Effect of Reader and Patient Parameters on the Performance of Last-Image-Hold for Fluoroscopic Grading of Vesicoureteric Reflux.

OBJECTIVE. The purpose of this study is to determine the effect of different reader and patient parameters on the degree of agreement and the rate of misclassification of vesicoureteric reflux grading on last-image-hold frames in relation to spot-exposed frames from voiding cystourethrography (VCUG) as well as to determine the nature of reflux misclassification on last-image-hold frames. MATERIALS AND METHODS. Blinded readers conducted a retrospective evaluation of last-image-hold and spot-exposed frames of the renal fossae from 191 sequential VCUG examinations performed during a five-year period. Kappa tests were used to determine the agreement between reflux gradings and to assess the impact of reader and patient parameters. Pearson product-moment correlations were used to evaluate the effect of patient parameters on reader level of certainty regarding reflux grading. RESULTS. We measured almost perfect overall agreement for more experienced readers and substantial overall agreement for less experienced readers. Point estimates of overall misclassification were less than 2% for more experienced readers and less than 4% for less experienced readers. The readers' level of certainty about reflux grading had a positive impact on agreement values and misclassification rates. Experienced readers' most common misclassification was assigning reflux a grade of 3 on a spot-exposed frame and a grade of 2 on an equivalent last-image-hold frame. Inexperienced readers' most common misclassification involved missing reflux altogether. CONCLUSION. Instances of grade 2 reflux on last-image-hold frames may warrant supplemental evaluation with spot-exposed frames. Otherwise, a reader's level of certainty regarding reflux grading on a last-image-hold frame may help determine whether a supplemental spot-exposed frame would be beneficial.

Intense iodine activity caused by mosquito bite.

A 12-year-old girl with a history of papillary thyroid cancer underwent radioiodine remnant ablation using (131)I. Posttherapy whole-body (131)I scintigraphy revealed not only the known activity in the neck but also increased activity in the superficial posterior right upper thigh. On further clinical evaluation, the patient was found to have a mosquito bite with surrounding hyperemia at the site of the abnormal activity.

Heterogeneity of intramural function in hypertrophic cardiomyopathy: mechanistic insights from MRI late gadolinium enhancement and high-resolution displacement encoding with stimulated echoes strain maps.

BACKGROUND: In hypertrophic cardiomyopathy (HCM), myocardial abnormalities are commonly heterogeneous. Two patterns of late gadolinium enhancement (LGE) have been reported: a bright "confluent" and an intermediate intensity abnormality termed "diffuse," each representing different degrees of myocardial scarring. We used MRI to study the relation between intramural cardiac function and the extent of fibrosis in HCM. The aim of this study was to determine whether excess collagen or myocardial scarring, as determined by LGE MRI, are the primary mechanisms leading to heterogeneous regional contractile function in patients with HCM. METHODS AND RESULTS: Intramural left ventricular strain, transmural left ventricular function, and regions of myocardial fibrosis/scarring were imaged in 22 patients with HCM, using displacement encoding with stimulated echoes (DENSE), cine MRI, and LGE. DENSE systolic strain maps were qualitatively and quantitatively compared with LGE images. Intramural systolic strain by DENSE was significantly depressed within areas of confluent and diffuse LGE but also in the core of the most hypertrophic nonenhanced segment (all P < 0.001 versus nonhypertrophied segments). DENSE demonstrated an unexpected inner rim of largely preserved contractile function and a noncontracting outer wall within hypertrophic segments in 91% of patients. CONCLUSIONS: LGE predicted some but not all of the heterogeneity of intramural contractile abnormalities. This indicates that myocardial scarring or excess interstitial collagen deposition does not fully explain the observed contractile heterogeneity in HCM. Thus, myofibril disarray or other nonfibrotic processes affect systolic function in a large number of patients with HCM.

The value of the internship year for radiologists: a retrospective analysis as assessed by current residents and fellows.

RATIONALE AND OBJECTIVES: The purposes of the study were to determine (a) if radiology residents and fellows view their internship year as a valued prerequisite for their career as a radiologist and as a physician, (b) how their postgraduate year (PGY)-1 was perceived with regard to a specific type of internship (i.e., internal medicine, transitional year, or surgery), and (c) how their internship is considered from the vantage point of their current year of training and subspecialty career choice. MATERIALS AND METHODS: A survey was sent to all current U.S. radiology residents and fellows from a list derived from the American College of Radiology database. They were polled regarding their experiences in their preliminary year (PGY-1). Responses were coded on a 5-point Likert scale. RESULTS: Response rate for the study was 35%. Although 70% of respondents maintained that their internship year was necessary for their development as a physician, only 49% indicated that it was necessary for their development as a radiologist. Of respondents who graduated from surgical internships, 72% claimed that their PGY-1 was important for their development as a radiologist, compared to 44% of former transitional year interns and 49% of internal medicine interns (P<.001). When disaggregated by subspecialty career choice, participants were evenly divided about their perceptions of their intern year. However, among those considering interventional radiology, 67% of respondents considered their internship important to their development as a radiologist (P<.001). CONCLUSION: Overall, these data suggest that although the internship year was believed to have merit, the transitional year was least liked by radiology trainees. Efforts should be made to determine why the transitional year does not fare so well in the hope that structural improvements in it can be undertaken to make the year seem more worthwhile and more highly regarded.

Critique of the transitional year internship and its relationship to radiology residency.

RATIONALE AND OBJECTIVES: The purpose of the study is to determine if transitional year program (TYP) requirements foster realization of standards of excellence and clinical relevance for future radiologists and to explore demographic and economic factors pertinent to TYPs. MATERIALS AND METHODS: A list of accredited TYPs were obtained from the American Medical Association's Graduate Medical Education (ACGME) Directory 2006-2007. Specialty distribution of TYP graduates was examined from statistics provided by the ACGME, and data from the 2007 Main Residency Match was analyzed. Data derived from a concurrent survey of the perception of the value of internship sent to all current radiology residents and fellows was assessed. The institutional costs of employing TYP interns versus physician assistants were also calculated. RESULTS: Forty-one of the 125 TYPs lack residencies in internal medicine (IM), general surgery (GS), or both, and approximately two-third of these lack full medical school affiliation. The interns who will graduate from these 41 programs account for 103 of the 1,128 radiology residents in their post-graduate year 2. Despite the longest elective time offered in TYPs compared to conventional preliminary programs, current radiology trainees who had participated in preliminary IM or GS internships were more satisfied compared to trainees completing TYPs. CONCLUSIONS: The requirements of the transitional internship and compliance with them need to be carefully assessed to determine their efficacy. Despite the strong economic impetus for hiring TYP interns, the availability of open slots in existing preliminary programs in IM and GS, coupled with radiology residents' greater level of satisfaction with traditional over transitional internships, makes the existence of TYPs less compelling.

In vivo T2-weighted magnetic resonance imaging can accurately determine the ischemic area at risk for 2-day-old nonreperfused myocardial infarction.

OBJECTIVES: To determine whether in vivo T2-weighted cardiac magnetic resonance imaging (MRI) delineates the area at risk (AAR) in 2-day-old nonreperfused myocardial infarction (MI). AAR was defined as the size of the perfusion defect on day 0. MI and the residual ischemic viable border zone comprise the AAR. MATERIALS AND METHODS: Fourteen dogs with permanent coronary artery occlusion were imaged on day 0 and day 2. The size of the AAR as measured by first-pass magnetic resonance perfusion on day 0 was compared with retrospectively determined AAR using day 2 T2-weighted MRI. Triphenyltetrazolium chloride staining was used to measure infarct size. Microspheres were used to detect residual perfusion. RESULTS: Hyperintense zones on day 2 T2-weighted magnetic resonance images accurately depicted the AAR as measured by first-pass perfusion on day 0 (38.9 +/- 3.0 vs. 36.3% +/- 3.3% of left ventricular, P = 0.07). Good correlation (R = 0.91) and Bland-Altman agreement was observed between the AAR measurements and the corresponding T2-weighted hyperintense regions. Both measures of AAR were larger than the infarcted zone (25.6% +/- 2.5% of left ventricular area; P < 0.001). CONCLUSIONS: Hyperintense regions visualized with in vivo T2-weighted cardiac MRI allow determination of the AAR 2 days postinfarction in nonreperfused MI.

Indian radiologists in the United States: hierarchical distribution and representation.

PURPOSE: To evaluate both the distribution of radiologists of Indian ancestry and nativity in the United States in training and beyond and their representation in hierarchal positions in major radiology organizations. MATERIALS AND METHODS: The annual membership lists of the Radiological Society of North America (RSNA) and the ACR over the past decade were analyzed for the number and locations of radiologists of Indian ancestry or nativity. To evaluate the progression and current extent of enrollment of members of this cohort in positions of leadership in radiology organizations, their overall membership and their specific participation in RSNA and ACR committees were tabulated. Their listing in the latest directories of chairpersons and program directors in radiology was assessed. The distribution of ethnic Indian radiologists in training was calculated by examining resident rosters by academic program and state. RESULTS: Since the passage of the Immigration and Nationality Act of 1965, individuals of Indian ancestry have constituted a growing minority of radiologists. In 2002, they constituted 5.5% of all RSNA members. Recently, their numbers in training programs have increased greatly. They are now estimated to constitute 13.3% of all residents, predominantly because of the entry of the American-born offspring of Indian immigrants. Yet ethnic Indians are markedly underrepresented in the hierarchy of major radiology organizations. In both 1999 and 2003, there were no Indian-surnamed representatives on most major committees and none in board-level positions of both the ACR and the RSNA. The number of radiologists of Indian birth or background who are program directors has increased slightly over the past 10 years from 2:196 (1%) in 1993 to 7:196 (3.5%) in 2003. The representation of radiologists of Indian ethnicity on the mastheads of both the American Journal of Roentgenology and Radiology remains meager; fewer than 2% of these journals' assistant editors and editors are of Indian ethnicity. CONCLUSION: The percentage of radiologists identifiable as Indian by nativity or ethnicity is growing rapidly, predominantly because of an increase in the number of American-born trainees. Yet only a few more senior members of this group have secured positions of leadership in the specialty, restricting the number of ethnically similar role models for Indian junior members of the specialty to emulate.

Self-subsidization of educational expenses by senior radiology residents.

RATIONALE AND OBJECTIVES: The purpose of this study is to document the degree of self-subsidization of educational expenses by senior radiology residents. MATERIALS AND METHODS: Questionnaires were distributed to all radiology residents (n = 176) attending the New Jersey Medical School board review course held twice in 2006. Respondents (n = 175) documented the number and source of financial support for review courses they had or would attend, including the AFIP course in radiologic pathology. They also listed the amount of additional financial allowances paid to them by their programs and cited the funding source for the radiology board examinations. RESULTS: Average AFIP expenditure, including tuition, room, board, and travel, equaled 3,969 dollars +/- 45 dollars, of which 46% was paid by the residents themselves. The respondents attended, on average, two review courses costing 4,116 dollars +/- 149 dollars, bearing 77% of the costs. The average additional allowance paid to residents was 1,938 dollars +/- 156 dollars. Total board expenditures of 3,120 dollars, including fees and travel, were borne entirely by the residents. Total out-of-pocket expenses for these activities was 7,928 dollars +/- 165 dollars, which amounted to 16% of senior residents' average annual salary (49,746 dollars). CONCLUSION: The desire by both programs and trainees for success on the radiology board examination has stimulated the growth of review courses. The enduring popularity of the AFIP course has made this activity an essential rotation for most radiology residency programs. Each of these off-site opportunities incurs significant financial obligations to residents, and when added to the cost of the board exams, equals 16% of their average annual salary. Thus radiology residents are subsidizing their education to a considerable degree relative to their salaries. This study reveals that senior radiology residents significantly subsidize their education and bear the burden of hidden costs associated with their training.

Retrospective determination of the area at risk for reperfused acute myocardial infarction with T2-weighted cardiac magnetic resonance imaging: histopathological and displacement encoding with stimulated echoes (DENSE) functional validations.

BACKGROUND: The aim of this study was to determine whether edema imaging by T2-weighted cardiac magnetic resonance (CMR) imaging could retrospectively delineate the area at risk in reperfused myocardial infarction. We hypothesized that the size of the area at risk during a transient occlusion would be similar to the T2-weighted hyperintense region observed 2 days later, that the T2-weighted hyperintense myocardium would show partial functional recovery after 2 months, and that the T2 abnormality would resolve over 2 months. METHODS AND RESULTS: Seventeen dogs underwent a 90-minute coronary artery occlusion, followed by reperfusion. The area at risk, as measured with microspheres (9 animals), was comparable to the size of the hyperintense zone on T2-weighted images 2 days later (43.4+/-3.3% versus 43.0+/-3.4% of the left ventricle; P=NS), and the 2 measures correlated (R=0.84). The infarcted zone was significantly smaller (23.1+/-3.7; both P<0.001). To test whether the hyperintense myocardium would exhibit partial functional recovery over time, 8 animals were imaged on day 2 and 2 months later. Systolic strain was mapped with displacement encoding with stimulated echoes. Edema, as detected by a hyperintense zone on T2-weighted images, resolved, and regional radial systolic strain partially improved from 4.9+/-0.7 to 13.1+/-1.5 (P=0.001) over 2 months. CONCLUSIONS: These findings are consistent with the premise that the T2 abnormality depicts the area at risk, a zone of reversibly and irreversibly injured myocardium associated with reperfused subendocardial infarctions. The persistence of postischemic edema allows T2-weighted CMR to delineate the area at risk 2 days after reperfused myocardial infarction.