Journal of the American College of Radiology RSS feed: Current Issue. For full-text online access, visit the JACR 's website at www.jacr.org . The official journal of the American College of Radiology, JACR aims to enhance the practice of diagnostic radiology, interventional radiology, radiation oncology, and medical physics by publishing important and practical articles on clinical practice, practice management, health services research and policy, and education - topics not well addressed in other peer-reviewed journals in the field.http://www.jacr.org/?rss=yesElsevier Inc.en © 2010 American College of Radiology. Published by Elsevier Inc. All rights reserved. Journal of the American College of Radiology1546-144078August 2010 © 2010 American College of Radiology. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.jacr.org/article/PIIS1546144010003467/abstract?rss=yesThe first decade of the 21st century is at an end, and it has been a decade of incredible turmoil. After a moderately quiet final decade of the past century, the world has witnessed unspeakable terrorism, earth-shattering disasters natural and manmade, the resurgence of widespread armed international conflict, global financial meltdowns, unbridled individual and corporate financial ethics violations, the escalation of nuclear expansion by rogue nations, and inability of the US Congress to free itself from its political shackles.A World in Turmoil: Chaos, or a New World Order?John A. Patti10.1016/j.jacr.2010.06.021Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2ACR Chair's Memo551551http://www.jacr.org/article/PIIS1546144010002279/abstract?rss=yesQuality is Job 1. —Ford Motor CompanyThe motto of the ACR is “Quality Is Our Image”: it says so right on the cover of the journal. Except that it already was taken by Ford, it could just as well be “Quality is Job 1.” I like the terseness of that statement, its forcefulness of expression. It says a great deal in just a few words and sounds like it means it.Just When You Think Things Can't Get Any Better…Bruce J. Hillman10.1016/j.jacr.2010.04.017Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Editorial552552http://www.jacr.org/article/PIIS154614401000150X/abstract?rss=yesA recent policy change at Blue Cross Blue Shield (BCBS) for Texas, Illinois, New Mexico, and Oklahoma regarding musculoskeletal (MSK) ultrasound illustrates how the status of reimbursement for diagnostic imaging can change overnight. On September 1, 2009, BCBS issued its policy “Non-Operative Spinal and Musculoskeletal Ultrasound” (RAD602.016), which deems all MSK ultrasound studies “experimental.” Health care providers who perform MSK ultrasound found themselves denied Current Procedural Terminology® code 76880 and other codes for billing and reimbursement for MSK ultrasound. This change sent shock waves throughout a variety of medical communities, ranging from radiology to podiatry. A variety of sources, including ourselves, the American Institute of Ultrasound in Medicine, and other organizations and health care providers, sent letters to BCBS asking them to correct what was perceived as an obvious mistake. We are happy to report that Allan Chernov, MD, the medical director of Blue Shield of Texas, and the staff of BCBS revisited this issue and restored the original policy on February 1, 2010. The evaluation of MSK ultrasound remains ongoing, which means, as Yogi Berra said, that “it ain't over till it's over.” Certainly we applaud Dr Chernov and others at BCBS for listening to reason, but some of us are still asking ourselves (as David Byrne did in the Talking Heads song “Once in a Lifetime”), “How did we get here?”Denying Payments for Musculoskeletal Ultrasound: How Did We Get Here?Levon N. Nazarian, Archie A. Alexander10.1016/j.jacr.2010.03.009Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Opinion553556http://www.jacr.org/article/PIIS1546144010001699/abstract?rss=yesRadiologists are the medical specialists with the most in-depth knowledge of radiation-related risks. We are formally and extensively educated and tested on radiation safety in our residency training and during our board examinations. As the “gatekeepers” of medical imaging examinations, we are charged with protecting the public from excessive or unnecessary radiation. To that end, the guiding philosophy is to conduct examinations using radiation doses that are as low as reasonably achievable. Accordingly, it is the goal of all radiologists to ensure that the minimum dose of radiation is used for appropriate diagnostic or therapeutic indications. Likewise, radiologists should recommend alternative tests if similar information can be obtained with less radiation.Radiation Safety: Have We Let the Public Down?Mark Otto Baerlocher, Andy Myers, Murray R. Asch10.1016/j.jacr.2010.03.023Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Opinion557558http://www.jacr.org/article/PIIS1546144010002644/abstract?rss=yesHealth care reform has passed. On March 23 and March 30, 2010, President Barack Obama signed into law the long-debated legislation that promises to expand coverage, reduce costs, and improve the quality of health care for Americans.Leadership for the AgesMichael J. Pentecost10.1016/j.jacr.2010.05.010Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Washington Watch559560http://www.jacr.org/article/PIIS1546144010002711/abstract?rss=yesA major tool for reforming the health care system is health care IT (HIT). The federal government has created an incentive program to encourage the meaningful use of HIT, which was the topic of a recent column []. A key component of HIT tools for enabling quality improvement and reduction in waste is decision support (DS). Decision support can be broadly defined as online educational content embedded in HIT-enabled provider workflow to guide providers in making better informed clinical decisions. To qualify for HIT meaningful use incentives beyond 2012 and to avoid penalties beyond 2014, referring physicians must have various DS tools (including DS to help reduce the inappropriate use of imaging) embedded within their workflow []. This seemingly inevitable path has led to discussion and speculation in the radiology community as to the best source of DS, specifically DS to help reduce the inappropriate use of imaging.Can Radiology Professional Society Guidelines Be Converted to Effective Decision Support?Ramin Khorasani10.1016/j.jacr.2010.05.017Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Bits and Bytes561562http://www.jacr.org/article/PIIS1546144010001985/abstract?rss=yesIn the United States, the Institute of Medicine's focus on patient safety and quality care, as well as CMS's drive toward the development of metrics for pay for performance, has renewed emphasis on improving the quality of patient care in imaging and maximizing patient outcomes for limited resources. This special issue of JACR presents global initiatives in the provision of quality imaging care, some of which may serve as guide posts for US-based initiatives.Introduction: Quality in Diagnostic Imaging: Learning From Worldwide InitiativesRuth C. Carlos, Stacy Goergen10.1016/j.jacr.2010.04.003Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles563564http://www.jacr.org/article/PIIS1546144010001535/abstract?rss=yesThe UK National Health Service (NHS) came into being in 1948, offering health care for all, free at the point of access. Over the past 6 decades, the NHS has grown to become the world's largest publicly funded health service. The authors present an overview of the NHS, from its conception to the present day, with a particular emphasis on how the changing environment of the NHS has affected the provision of radiologic services. The authors review the current landscape of the NHS with regard to radiology provision, from training and research to funding and the private sector, and touch on the likely future of the service.Radiology Provision in the United Kingdom: An OverviewSara Upponi, Ashley S. Shaw10.1016/j.jacr.2010.03.012Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles565572http://www.jacr.org/article/PIIS1546144010001584/abstract?rss=yesIn Canada, equal access to health care is the goal, but this is associated with wait times. Wait times should be fair rather than uniform, taking into account the urgency of the problem as well as the time an individual has already waited. In November 2004, the Ontario government began addressing this issue. One of the first steps was to institute benchmarks reflecting “acceptable” wait times for CT and MRI. A public Web site was developed indicating wait times at each Local Health Integration Network. Since starting the Wait Time Information Program, there has been a sustained reduction in wait times for Ontarians requiring CT and MRI. The average wait time for a CT scan went from 81 days in September 2005 to 47 days in September 2009. For MRI, the resulting wait time was reduced from 120 to 105 days. Increased patient scans have been achieved by purchasing new CT and MRI scanners, expanding hours of operation, and improving patient throughput using strategies learned from the Lean initiative, based on Toyota's manufacturing philosophy for car production. Institution-specific changes in booking procedures have been implemented. Concurrently, government guidelines have been developed to ensure accountability for monies received. The Ontario Wait Time Information Program is an innovative first step in improving fair and equitable access to publicly funded imaging services. There have been reductions in wait times for both CT and MRI. As various new processes are implemented, further review will be necessary for each step to determine their individual efficacy.Improving Equitable Access to Imaging Under Universal-Access Medicine: The Ontario Wait Time Information Program and Its Impact on Hospital Policy and ProcessAnia Z. Kielar, Robert H. El-Maraghi, Mark E. Schweitzer10.1016/j.jacr.2010.03.017Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles573581http://www.jacr.org/article/PIIS1546144010001559/abstract?rss=yesRadiology incident reporting systems provide one source of invaluable patient safety data that, when combined with appropriate analysis and action, can result in significantly safer health care, which is now an urgent priority for governments worldwide. Such systems require integration into a wider safety, quality, and risk management framework because many issues have global implications, and they also require an international classification scheme, which is now being developed. These systems can be used to inform global research activities as identified by the World Health Organization, many of which intersect with the activities of and issues seen in medical imaging departments. How to ensure that radiologists (and doctors in general) report incidents, and are engaged in the process, is a challenge. However, as demonstrated with the example of the Australian Radiology Events Register, this can be achieved when the reporting system is integrated with their professional organization and its other related activities (such as training and education) and administered by a patient safety organization.Establishing National Medical Imaging Incident Reporting Systems: Issues and ChallengesD. Neil Jones, Klee A. Benveniste, Timothy J. Schultz, Catherine J. Mandel, William B. Runciman10.1016/j.jacr.2010.03.014Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles582592http://www.jacr.org/article/PIIS1546144010001547/abstract?rss=yesAdverse events contribute to significant patient morbidity and mortality on a global scale, and this has been documented in a number of international studies. Despite this, there is limited understanding of medical imaging's involvement in such events. Incident reporting is a key feature of high-reliability organizations because, understandably, it is essential to know where things go wrong and why as the very first step in formulating preventative and corrective strategies. Although anesthesiology has led the way, health care in general has been slow to adopt this technique, and this includes medical imaging. Knowledge as to where medical imaging incidents are initiated and detected, and why, is not well documented or appreciated, although this is critical information in relation to quality improvement. Using an online radiology reporting system, the authors therefore sought to gain further insight and also ascertain where failures are located in the imaging cycle, and whether different incidents sources provide different information. Last, the authors sought to examine the resilience of the imaging system using these incident data.Where Failures Occur in the Imaging Care Cycle: Lessons From the Radiology Events RegisterD. Neil Jones, M.J.W. Thomas, Catherine J. Mandel, J. Grimm, N. Hannaford, Timothy J. Schultz, William Runciman10.1016/j.jacr.2010.03.013Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles593602http://www.jacr.org/article/PIIS1546144010001511/abstract?rss=yesComparative effectiveness research is intended to provide evidence to improve patient outcomes through the use of the most appropriate health technology affordable. The authors present 5 case studies, focusing on the use of plain radiography in common clinical scenarios, to illustrate the considerable scope for comparative effectiveness research within medical imaging and the different levels of evidence currently in existence to guide the improved use of medical imaging. These are blunt ankle injury, breast cancer follow-up, low back pain, routine daily chest x-rays in intensive care, and screening for breast cancer. Although there are established models for evaluating new technologies, especially pharmaceuticals, against the most commonly used current technology, the evaluation of technologies in current clinical practice is in an early phase of development. Because evaluation resources are limited, one major challenge is developing ways to identify established technologies for evaluation to refine the indications for their use. A set of criteria with which to identify established technologies that may not be delivering value for money is described, and their use is illustrated in relation to the 5 case studies. These criteria could be incorporated into literature search strategies, stakeholder consultations, and utilization scanning. Once identified, these technologies should be formally evaluated for their performance in improving patient health without restricting the availability of other effective interventions.Addressing “Waste” in Diagnostic Imaging: Some Implications of Comparative Effectiveness ResearchAdam G. Elshaug, Taryn Bessen, John R. Moss, Janet E. Hiller10.1016/j.jacr.2010.03.010Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles603613http://www.jacr.org/article/PIIS1546144010001560/abstract?rss=yesPurpose: The aims of this study were to collect data relating to radiation dose delivered by multidetector CT scanning at 10 hospitals and private practices in Queensland, Australia, and to test methods for dose optimization training, including audit feedback and didactic, face-to-face, small-group teaching of optimization techniques.Methods: Ten hospital-based public and private sector radiology practices, with one CT scanner per site, volunteered for the project. Data were collected for a variety of common adult and pediatric CT scanning protocols, including tube current–time product, pitch, collimation, tube voltage, the use of dose modulation, and scan length. A one-day feedback and optimization training workshop was conducted for participating practices and was attended by the radiologist and medical imaging technologist responsible for the project at each site. Data were deidentified for the workshop presentation. During the feedback workshop, a detailed analysis and discussion of factors contributing to dose for higher dosing practices for each protocol occurred. The postoptimization training data collection phase allowed changes to median and spread of doses to be measured.Results: During the baseline survey period, data for 1,208 scans were collected, and data from 1,153 scans were collected for the postoptimization dose survey for the 4 adult protocols (noncontrast brain CT, CT pulmonary angiography , CT lumbar spine, and CT urography). A mean decrease in effective dose was achieved with all scan protocols. Average reductions of 46% for brain CT, 28% for CT pulmonary angiography, 29% for CT lumbar spine, and 24% CT urography were calculated. It proved impossible to collect valid pediatric data from most sites, because of the small numbers of children presenting for multidetector CT, and phantom data were acquired during the preoptimization and postoptimization phase. Substantial phantom dose reductions were demonstrated at all sites.Conclusion: Audit feedback and small-group teaching about optimization enabled clinically meaningful dose reduction for a variety of common adult scans. However, access to medical radiation physicists, assistance with time-consuming data collection, and technical support from a medical imaging technologist were costly and critical to the success of the program.Multidetector CT Dose: Clinical Practice Improvement Strategies From a Successful Optimization ProgramAnthony B. Wallace, Stacy K. Goergen, Daniel Schick, Tina Soblusky, Damien Jolley10.1016/j.jacr.2010.03.015Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles614624http://www.jacr.org/article/PIIS1546144010001523/abstract?rss=yesThe integration of electronic medical record (EMR) systems into clinical practice has been spurred by general consensus and recent federal incentives and is set to become a standard feature of clinical practice in the US. We discuss how the addition of advanced search capabilities to the EMR can improve the radiologist's ability to integrate contextual data into workflows associated with both for diagnostic and interventional procedures.Advanced Search of the Electronic Medical Record: Augmenting Safety and Efficiency in RadiologyMichael Zalis, Mitchell Harris10.1016/j.jacr.2010.03.011Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles625633http://www.jacr.org/article/PIIS1546144010001572/abstract?rss=yesPurpose: A literature review was carried out, guided by the question, What are the important elements of a high-quality radiology written report?Methods: Two papers known to the authors were used as a basis for 5 PubMed search strategies. Exclusion criteria were applied to retrieved citations. Reference lists of retrieved citations were scanned for additional relevant papers and exclusion criteria applied to these. Web sites of professional radiology organizations were scanned for guidelines relating to the written radiology report. Retrieved guidelines were appraised using the Appraisal of Guidelines for Research & Evaluation instrument. Methodologies of retrieved papers were not suitable for conventional appraisal, and an evidence table was constructed.Results: The search strategy identified 25 published papers and 4 guidelines. Published study methodologies included 1 randomized controlled trial; 1 before-and-after study of interventions; 10 observational studies, audits, or analyses; 12 surveys; and 1 narrative review of the literature.Conclusions: Existing guidelines have a number of weaknesses with regard to scope and purpose, methods of development, stakeholder consultation, and editorial independence and applicability. There is a major gap in published studies relating to testing of interventions to improve report quality using conventional randomized controlled trial methods. Published studies and guidelines generally support report content, including clinical history, examination quality, description of findings, comparison, and diagnosis. Important report attributes include accuracy, clarity, and certainty. There is wide variation in the language used to describe imaging findings and diagnostic certainty. Survey participants strongly preferred reports with structured or itemized formats, but few studies exist regarding the effect of report structure on quality.Quality of the Written Radiology Report: A Review of the LiteratureFelicity Pool, Stacy Goergen10.1016/j.jacr.2010.03.016Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Original Articles634643http://www.jacr.org/article/PIIS1546144010002000/abstract?rss=yesIndividuals conducting their first quality improvement projects frequently make the mistake of treating the projects as purely technical problems and ignore the human component. The scenario commonly unfolds like this: individuals select a project because they already believe they know what the problem is and exactly how to fix it. When starting the project, they bypass the process entirely and jump to the solution. No one else adheres to the solution, and the project sinks into the swamp. Individuals then wrongly blame the people with whom they work for the failure. The real failure was ignoring the “process of change.” The truth about persistent quality problems is that if the problem were that easy to solve, it almost certainly would have been solved already. The usual reason a problem looks trivial is that it is being considered from a single, narrow perspective. That is why many problems turn out to be icebergs: only a small portion of the problem is visible, but the hidden portion ends up sinking the project.Don't Ignore the “Process” to Quality ImprovementF. Jacob Seagull, Paul Nagy10.1016/j.jacr.2010.04.005Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Quality Matters644645http://www.jacr.org/article/PIIS1546144010000918/abstract?rss=yesAs a state institution that received initial full accreditation in 1978 and that operates without an integrated teaching hospital, the University of South Florida (USF) meets the American Association of Medical Colleges [] classification as a community-based medical school. Because it does not have an integrated hospital, USF has faced some challenges with regard to establishing and maintaining ancillary departments such as radiology, anesthesiology, and pathology to carry out its academic missions. Before 2008, the Department of Radiology at USF evolved such that it was based primarily at the H. Lee Moffitt Cancer Center, a clinical and research facility located on the university's main campus. In the months preceding January 2008, when the Moffitt Cancer Center began to directly employ most of its physicians, including those in radiology, the medical school faced a decision regarding the future direction of the department. Around this same time, USF was also opening two large multispecialty ambulatory care clinics. Because both of these centers were to have outpatient diagnostic imaging centers, radiologist staffing would be required. The first option considered by the university was an arrangement whereby the academic department would remain based in the Moffitt Cancer Center, but the radiologists would be directly employed by the cancer center rather than the university. The other option the university contemplated was a creative, more entrepreneurial model involving a university-private partnership with Radiology Associates of Tampa (RAT), a longtime educational partner of the university involved in the residency training program. The decision had significant political and financial implications at a time when the medical college was ascending as a nationally prominent research entity. In this report, we describe the creation of a novel university-community partnership between USF and RAT to solve the clinical service and teaching needs of the diagnostic radiology department at our community-based medical school.A Novel Hybrid Private-Academic Practice Model for a Radiology Department at a Community-Based Medical SchoolTodd R. Hazelton, Carlos R. Martinez, Bruce R. Zwiebel, Raul R. Otero, Robert J. Belsole, Stephen K. Klasko10.1016/j.jacr.2010.02.011Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2The Voice of Experience646649http://www.jacr.org/article/PIIS1546144010002565/abstract?rss=yesMRI examination time is equivalent to x-ray CT radiation dose. Just as we limit dose for CT examinations, we suggest that MRI examination time should be limited. Making MRI examinations shorter would make them less expensive, enable more MRI examinations because more people could be imaged, and extend the range of diagnostic procedures that can be done routinely by MRI.MRI: Time Is Dose—and Money and VersatilityWilliam A. Edelstein, Mahadevappa Mahesh, John A. Carrino10.1016/j.jacr.2010.05.002Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Technology Talk650652http://www.jacr.org/article/PIIS1546144010002218/abstract?rss=yesToday, Henry S. Kaplan, MD, ranks as one of the foremost radiologists in the history of American medicine. Trained as a general radiologist, his focus on cancer and radiation biology, directed toward radiation oncology, allowed this remarkable physician–scientist to change a once fatal cancer, Hodgkin's disease, to one that is highly curable today.Sarah S. Donaldson10.1016/j.jacr.2010.04.014Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Book Review653653http://www.jacr.org/article/PIIS1546144010002267/abstract?rss=yesAbout 2 years after Wilhelm Conrad Roentgen discovered x-rays in his physics laboratory in Germany, French scientists Henri Becquerel and Pierre and Marie Curie discovered that some minerals contained radioactive energy comparable with the electromagnetic energy of x-rays. In the next few years, the Curies worked with pitchblende to define and extract radioactive substances. Their triumph was the extraction of radium, the most potent energy, which amounted to less than an ounce within a ton of its basic mineral.William DuaneOtha Linton10.1016/j.jacr.2010.04.016Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2They Were Giants654654http://www.jacr.org/article/PIIS1546144010002723/abstract?rss=yesAccording to the article by Mahadevappa Mahesh, MS, PhD [], in the May issue of JACR, in the name of security, we should now begin a great public health experiment with the use of x-ray backscatter machines. Contrary to every policy enacted since the effects of radiation were understood, we are engaging in a mass experiment of irradiation of not just adults but also pregnant women, fetuses, children, women of childbearing age, men who may conceive after exposure, and everyone unfortunate enough to have to be in an airport. The results will not be known for 20 years. Imagine if, as an investigator at the University of California, San Francisco, I had asked my institutional review board to allow me to carry out an experiment involving indiscriminate exposure to x-rays of a randomly selected population, with no informed consent.Re: “Airport Full-Body Scanners”Leon Kaufman10.1016/j.jacr.2010.05.018Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Letters to the Editor655656http://www.jacr.org/article/PIIS1546144010003339/abstract?rss=yesI would like to respond to Dr Kaufman in the following ways. First, I would like to address the issues listed in the second and final paragraphs of Dr Kaufman's letter, regarding radiation doses and how they were measured. As reported in the National Council on Radiation Protection and Measurements [] commentary, the effective doses were derived from field measurements by the American National Standards Institute and Health Physics Society N43.17 subcommittee members (which included health physicists and experts from academia, regulatory agencies, and industry), and the methodology used in their calculation is described in detail in the American National Standards Institute [] standards.Author's ReplyMahadevappa Mahesh10.1016/j.jacr.2010.06.015Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Letters to the Editor656657http://www.jacr.org/article/PIIS1546144010003704/abstract?rss=yesForthcoming Articles10.1016/S1546-1440(10)00370-4Journal of the American College of Radiology 7, 8 (2010)2010-08-01Journal of the American College of Radiology2010-08-0178S1546-1440(10)X0007-2Other Content659659