Improving Radiology Trainees' Perception Using Where's Waldo?

RATIONALE AND OBJECTIVES: Perception is an essential skill leading to expertise in diagnostic radiology. We determined if practicing "Where's Waldo?" images improves accuracy and speed with which first and second year radiology residents detect abnormalities on chest radiographs (CXRs). MATERIALS AND METHODS: Residents at three institutions were pretested using 50 CXRs, identifying locations of potential abnormalities. They were then split into trained (examining 7 "Where's Waldo?" images over three weeks) and control groups (no "Where's Waldo?"). They were then re-tested on the 50 CXRs. At one site, visual search parameters were acquired. Data were analyzed with repeated measures ANOVAs. RESULTS: There was no significant difference in performance for trained vs control (F = 0.622, p = 0.436), with both improving significantly on post-test (F = 4.72, p = 0.037). Session time decreased significantly for both groups from pre to post-test (F = 81.47, p < 0.0001) and the decrease was significantly more (F = 31.59, p < 0.0001) for the trained group than the control group as well as for PGY with PGY3 having a larger average decrease in session time than PGY2. Eye-tracking data also showed significant increases in per image search efficiency with training. CONCLUSION: Practicing "Where's Waldo?" or similar nonradiology search tasks may facilitate the acquisition of radiology image search but not detection skills, impacting reading efficiency more than detection accuracy.

Vascular imaging in the initial evaluation of embolic stroke source.

PURPOSE: During acute ischemic stroke evaluations, neurovascular imaging is commonly performed to localize the source of a thromboembolus and to identify vascular stenoses. In this study, we aimed to analyze 1) the usefulness of intracranial and/or cervical CTA and MRA and carotid doppler ultrasound (DUS) for identifying the stroke source and 2) the incidence of vascular stenoses across stroke etiologies. METHODS: We retrospectively reviewed intracranial and/or cervical CTA, DUS and MRA studies to identify the source of the acute stroke by Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria for 200 consecutive patients admitted with a stroke to our tertiary hospital. Stroke etiologies were ascertained and the rates of intracranial and cervical vascular stenoses were stratified by stroke type. RESULTS: Of 200 patients, the most probable sources of stroke were small vessel disease (29%), cardioembolic (26.0%) and atheroembolic (23.5%). Across all groups, 27.5% of patients had ≥70% stenosis on neurovascular imaging. The rate of ≥70% vascular stenosis in the neck was 6.9% and 5.8% in the small vessel and cardioembolic categories, respectively. CONCLUSIONS: The TOAST etiologies of strokes were nearly equally distributed. Neurovascular imaging was of high utility for identifying large vessel intracranial stenoses in patients presenting with acute stroke across all etiologies, although neck CTA/MRA had a lower rate of positive studies with cardiogenic and small vessel strokes. These findings have implications on the use of CTA/MRA in acute stroke work-up.

Trends in Mortality Rates for Gastrointestinal Cancers in Fars Province, Iran (2005-2015).

PURPOSE: In Iran, cancers are the third leading cause of death, and gastrointestinal cancers are the primary cause of mortality among all the cancers. This study aimed to determine the trend of crude and age-standardized mortality rates (ASMR) for different types of gastrointestinal cancers over an 11-year period in Fars province (Iran). METHODS: In this study, all the mortality data for gastrointestinal cancers were derived from the Electronic Death Registration System (EDRS) between 2005 and 2015. Subsequently, we calculated the crude and age-standardized mortality rates (ASMR) and their trends for different types of gastrointestinal cancers based on age groups and gender over the study period. RESULTS: A total of 6547 deaths from gastrointestinal cancers were identified, with an average age of 66.0 ± 16.4 years. The crude and age-standardized mortality rates for gastrointestinal cancers were respectively 10.9 and 15.0 per 100,000 population in 2005 which significantly increased to 17.4 and 19.4 per 100,000 population in 2015 (P < 0.001). The ASMR for colon, pancreatic, and oral cancers showed an increasing trend; for small intestine cancers, a decreasing trend; and for esophageal, gastric, rectal, and hepatobiliary cancers displayed an almost constant trend. CONCLUSIONS: Our study shows a higher ASMR and an increasing trend of gastrointestinal cancers in Fars province. Prevention and early diagnosis programs with screening techniques should be implemented to control the mortality rate of gastrointestinal cancers in the future.

Fellowship Candidate Factors Considered by Program Directors.

OBJECTIVE: The neuroradiology fellowship match has been in existence for about 20 years. However, the elements by which neuroradiology fellowship program directors evaluate candidates have not been clearly elucidated. We sought to identify the factors that program directors use to rank neuroradiology fellowship applicants. METHODS: An anonymous Qualtrics online five-question survey about educational credentials, personal traits, extracurricular activities, and demographic characteristics was sent to 72 neuroradiology program directors in April 2019. Each question required ranking of 10 factors based on different characteristics of fellowship candidates. Items included gender, nationality, US Medical Licensing Examination scores, internal applicants, work and research experience, recommendation letters, residency program, medical school attended, and visa status. Program directors had the ability to list any new characteristics that were not included in the survey. RESULTS: In all, 68 of 72 (94.4%) neuroradiology programs responded to the survey. The most important criteria by which candidates were assessed were (1) residency program attended for educational credential, (2) personality as assessed by faculty at interviews for candidate personal traits, (3) research performed for candidate's extracurricular activities, and (4) likelihood of coming to or previous experience in the fellowship geographic area. Neuroradiology program directors independently stressed residency program attended, personality assessed during the interview by faculty, internal candidate status, letters of recommendation, and research activities as their top five criteria in ranking the candidates. CONCLUSION: Multiple factors are weighed by neuroradiology fellowship program directors in selecting fellows, but recent experiences in residency, research, and faculty interactions are prioritized. Internal candidates have an advantage for remaining as fellows within their residency programs.

Musculoskeletal Radiology Reports: Overlooked or Valuable?

The electronic medical record (EMR) can reveal preferences of clinicians regarding imaging services. We sought to evaluate viewing habits for reports and images of musculoskeletal (MSK) studies by ordering clinicians. We hypothesized that MSK reports are important to clinical management, especially for advanced imaging modalities. We tracked the image and report access of all MSK studies ordered in September 2016 over 8 months using logs of the EMR (Epic Systems, Verona, WI), and by an independent analysis of the institutional PACS (Picture Archiving and Communication Systems) (Carestream Health, Rochester, NY). The time stamps were extracted for when images and reports were viewed. We categorized MSK studies by modality and provider department. We also compared the rates of viewing reports and images among different modalities and departments using the chi-square test. Of the 8143 viewed MSK studies, 7842 (96.3%) reports (with/without images) and 3916 (48.1%) imaging data (with/without reports) were viewed. Viewing reports alone occurred in 4227 (51.9%) studies. CT and MRI reports alone views occurred more often in comparison to radiographs ([482/706; 68.3%] for CT and [981/1713; 57.3%] for MRI vs. [2764/5724; 48.3%] for radiography, p < 0.001). Orthopedists ordered the highest number of MSK studies and viewed reports 99.2% (3216/3242) of the time, including a 54.6% (1770/3242) rate of viewing reports alone and a 44.6% (1446/3242) rate of viewing both reports and images. They viewed images without reports in 0.8% (27/3242) of cases. MSK reports were viewed significantly more frequently than the images across all modalities and all relevant specialties.

Functional Connectivity in Neurodegenerative Disorders: Alzheimer's Disease and Frontotemporal Dementia.

Neurodegenerative disorders are a growing cause of morbidity and mortality worldwide. Onset is typically insidious and clinical symptoms of behavioral change, memory loss, or cognitive dysfunction may not be evident early in the disease process. Efforts have been made to discover biomarkers that allow for earlier diagnosis of neurodegenerative disorders, to initiate treatment that may slow the course of clinical deterioration. Neuronal dysfunction occurs earlier than clinical symptoms manifest. Thus, assessment of neuronal function using functional brain imaging has been examined as a potential biomarker. While most early studies used task-functional magnetic resonance imaging (fMRI), with the more recent technique of resting-state fMRI, "intrinsic" relationships between brain regions or brain networks have been studied in greater detail in neurodegenerative disorders. In Alzheimer's disease, the most common neurodegenerative disorder, and frontotemporal dementia, another of the common dementias, specific brain networks may be particularly susceptible to dysfunction. In this review, we highlight the major findings of functional connectivity assessed by resting state fMRI in Alzheimer's disease and frontotemporal dementia.

Magnetic resonance imaging findings in Parinaud's syndrome: comparing pineal mass findings to other etiologies.

PURPOSE: In a recent study, it was found that, although intrinsic midbrain signal abnormality (IMSA) on MRI is associated with Parinaud's syndrome (PS) in patients with pineal gland masses (PM), it had no predictive value with respect to resolution of PS. We sought to compare the PM and non-pineal etiologies (NPE) of PS by reviewing imaging features of PS and whether or not they are predictive of resolution of symptoms. METHODS: We reviewed electronic medical records from 1980 to 2017 and identified 71 patients with PS from any etiology who had MR imaging: 26 with PM and 45 with NPE. We subdivided the 45 NPE patients into those with intrinsic midbrain lesions (IMBL) (n = 23) and those with extrinsic midbrain lesions (EMBL) (n = 22). PS resolution and hydrocephalus data were collected. Imaging studies were reviewed for the presence of IMSA and hydrocephalus. RESULTS: PS patients with EMBL were less likely to have IMSA than those with PM or IMBL (p ≤0.001). PS resolution occurred more commonly with PM than IMBL and NPE (p = 0.03, p = 0.01). For all NPE patients, resolution of PS occurred with equal frequency in patients with and without IMSA (p = 1.00). Hydrocephalus occurred more frequently in patients with PM and EMBL than IMBL (p = 0.01, p = 0.03). CONCLUSIONS: IMSA is present more often in patients with PS from PM or IMBL than in patients with EMBL. EMBL, including PM, have an increased likelihood for PS resolution. There is no predictive value of IMSA with respect to resolution of PS in NPE as well as PM.

The epidemiology of suicide in the elderly population in Southern Iran, 2011-2016.

BACKGROUND: The epidemiology of suicide within the elderly is unique to each cultural setting. In most countries, despite the higher rate of suicide attempts among adolescents and young people, the rate of suicide deaths in the elderly is higher than other age groups. The purpose of this study was to investigate the suicide rates among persons 65 years and above in Fars, Iran. METHODS: In this cross-sectional study, we investigated suicide cases (65 years and older) during 2011-2016 in Fars, Iran. The data were collected from the Mental Health and Suicide Surveillance Systems of Fars province, using filled forms that included suicide and demographic information. After eliminating duplications, suicidal rates were calculated. RESULTS: Of 299 suicide attempts, 64.9% were men, and 69.6% were urban residents. The rate of suicide attempts and deaths were 21.47 and 4.52 per 100,000 population, respectively; and the case fatality rate (CFR) of suicide was 21.07% during the study period. The rate of suicide attempts and deaths in this population showed an increase during the study years. CONCLUSIONS: Considering the increasing trend of suicide rates in the elderly in Fars, Iran, measures should be taken to facilitate the access of this group to the mental health care system and psychological counseling.

Missed Opportunity: Neuroradiology Training Programs and Social Media.

OBJECTIVE. The purpose of this study was to ascertain the degree to which the academic neuroradiology community is embracing social media in its messaging. The hypothesis was that, compared with peer neurosurgery and neurology programs, a majority of neuroradiology programs would actively engage through Facebook and Twitter accounts. MATERIALS AND METHODS. An Internet search was conducted for Facebook, Twitter, LinkedIn, and Instagram accounts for the 75 National Resident Matching Program-registered U.S. neuroradiology fellowship programs and their division chiefs and for the neurosurgery and neurology social media accounts of the same institutions. The content and audience responses of the neuroradiology accounts were categorized. RESULTS. Only 8 of 75 neuroradiology programs had one or more social media accounts. Neurosurgery (odds ratio, 5.9; 95% CI, 2.5-14.0) and neurology (odds ratio, 3.2; 95% CI, 1.3-7.9) had a significantly greater social media presence than neuroradiology did. Larger neuroradiology programs (five or more fellowship positions) had significantly greater likelihood (odds ratio, 7.6,; 95% CI, 1.6-36.4) of having social media accounts compared with those with fewer than five positions. Division chiefs had accounts on LinkedIn more than other media. Few neuroradiology chiefs actively engaged professionally on Facebook and Twitter. Most neuroradiology programs used social media more for recruitment and program information than for education, research, or patient information. CONCLUSION. Most neuroradiology training programs do not have social media accounts and do not use social media for education, engagement, recruitment, or research promulgation. Neurosurgery and neurology programs have more but still limited World Wide Web representation. There is an opportunity for neuroradiology programs to have greater impact in this arena.

MRI findings in Parinaud's syndrome: a closer look at pineal masses.

PURPOSE: The association between MRI findings in patients with pineal lesions and the presence or absence of Parinaud's syndrome (PS) remains poorly described. We sought to better understand what MRI characteristics of a pineal lesion make PS more likely. Can these features predict prognosis for clinical resolution? Based on the anatomical relationship of the pineal gland and midbrain, we hypothesized that the degree of midbrain injury by a pineal mass as assessed by abutment, displacement, or intrinsic midbrain signal abnormality (IMSA) may predict PS. METHODS: We reviewed our institution's databases to find patients with MRI evidence of an intrinsic lesion of the pineal gland. Seventy-seven patients with intrinsic pineal gland lesions, 26 with PS and 51 without PS (NPS), were identified. Data regarding clinical history were collected, and an experienced neuroradiologist reviewed all MRI studies and recorded mass size, midbrain abutment, displacement by the pineal lesion, and presence or absence of IMSA. RESULTS: IMSA occurred with increased frequency in pineal lesions with PS (85%) when compared with NPS (39.2%) (p = 0.0001). Midbrain abutment, compression, and displacement occurred with similar frequencies in both groups, with no statistically significant difference. Hydrocephalus was present in 80.8% of patients with PS and 84% without PS (p = 0.75). CONCLUSION: IMSA in a patient with an intrinsic pineal gland mass is associated with PS. Other findings such as hydrocephalus and midbrain displacement are common in patients with pineal masses both with and without PS and do not have any predictive value.

"Worst Headache of Life" in a Migraineur: Marginal Value of Emergency Department CT Scanning.

PURPOSE: The ACR Appropriateness Criteria recommend performing noncontrast head CT (NCCT) for patients with sudden severe headache ("worst headache of life" [WHOL] or "thunderclap headache" [TCH]). The aim of this study was to assess the value of NCCT scanning in patients with known migraine histories and WHOL or TCH. The hypothesis was that there would be little utility in performing emergency department (ED) NCCT scans in migraineurs without other red flags, even if they had WHOL or TCH. METHODS: The ED NCCT scans of all patients reporting WHOL or TCH who had established diagnoses of migraine were retrospectively reviewed over a 5-year period. Patients without known intracranial pathology, cancer, or immunocompromising disease or recent head trauma were included as the main study group. For comparison, patients with any of those factors were included as the comparison group. Scans were graded as (1) normal, (2) minor unimportant findings, (3) findings requiring intervention or follow-up, or (4) critical. RESULTS: Two hundred twenty-four patients with the chief symptom of WHOL or TCH and a history of migraine who underwent ED NCCT were studied. In the main study group, no patients had grade 4 imaging findings (0%), one had a false-positive grade 3 finding (0.8%), and there were no cases of subarachnoid hemorrhage (0%). In the comparison group, six patients had grade 4 imaging findings (6.5%) and three had grade 3 findings (3.3%). CONCLUSIONS: NCCT in known migraineurs with WHOL or TCH who do not have intracranial pathology, cancer, immunocompromising disease, or recent head trauma yielded no critical findings. Therefore, the value of scanning these patients is questionable.

Incidental findings on cervical spine computed tomography scans: overlooked and unimportant?

PURPOSE: Imaging of the cervical spine for trauma or degenerative disease includes multiple areas of the head and neck that may harbor incidental findings. We sought to determine the incidence of common "incidentalomas" on cervical spine CT scans, their importance, and how often these lesions are mentioned in reports. METHODS: We retrospectively reviewed the cervical spine CTs and reports of all patients scanned between October 2017 and January 2018 for Tornwaldt cysts (TC), thyroglossal duct cysts and remnants (TGDC), laryngoceles (LC), pharyngoceles (PC), carotid artery calcified stenosis (CACS), and aberrant right subclavian arteries (ARSA). Descriptive statistics were performed, and the incidence of cancers (in PC and LCs) and strokes (in high-grade carotid stenosis) was assessed. RESULTS: Among 2116 patients, the incidences of findings were TC 6.6% (138/2100), TGDC 6.3% (122/1770), LC 9.4% (197/2100), PC 6.4% (135/2100), CACS 4.7% (100/2114), and ARSA 0.86% (18/2097). Of the 2116 patients studied, 600/2116 (28.3%) had at least one incidental finding. Only 2.9% (20/701) of incidentalomas were mentioned in the official reports. CONCLUSION: Cervical incidentalomas vary in rates from ARSA (0.86%) to LC (9.4%). They are rarely mentioned in radiologists' reports. Whether improved vigilance and reporting of these incidentalomas would benefit patient care should be explored.