One-week radiology boot camp for pre-clerkship medical students: A novel format improving image interpretation and confidence.

RATIONALE AND OBJECTIVES: To measure change in radiology knowledge, confidence in radiology skills, and perceptions pertaining to radiology following a one-week boot camp elective for undergraduate medical students. MATERIALS AND METHODS: A five-day comprehensive radiology boot camp was developed including sessions on image interpretation, procedural skills, and appropriate image ordering. A multiple-choice quiz was administered before and after the elective, utilizing radiology questions from the validated AMSER STARS database. Additionally, a pre- and post-elective survey was administered assessing radiology career interest, confidence in radiology-based skills, and the potential ability of radiology-based skills to increase confidence in specialties other than radiology. Responses from the assessments were analysed using paired t-tests. RESULTS: 15 students enrolled in the course and 14 completed all assessments. The average score on the quiz increased from 50.1% to 66.0% (p<0.001). On the post-elective survey, the average student confidence score increased by more than one point on a six-point Likert scale in each of radiographic interpretation (p=0.004), ultrasound interpretation (p=0.0002), CT/MRI interpretation (p=0.02), general radiology knowledge including procedural skills (p=0.0001), and appropriate image ordering (p=0.004). Average student satisfaction with the elective was 8.1 out of 10. CONCLUSION: A one-week radiology boot camp for pre-clerkship medical students improved radiology knowledge and confidence in radiology skills, showing potential for this format to meet the demand for increased radiology content in undergraduate training. Students indicated that confidence in radiology knowledge would increase confidence on non-radiology clerkship rotations, highlighting the importance of how a one-week radiology bootcamp can impact both future radiology and non-radiology clerkship experiences.

Isopropyl alcohol inhalation for the treatment of nausea in adult emergency department patients: a systematic review and meta-analysis.

BACKGROUND: Nausea and vomiting is a common ED chief complaint. However, randomised trials comparing antiemetic agents to placebo have not demonstrated superiority. This systematic review investigates the efficacy of inhaled isopropyl alcohol (IPA) compared with usual care or placebo in adults presenting to the ED with nausea and vomiting. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, other relevant trial registries, journals, and conference proceedings up to September 2022. Randomised controlled trials using IPA to treat adult ED patients with nausea and vomiting were included. The primary outcome was change in severity of nausea, measured by a validated scale. A secondary outcome was vomiting during the ED stay. We used a random-effects model for the meta-analysis, and assessed certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation system. RESULTS: Two trials comparing inhaled IPA to saline placebo and including a total of 195 patients were pooled for meta-analysis of the primary outcome. A third study comparing a group receiving inhaled IPA and oral ondansetron to another group receiving inhaled saline placebo and oral ondansetron did not qualify for the original registered protocol, but was included in a secondary analysis. All studies were judged to be at low or unclear risk of bias. The pooled mean difference for the primary analysis was a reduction in reported nausea of 2.18 on a 0-10 scale (95% confidence interval (CI) 1.60 to 2.76), favouring IPA over placebo, where the minimum clinically significant difference was defined as 1.5. The evidence level was graded as moderate, due to imprecision from low patient numbers. Only the study included in the secondary analysis assessed the secondary outcome of vomiting, and did not find a difference between intervention and control. CONCLUSION: This review suggests that IPA likely has a modest effect in reducing nausea in adult ED patients, compared with placebo. Larger multicentre trials are needed, as the evidence is limited by few trials and patients. PROSPERO REGISTRATION NUMBER: CRD42022299815.

Pancreatic ductal adenocarcinoma (PDAC) regional nodal disease at standard lymphadenectomy: is MRI accurate for identifying node-positive patients?

OBJECTIVE: To determine the accuracy of qualitative and quantitative MRI features for the diagnosis of pathologic regional lymph nodes at standard lymphadenectomy in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: All adult patients with pancreatic MRI performed from 2011 to 2021 within 3 months of a pancreaticoduodenectomy were eligible for inclusion in this single-center retrospective cohort study. Regional nodes at standard lymphadenectomy were independently reviewed by two fellowship-trained abdominal radiologists for the following qualitative features: heterogeneous T2 signal, round shape, indistinct margin, peri-nodal fat stranding, and restricted diffusion greater than the spleen. Quantitative characteristics including primary tumor size, largest node short- and long-axes length, number of regional nodes, absolute apparent diffusion coefficient (ADC) values, and ADC node-to-spleen signal index were assessed. Analysis was at the patient-level with surgical pathology as the reference standard. RESULTS: Of 75 patients, 85% (64/75) were positive for regional nodal disease on histopathology. None of the qualitative variables evaluated on MRI was associated with pathologic nodes. Median primary tumor maximum diameter was slightly larger for patients with pathologic nodes compared to those without (18 mm (10-42 mm) vs 16 mm (9-22 mm), p = 0.027). None of the other quantitative features was associated with pathologic nodes. Radiologist opinion was not associated with pathologic nodes (p = 0.520). Interobserver agreement was fair (kappa = 0.257). CONCLUSIONS: Lymph node morphologic features and radiologist opinion using MRI are of limited value for diagnosing PDAC regional nodal disease. Improved diagnostic techniques are needed given the prognostic implications of pathologic lymph nodes in these patients. KEY POINTS: • Multiple lymph node morphologic features routinely assessed on MRI for malignancies elsewhere in the body are likely not applicable when assessing for pancreatic ductal adenocarcinoma nodal disease. • Interobserver agreement for the presence or absence of pancreatic ductal adenocarcinoma lymph node morphologic features on MRI is fair (kappa = 0.257). • Many more lymph nodes are resected at PDAC standard lymphadenectomy than are detectable on MRI, median 25 vs 5 (p < 0.001), suggesting improved diagnostic techniques are needed to identify PDAC nodal disease.

Reversed diastolic flow in a renal transplant due to ureteric obstruction from intraluminal blood clot.

Reversal of arterial diastolic flow is commonly considered a sign of transplant renal vein thrombosis until proven otherwise, with the differential including acute rejection, acute tubular necrosis, and perirenal hematoma. We discuss a case of a patient who presented with decreased urine output on the second postoperative day following living unrelated kidney transplantation. Doppler ultrasound was performed and demonstrated reversal of diastolic flow in the transplant renal artery. Prompt surgical exploration revealed intraluminal blood clot obstructing the ureter. To our knowledge, this is the first reported case of reversed diastolic flow secondary to ureteral obstruction by an intraluminal blood clot.

Which Aspects of the CanMEDS Competencies are Most Valued in Radiologists? Perspectives of Trainees From Other Specialties.

PURPOSE: Radiologists work primarily in collaboration with other healthcare professionals. As such, these stakeholder perspectives are of value to the development and assessment of educational outcomes during the transition to competency-based medical education. Our aim in this study was to determine which aspects of the Royal College CanMEDS competencies for diagnostic radiology are considered most important by future referring physicians. METHODS: Institutional ethics approval was obtained. After pilot testing, an anonymous online survey was sent to all residents and clinical fellows at our university. Open-ended questions asked respondents to describe the aspects of radiologist service they felt were most important. Thematic analysis of the free-text responses was performed using a grounded theory approach. The resulting themes were mapped to the 2015 CanMEDS Key Competencies. RESULTS: 115 completed surveys were received from residents and fellows from essentially all specialties and years of training (out of 928 invited). Major themes were 1) timeliness and accessibility of service, 2) quality of reporting, and 3) acting as a valued team member. The competencies identified as important by resident physicians were largely consistent with the CanMEDS framework, although not all key competencies were covered in the responses. CONCLUSIONS: This study illustrates how CanMEDS roles and competencies may be exemplified in a concrete and specialty-specific manner from the perspective of key stakeholders. Our survey results provide further insight into specific objectives for teaching and assessing these competencies in radiology residency training, with the ultimate goal of improving patient care through strengthened communication and working relationships.

MRI LI-RADS Version 2018: Impact of and Reduction in Ancillary Features.

OBJECTIVE. The purpose of this study is to determine the impact of LI-RADS ancillary features on MRI and to ascertain whether the number of ancillary features can be reduced without compromising LI-RADS accuracy. MATERIALS AND METHODS. A total of 222 liver observations in 81 consecutive patients were identified on MRI between August 2013 and December 2018. The presence or absence of major and ancillary features was used to determine the LI-RADS category for LR-1 to LR-5 observations. Final diagnosis was established on the basis of pathologic findings or one of several composite clinical reference standards. Diagnostic accuracy was compared with and without ancillary features by use of the z test of proportions. Decision tree analysis and machine learning-based feature pruning were used to identify noncontributory ancillary features for LI-RADS categorization. Interobserver agreement with and without ancillary features was measured using the Krippendorff alpha coefficient, and comparisons were made using bootstrapping. A p < .05 was considered statistically significant. RESULTS. Application of ancillary features resulted in a change in the LI-RADS category of seven hepatocellular carcinomas (HCCs), with the category of six of seven (86%) HCCs upgraded; 51 benign observations also had a change in LI-RADS category, with the category of 33 (65%) of these observations downgraded. When ancillary features were applied, the percentage of HCCs in each LI-RADS category did not differ significantly compared with major features alone (p = .06-.49). Decision tree analysis and the machine learning model identified five ancillary features as noncontributory: corona enhancement, nodule-in-nodule, mosaic architecture, blood products in mass, and fat in a mass, more than in adjacent liver. Interobserver agreement was high with and without application of ancillary features; however, it was significantly higher without ancillary features (p < .001). CONCLUSION. Although ancillary features are an important component of LI-RADS, their impact may be small. Several ancillary features likely can be removed from LI-RADS without compromising diagnostic performance.

Contrast-enhanced ultrasound in the diagnosis of infiltrative hepatocellular carcinoma: A report of three cases.

Infiltrative hepatocellular carcinoma (HCC) is a challenging imaging diagnosis due to its ill-defined appearance and variable enhancement, which may be difficult to distinguish from background changes from cirrhosis. The literature on the role of contrast-enhanced ultrasound (CEUS) in the diagnosis of infiltrative HCC is currently limited. CEUS has greater sensitivity for contrast enhancement due to its temporal resolution, and can be used when there is contraindication to CT or MRI contrast. We present 3 cases where CEUS aided in the diagnosis of infiltrative HCC in patients with equivocal CT and MRI findings and/or renal failure, with significant implications for management. As current guidelines focus on the role of CEUS in characterizing defined focal liver lesions or discrete observations on precontrast US, further studies are warranted to validate the utility of CEUS in the noninvasive diagnosis of infiltrative HCC and delineate its role in algorithms for imaging workup.

Resident Physicians' Perceptions of Diagnostic Radiology and the Declining Interest in the Specialty.

RATIONALE AND OBJECTIVES: The relative competitiveness of radiology and the number of first-choice applicants to diagnostic radiology have steadily declined over the past decade. The purpose of this study was to identify factors contributing to the declining interest in diagnostic radiology as a career and to explore factors affecting specialty choice. MATERIALS AND METHODS: A retrospective survey was distributed to resident physicians at a single academic center between July and August 2017. Participants identified factors affecting career choice and evaluated level of agreement with statements regarding radiology using 5-point Likert scales. Higher scores indicated stronger agreement. RESULTS: One hundred and fifty-two resident physicians from Canada participated (21.5% response rate): 20 radiology and 132 nonradiology. Of the total, 27% were registered in postgraduate year (PGY) 1, 23% in PGY 2, 15% in PGY 3, 19% in PGY 4, and 16% in PGY 5, or above. Sixty-one percent of the respondents self-reported as female, 34% as male, and 5% as other/unknown. Of those in radiology, 40% self-reported as female, 55% as male, and 5% as other/unknown, compared to 64% female, 31% male, and 5% other/unknown in other specialties. Regardless of specialty, positive clinical/mentoring experiences strongly affected career choice. Radiology residents were attracted to diverse pathology (M = 4.5) and positive staff/resident interactions (M = 4.4). Nonradiology residents were deterred by lack of patient contact (M = 3.9) and dark work environment (M = 3.6). Resident physicians who had applied to radiology were more likely to report positive mentorship during medical school, disagree that technology will replace radiologists, and desire a higher income specialty (Wald = 56.6, p < 0.001). More recent graduates showed a higher level of concern regarding the potential negative impact of technology and outsourcing on the profession (F (3, 189) = 2.6, p = 0.05). Several trainees (21%) considered radiology, but lacked mentorship (52%) and identified job market concerns (29%). CONCLUSION: More recent graduates are relatively more concerned about technology replacing radiologists, and radiology applicants have less concern about artificial intelligence replacing radiologists. As positive interactions with radiologists and mentorship are key influencers, our results advocate for early training exposure and reinforcement regarding the positive outlook of the profession.

Pyogenic hepatic abscesses secondary to choledocholithiasis eight years post-cholecystectomy: A case report.

Cholecystectomy is the gold standard surgical treatment for acute calculous cholecystitis. Only approximately 0.4 % of these patients subsequently develop choledocholithiasis. The incidence of hepatic abscesses in these patients is unknown, but is likely low, considering there are approximately 2-15 cases of hepatic abscesses per 100,000 people in the US. The authors report the case of a 62-year-old man whose CT scan revealed hepatic abscesses secondary to choledocholithiasis, eight years after a cholecystectomy.

Incidentally detected total agenesis of the falx cerebri: Potential significance of this rare finding.

Absence of the falx cerebri is a rare radiological finding, which is generally described in relation with varying degrees of holoprosencephaly or other structural central nervous system anomalies. We present a case of non-syndromic, asymptomatic absence of falx cerebri in an elderly patient, which was discovered incidentally on a computed tomography examination of the head. The superior sagittal sinus was narrowed, but present. Relevant anatomic and embryological considerations are discussed, as well as potential implications for clinical practice.

Cecal fecaloma: A rare cause of right lower quadrant pain.

Fecalomas are masses of hardened feces that become impacted and accumulate. They are much harder in consistency than fecal impaction due to the associated coprostasis and are typically found in the sigmoid colon or rectum. Cecal fecalomas are much rarer. To date, only five cases have been previously reported in the English-language literature. We present the CT appearance of a surgically confirmed cecal fecaloma in a patient who presented with right lower quadrant pain, nausea, and vomiting, mimicking an acute appendicitis.

Women in Radiology: Exploring the Gender Disparity.

PURPOSE: In 2015, only 1.5% of female Canadian medical students pursued radiology as a specialty, versus 5.6% of men. The aim of this study was to determine what factors attract and deter Canadian medical students from pursuing a career in radiology, and why fewer women than men pursue radiology as a specialty. METHODS: An anonymous online survey was e-mailed to English-speaking Canadian medical schools, and 12 of 14 schools participated. Subgroup analyses for gender and radiology interest were performed using the Fisher exact test (P < .05). RESULTS: In total, 917 students (514 women; 403 men) responded. Direct patient contact was valued by significantly more women who were not considering specialization in radiology (87%), compared with women who were (70%; P < .0001). Physics deterred more women (47%) than it did men (21%), despite similar educational backgrounds for the two gender groups in physical sciences (P < .0001). More women who were considering radiology as a specialty rated intellectual stimulation as being important to their career choice (93%), compared with women who were not (80%; P = .002). Fewer women who were not interested in radiology had done preclinical observerships in radiology (20%), compared with men who were not interested in radiology (28%; P = .04). CONCLUSIONS: A perceived lack of direct patient contact dissuades medical students from pursuing radiology as a career. Women have less preclinical radiology exposure than do men. Programs that increase preclinical exposure to radiology subspecialties that have greater patient contact should be initiated, and an effort to actively recruit women to such programs should be made.

Thyroid Biopsy Specialists: A Quality Initiative to Reduce Wait Times and Improve Adequacy Rates.

PURPOSE: To develop and implement a program where selected sonographers would be trained to perform thyroid biopsies independently under the supervision of a radiologist, with the goal of improving efficiency and quality. MATERIALS AND METHODS: Institutional research ethics board approval was obtained for this retrospective study, with waiver of informed consent. After approval from the relevant regulatory bodies, four sonographers successfully completed a training program and began to perform all thyroid biopsies (with informed consent) in a room adjacent to the main radiologist-run biopsy room, where the radiologist was available for backup as needed. In the preimplementation period (January 2010 to April 2011), 1321 nodules were biopsied, 29 of which included on-site cytopathology assessment. In the postimplementation period (August 2011 to July 2012), 1347 nodules were biopsied, 103 of which underwent on-site cytopathology assessment. Wait times and adequacy rates were calculated for both periods. RESULTS: Patient wait times decreased from a mean of 80-90 days before implementation of the thyroid biopsy specialist program to 20-30 days afterward. The percentage of adequate samples improved from 74.6% (985 of 1321 nodules) to 78.6% (1059 of 1347 nodules), with a P value of .015 (74.1% [957 of 1292 nodules] to 77.5% [964 of 1244 nodules] when excluding nodules with on-site cytopathology assessment, P = .0497). The percentage of malignant samples showed no significant change in the two time periods, 5.1% (68 of 1321 nodules) before implementation of the program versus 5.4% (73 of 1347 nodules) after implementation, P = .823 (5.1% [66 of 1292 nodules] vs 5.3% [66 of 1244 nodules] in the respective time periods when excluding nodules with on-site cytopathology assessment, P = .888). No major procedural complications occurred. CONCLUSION: Sonographers can be successfully trained to perform ultrasonography-guided thyroid biopsies safely under the supervision of a radiologist, which can improve wait times and adequacy rates.

The next generation HydroCoil: initial clinical experience with the HydroFill embolic coil.

BACKGROUND: Complete packing of intracranial aneurysms has demonstrated a significant decrease in aneurysm recurrence rates with increased volumetric filling. The HydroCoil Embolization System (HES) was developed to increase volumetric filling within the aneurysm sac to maintain long term occlusion. To further enhance ease of HES deployment, a new next generation embolic coil, the HydroFill coil, was developed. OBJECTIVE: To report the first clinical experience with the HydroFill coil, focusing on safety and effectiveness, with immediate and long term follow-up on cases performed at a single institution by a single operator. METHODS: Retrospective angiographic and clinical analysis was performed on a non-randomized single arm registry of the first consecutive 11 patients with 14 intracranial saccular aneurysms treated during a 9 month period. RESULTS: The immediate angiographic occlusion rate according to the Raymond scale was 100%. Overall packing density of all coils used was 13-135% (mean 64%). The immediate complication rate was 9% (1/11 patients), secondary to a parent vessel occlusion which resolved after intravenous administration of eptifibatide (Integrilin) without neurological sequelae. The angiographic/MR angiography follow-up period for this series was 13-30 months, with an overall complete occlusion rate of 86% (12/14 aneurysms). 2/14 aneurysms (14%) converted from complete occlusion to filling of small neck remnants. Of the two, one (7%) was a cavernous aneurysm that was retreated. CONCLUSIONS: Although this initial case series is small, this study demonstrates safe deployment of the HydroFill coil in ruptured and unruptured aneurysms without major complications, and with a high rate of occlusion on long term follow-up.

Extraspinal findings at lumbar spine CT examinations: prevalence and clinical importance.

PURPOSE: To prospectively determine the prevalence and clinical importance of extraspinal abnormalities in adult outpatients undergoing computed tomography (CT) of the lumbar spine. MATERIALS AND METHODS: Institutional review board approval was obtained for this prospective study. Informed consent was obtained from 400 consecutive adult outpatients (mean age, 49 years; 212 male and 188 female patients) undergoing lumbar spine CT for low back pain and/or radiculopathy. Those with known malignancy were excluded. Dedicated spinal and abdominal full-field-of-view (FOV) images for each patient were reviewed by at least one neuroradiologist and two body radiologists. Extraspinal abnormalities were classified according to the CT Colonography Reporting and Data System (C-RADS). The electronic medical record of the patients with C-RADS E3 and E4 extraspinal findings were reviewed to assess how many of these findings were previously unknown, and the patients were followed up 24-36 months after the initial CT to determine their work-up and outcome. RESULTS: Extraspinal findings were present on images in 162 (40.5%) of 400 lumbar spine CT examinations; 59 (14.8%) patients had indeterminate or clinically important findings requiring clinical correlation or further evaluation. After review of the electronic medical record, the prevalence of clinically important findings was 4.3%, comprising an early-stage renal cell carcinoma and transitional cell carcinoma, chronic lymphocytic leukemia, sarcoidosis, and 13 abdominal aortic aneurysms. Excluding anatomic variants, the full FOV was required to best visualize extraspinal abnormalities in 127 (79.4%) of 160 patients. CONCLUSION: Reviewing the full-FOV images from lumbar spine CT examinations will result in the detection of a small number of substantial extraspinal pathologic findings in addition to many benign incidental findings.