The content of the report sheet provided in the guidelines was transferred one to one. Additionally, a text field was included to allow for further remarks. In the period under review, 7 radiologists performed 44 evaluations in line with § 16 of the German Transplantation Act. Users of the template, referring physicians and the employees of the transplantation office reported a high degree of satisfaction. Conclusion  Implementing report sheets that are required by law (e. g. in the guidelines regarding § 16 of the German Transplantation Act) in the clinical routine electronically is easy and achieves a high degree of acceptance. The standard supported by the German Radiological Society (IHE - "Management of radiology report templates") allows for a quick response to the growing demand for structured and standardized reporting. Key Points   · Report sheets as required by law can easily be incorporated electronically into the clinical routine.. · Templates for structured reporting as supported by the German Radiological Society allow for a quick response to the growing demand for standardized reporting.. · Radiologists as well as referring physicians report a high degree of satisfaction with the electronic version of the report sheet.. Citation Format · Pinto dos Santos D, Arnhold G, Mildenberger P et al. Guidelines Regarding §16 of the German Transplantation Act - Initial Experiences with Structured Reporting. Fortschr Röntgenstr 2017; 189: 1145 - 1151., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To compare the diagnostic accuracy of medical-grade and calibrated consumer-grade digital displays for the detection of subtle bone fissures., Methods: Three experienced radiologists assessed 96 digital radiographs, 40 without and 56 with subtle bone fissures, for the presence or absence of fissures in various bones using one consumer-grade and two medical-grade displays calibrated according to the DICOM-Grayscale Standard Display Function. The reference standard was consensus reading. Subjective image quality was also assessed by the three readers. Statistical analysis was performed using receiver operating characteristic analysis and by calculating the sensitivity, specificity, and Youden's J for each combination of reader and display. Cohen's unweighted kappa was calculated to assess inter-rater agreement. Subjective image quality was compared using the Wilcoxon signed-rank test., Results: No significant differences were found for the assessment of subjective image quality. Diagnostic performance was similar across all readers and displays, with Youden's J ranging from 0.443 to 0.661. The differences were influenced more by the reader than by the display used for the assessment., Conclusion: No significant differences were found between medical-grade and calibrated consumer-grade displays with regard to their diagnostic performance in assessing subtle bone fissures. Calibrated consumer-grade displays may be sufficient for most radiological examinations., Key Points: • Diagnostic performance of calibrated consumer-grade displays is comparable to medical-grade displays. • There is no significant difference with regard to subjective image quality. • Use of calibrated consumer-grade displays could cut display costs by 60-80%.

Objectives: To identify the number of CT scans repeated in acute trauma patients receiving imaging before being referred to a trauma center, to define indications, and to assess radiation doses and costs of repeated CT., Methods: This retrospective study included all adult trauma patients transferred from other hospitals to a Level-I trauma center during 2014. Indications for repeated CT scans were categorized into: inadequate CT image data transfer, poor image quality, repetition of head CT after head injury together with completion to whole-body CT (WBCT), and follow-up of injury known from previous CT. Radiation doses from repeated CT were determined; costs were calculated using a nation-wide fee schedule., Results: Within one year, 85/298 (28.5%) trauma patients were transferred from another hospital because of severe head injury (n=45,53%) and major body trauma (n=23;27%) not manageable in the referring hospital, repatriation from a foreign country (n=14;16.5%), and no ICU-capacity (n=3;3.5%). Of these 85 patients, 74 (87%) had repeated CT in our center because of inadequate CT data transfer (n=29;39%), repetition of head CT with completion to WBCT (n=24;32.5%), and follow-up of known injury (n=21;28.5%). None occurred because of poor image quality. Cumulative dose length product (DLP) and annual costs of potential preventable, repeated CT (inadequate data transfer) was 631mSv (81'304mGy*cm) and 35'233€, respectively., Conclusion: A considerable number of transferred trauma patients undergo potentially preventable, repeated CT, adding radiation dose to patients and costs to the health care system., (Copyright © 2017 Elsevier B.V. All rights reserved.)