Supplemental ERAS application for radiology residency match: A primer.

The supplemental ERAS application that includes three components: past experiences, geographic preferences, and program signals was introduced in 2022 to complement the standard ERAS CV material. The goal was to help programs identify optimal candidates to interview and to improve the chances of applicants being invited for interviews at programs that align with their goals and interests. Based on limited data, Program signal is the most emphasized component by the programs. Applicants should realize that programs have used signals to determine who to interview (aligned with AAMC guidance), and to determine the program's candidate rank list (contrary to AAMC guidance). We have herein suggested options for leveraging benefits from the ERAS supplemental application which has now been incorporated into the full ERAS application.

Spinocerebellar ataxia-type 34: A case report and brief review of the literature.

Neurodegenerative disorders are classified as a group of diseases with progressive loss of neurons secondary to aggregation of misfolded proteins. A few of these neurodegenerative diseases have been associated with degeneration of the transverse pontocerebellar tracts and median pontine raphe nuclei. This specific neuron degeneration results in the radiologic hot cross bun sign (HCBS) on MRI T2 imaging and helps narrow down the differential diagnosis. While multiple system atrophy has a higher prevalence of the HCBS than other neurodegenerative diseases, the sign has also been described with other neurodegenerative disorders such as spinocerebellar ataxia (SCA), and variant Creutzfeldt-Jakob disease. Here, we present a case of spinocerebellar ataxia type 34 with a characteristic hot-cross bun sign and provide a brief review of the literature.

Facial nerve schwannoma: Case report and brief review of the literature.

Schwannomas are rare nerve sheath tumors that can occur throughout the body, and are symptomatic based on location, size, and impingement on adjacent structures. These tumors are often benign lesions and occur sporadically or from genetic conditions such as neurofibromatosis. Schwannomas may arise from peripheral nerves, gastrointestinal nerves, spinal nerve roots and cranial nerves. Facial nerve schwannomas arise from cranial nerve VII, commonly involving the geniculate ganglion, labyrinthine segment, and internal auditory canal. While small lesions are asymptomatic, larger lesions can cause facial nerve paralysis, and facial spasms. Lesions in the internal auditory canal can cause hearing loss, tinnitus, vertigo, and otalgia. High-resolution CT imaging and MRI imaging are useful for distinguishing between other pathologies that arise from the same region. High-resolution CT scans can show bony degeneration of nearby structures such as the labyrinth or ossicles. MRI imaging shows hypo intensity on T1 imaging, and hyperintensity on T2 imaging. On T1 postcontrast, enhancement can be homogenous or heterogeneous with cystic degeneration if the lesion is large. Nodular enhancement is commonly seen on facial nerve schwannomas within the internal auditory canal. Vestibular schwannomas involving CN VIII are more common, and appear similar to facial nerve schwannomas, but can be distinguished apart due to growth in the geniculate ganglion and/or the labyrinthine segment. Management of asymptomatic or mild lesions is typically conservative with follow up imaging, and surgery for larger lesions. Here, we present a case of a facial nerve schwannoma in a 57-year-old woman.

Online interactive medical neuroimaging exercise to identify human brain structures.

A persisting need remains for developing methods for inspiring and teaching undergraduate medical students to quickly learn to identify the hundreds of human brain structures, tracts and spaces that are clinically relevant (viewed as three-dimensional volumes or two-dimensional neuroimages), and to accomplish this with the option of virtual on-line methods. This notably includes teaching the essentials of recommended diagnostic radiology to allow students to be familiar with patient neuroimages routinely acquired using magnetic resonance imaging (MRI) and computed tomography (CT). The present article includes a brief example video plus details a clinically oriented interactive neuroimaging exercise for first year medical students (MS1s) in small groups, conducted with instructors either in-person or as an entirely online virtual event. This "find-the-brain-structure" (FBS) event included teaching students to identify brain structures and other regions of interest in the central nervous system (and potentially in head and neck gross anatomy), which are traditionally taught using brain anatomy atlases and anatomical specimens. The interactive, small group exercise can be conducted in person or virtually on-line in as little as 30 min depending on the scope of objectives being covered. The learning exercise involves coordinated interaction between MS1s with one or several non-clinical faculty and may include one or several physicians (clinical faculty and/or qualified residents). It further allows for varying degrees of instructor interaction online and is easy to convey to instructors who do not have expertise in neuroimaging. Anonymous pre-event survey (n = 113, 100% response rate) versus post-event surveys (n = 92, 81% response rate) were attained from a cohort of MS1s in a neurobiology course. Results showed multiple statistically significant group-level shifts in response to several of the questions, showing an increase in MS1 confidence with reading MRI images (12% increase shift in mean, p < 0.001), confidence in their approaching physicians for medical training (9%, p < 0.01), and comfort levels in working online with virtual team-based peers and with team-based faculty (6%, p < 0.05). Qualitative student feedback revealed highly positive comments regarding the experience overall, encouraging this virtual medium as a desirable educational approach.

Acute ischemic optic neuropathy in a case of heroin overdose.

Presence of acute optic disc and optic nerve infarction in a young man is uncommon finding. This is most commonly seen in the setting of vasculitis and infection. Ischemic optic neuropathy has been reported with cocaine use, amlodipine and alcohol use. To our knowledge there is no reported case of ischemic optic neuropathy in the setting of heroin / opioid use. MR imaging findings in the setting of substance use are similar to other etiologies of ischemic optic neuropathy, with high T2/FLAIR signal, diffusion restriction and abnormal gadolinium enhancement. Here we report a case of 23-year-old man with heroin use disorder presenting with optic nerve infarct resulting in acute painless monocular vision loss.

Primary nodular chest amyloidoma: A case report and review of literature.

Primary nodular chest wall amyloidoma, in which a solitary mass of amyloid is deposited in and around the lungs with no evidence of systemic amyloidosis, is extremely rare, most often asymptomatic, and may resemble primary bronchogenic carcinoma. As a result, there are fewer than 100 cases published in the literature and no controlled clinical trials. Primary nodular chest wall amyloidoma is typically diagnosed either as an incidental radiological finding or after very serious and destructive mass growth at which point late-stage respiratory and pain symptoms finally develop, most often in elderly patients. We present imaging studies of a 61-year-old male patient with an unusually massive and destructive chest wall mass, originating in the chest wall, diagnosed as chest wall amyloidoma by histopathology analysis. Our CT, MRI, and PET scan findings are consistent with and contribute to the developing pattern of imaging characteristics seen in other case studies, which can be used to identify amyloidoma before it becomes destructive using non-invasive imaging analyses.

"Resident Managed Peer-Mentoring Program": A Novel Way to Engage Medical Students and Radiology Residents in Collaborative Research.

RATIONALE AND OBJECTIVES: Engaging medical students and radiology residents in research during clinically focused training in residency can be challenging. We investigated extending a substantial degree of supervised autonomy to qualified residents to engage, mentor, and manage teams of medical students and other residents in research projects, fostering a system of laddered mentoring, referred to as "Resident Managed Peer Mentoring Program." The structure is as follows: a resident with research experience (preceptor) first identifies small-scale hypothesis driven projects which different novice learner-researchers at different levels of research background and training can undertake. The learner and preceptor then outline the learner's deliverables and set deadlines for outcomes, with regular faculty check-ins and oversight. MATERIALS AND METHODS: This observational study assessed the outcomes of our "Resident Managed Peer Mentoring Program" beginning November 2019. Primary outcomes were numbers of peer-reviewed publications credited to individual radiology physicians. Secondary outcomes were: numbers of radiology physicians who participated in publication and academic rank-based analysis of publication numbers for attending radiologists before and after the intervention. RESULTS: Number of peer-reviewed PubMed publications increased after our intervention (47.8%, in year-1; 167.4% in year-2). Increases also occurred in the number of radiology physicians who authored publications. The effect was largest for early career physicians. CONCLUSION: The "Resident managed peer-mentoring program" was a productive method that proved especially beneficial for students, residents, and early career physicians in our clinically focused training program. This approach may be transferable to other programs where an increase in research participation and productivity are valued.

Google Trends Data of Radiologists Who Accept Medicare: A Potential Tool for Predicting State Demand.

PURPOSE: To identify and analyze the demand for radiologists who accept Medicare per state from 2004 to 2009, as reflected by volume of Google searches, and to place such demand in context with other available data by state. METHODS: The number of radiologists who accept Medicare by state was divided by each state's population to achieve the radiologist density per 10,000 residents. Relative search volume (RSV) for the term "radiologist" was collected from Google Trends from 2004 to 2009. The Radiologist Demand Index (RDI) for each state was then calculated by dividing each state's RSV by the radiologist density for that state. To standardize values, each state's RDI was divided by the largest RDI to generate the Relative Radiologist Demand Index (RRDI). Utilization of medical imaging per 1000 Medicare beneficiaries in each state, overall health of a population in each state, and percentage of the population enrolled in Medicare in each state were used to compare trends with the RRDI. RESULTS: West Virginia had the greatest curiosity about radiologists who accept Medicare (as represented by proportion of Google searches) (RSV=100), followed by Mississippi (RSV=95), and Arkansas (RSV=87). Oregon demonstrated the lowest level of curiosity about radiologists who accept Medicare, by having the lowest proportion of google searches (RSV=43), followed by Vermont (RSV=49), California (RSV=50), and Colorado (RSV=50). The highest radiologist densities per population were found in Montana, D.C., and Wyoming (3.25, 1.56, 1.11, respectively). The lowest radiologist densities were found in Oklahoma, Texas, and Utah (0.4, 0.4, 0.41, 0.41, respectively). The RRDI was greatest in Louisiana (100), Arkansas (94.8), and Texas (86.3), and smallest in Montana (10.6), D.C. (17.7) and Wyoming (28.4). Positive trends between utilization of medical imaging per 1000 Medicare beneficiaries and state overall health and the RRDI were recognized. No trend between each state's RRDI and percentage of population enrolled in Medicare was noted. CONCLUSION: Imaging studies performed, an indirect measure of demand, showed trends with RRDI. Higher RRDI and imaging per 1000 Medicare beneficiaries trended with lower health scores for a state's general population. RRDI may be a useful tool reflecting each state's demand for radiologist who accepts Medicare.

Atypical imaging presentation of a massive intracavitary cardiac thrombus: A case report and brief review of the literature.

Intracavitary cardiac thrombi, uncommonly found in the right chambers, have been shown to form secondary to endocardial and myocardial diseases. The differential diagnosis for an intracavitary cardiac mass is broad, including primary cardiac tumors, cardiac metastases, anatomic variants, vegetations, and thrombi. Here we present a unique case with a large calcified intracavitary cardiac thrombus in a 26-year-old woman with obesity, immune thrombocytopenic purpura, and a new diagnosis of systemic lupus erythematosus. Initial imaging presentation in this case masqueraded as a tumor, delaying the true diagnosis. A combination of cardiac imaging techniques, including transthoracic and transesophageal echocardiograms, cardiac CT, and cardiac MRI were required to correctly diagnose this calcified bland thrombus.

Tracheobronchial amyloidosis: A case report and review of literature.

Tracheobronchial amyloidosis, manifested by amyloid deposits limited specifically to tracheal and bronchial tissue, is a rare manifestation with only a few hundred published cases. Patients classically present with symptoms related to fixed upper airway obstruction caused by tracheal stenosis. Clinical symptoms are non-specific and include hoarseness, dyspnea, cough, stridor, hemoptysis, and dysphagia, which are similar to those caused by more common airway disorders, often leading to incorrect, missed, and delayed diagnosis. The wide-spread use of computerized tomography (CT) imaging has the potential of dramatically advancing the early diagnosis of tracheobronchial amyloidosis. We present a case of a patient with chronic and progressive hoarseness, diagnosed with tracheobronchial amyloidosis, with a focus on unusually clear and precise CT soft tissue neck imaging. CT imaging demonstrated nodular circumferential raised mass-like thickening involving the long-segment posterior wall of the distal trachea. The wall thickening also extended into the proximal left main stem bronchi, but spared the distal bronchial tree. This resulted in moderate (approximately 50%) narrowing of the tracheal lumen, which explained the patient's hoarseness. Routine CT imaging of patients with chronic and progressive respiratory symptoms, including cough, hoarseness, and dyspnea, is recommended. Tracheobronchial amyloidosis is an uncommon disease, but it may become more commonly recognized with broader use of more effective CT imaging protocols.

Imaging in Differentiating Cerebral Toxoplasmosis and Primary CNS Lymphoma With Special Focus on FDG PET/CT.

OBJECTIVE. The purpose of this article is to present a brief review of literature evaluating different imaging modalities with special focus on 18F-FDG PET/CT in differentiating cerebral toxoplasmosis and primary CNS lymphoma. CONCLUSION. Differentiating cerebral toxoplasmosis and primary CNS lymphoma is crucial in the care of patients with HIV infection. Delayed diagnosis can lead to considerable morbidity and mortality. The reference standard for diagnosis is biopsy and histopathologic examination. Biopsy has disadvantages due to its invasive nature and associated complications. Noninvasive imaging can be an alternative to biopsy for differentiation of toxoplasmosis and primary CNS lymphoma. Despite advances in MRI techniques, prophylaxis of opportunistic infection, and treatment of HIV infection, clinical situations continue to arise in which the diagnosis is not clear. In these instances, molecular imaging can be helpful.

Nasal congestion and nasal obstruction: An unusual presentation of renal cell carcinoma.

Renal cell cancer (RCC) is among the 10 most common cancers affecting both genders in the United States. Advanced RCC often remains clinically silent for much of its natural history. This can make the diagnosis challenging, especially when presenting symptoms arise from a metastasis. Sinonasal malignancies are rare, accounting for <1% of all malignant tumors and 3% of malignant tumors of the upper aerodigestive tract. RCC is the most common infraclavicular malignant primary tumor that metastasizes to the nasal cavity and paranasal sinus, followed by breast and lung. We describe a case of a 59 year-old male presenting with nasal congestion and allergy-like symptoms for 6 months duration. CT examination revealed a large hyper-vascular mass within the right maxillary and ethmoid sinuses and nasal cavity. Primary RCC was recognized only after surgical removal of sinonasal mass. We discuss the epidemiology, clinical presentation, differential diagnosis, imaging, pathology, and treatment for sinonasal RCC.

Perspectives from the other side of the screen: how clinicians and radiologists communicate about diagnostic errors.

Background Miscommunication amongst providers is a major factor contributing to diagnostic errors. There is a need to explore the current state of communications between clinicians and diagnostic radiologists. We compare and contrast the perceptions, experiences, and other factors that influence communication behaviors about diagnostic errors between clinicians and radiologists. Methods A survey with questions addressing (1) communication around diagnostic error, (2) types of feedback observed, (3) the manner by which the feedback is reported, and (4) length of time between the discovery of the diagnostic error and disclosing it was created and distributed through two large academic health centers and through listservs of professional societies of radiologists and clinicians. Results A total of 240 individuals responded, of whom 58% were clinicians and 42% diagnostic radiologists. Both groups of providers frequently discover diagnostic errors, although radiologists encounter them more frequently. From the qualitative analysis, feedback around diagnostic error included (1) timeliness of error, (2) specificity in description or terminology, (3) collegial in delivery, and (4) of educational value through means such as quality improvement. Conclusions Clinicians and radiologists discover diagnostic errors surrounding the interpretation of radiology images, although radiologists discover them more frequently. There is significant opportunity for improvement in education and practice regarding how radiologists and clinicians communicate as a team and, importantly, how feedback is given when an error is discovered. Educators and clinical leaders should consider designing, implementing, and evaluating strategies for improvement.

An atypical case of acute posterior multifocal placoid pigment epitheliopathy with recurrent strokes.

PURPOSE: To report an atypical case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with central nervous system (CNS) vasculitis and recurrent strokes. OBSERVATIONS: A 57 year-old female presented with APMPPE after a febrile illness and rash. She developed an acute infarct on magnetic resonance imaging. Computed tomography angiography of the cerebral vasculature was normal. Cerebrospinal fluid (CSF) analysis and an extensive serum lab workup were also unremarkable. She was treated with high-dose corticosteroids and eventually transitioned to methotrexate. A month after being on treatment she developed a second stroke. A cerebral angiogram was obtained and did not show evidence of CNS vasculitis. The methotrexate was eventually stopped and the prednisone was tapered. Approximately 3 months later she developed a third stroke and worsening APMPPE-associated maculopathy in both eyes. She was eventually started on oral cyclophosphamide. CONCLUSIONS & IMPORTANCE: Although rare, CNS vasculitis is a known complication of APMPPE. This case is atypical given the development of multiple recurrent strokes, lack of inflammatory evidence on CSF analysis, and normal imaging of the cerebral vasculature. This report highlights the need for a high level of clinical suspicion for CNS vasculitis with APMPPE despite noncontributory cerebral angiographic imaging and normal CSF analysis.

Chronic enteroviral meningoencephalitis in a patient on rituximab for the treatment of psoriatic arthritis: A case report and brief literature review.

Enteroviruses are RNA viruses within the Picornaviridae family. Enteroviruses derive their name from the way they are typically transmitted via the intestinal tract. They commonly infect millions of people every year and often do not cause severe disease in immunocompetent patients with few exceptions. Aseptic meningitis is a classic manifestation and is usually self-limited, however, can lead to severe neurological complications in an immunocompromised individual. It has been well-described that patients with hypogammaglobulinemia are predisposed to developing chronic enteroviral meningoencephalitis [1]. This is the first reported case of enteroviral meningoencephalitis in a patient being treated for psoriatic arthritis with rituximab. Here we describe a 46-year-old female who presented with altered mental status, fever, and myalgia. Polymerase chain reaction (PCR) of her cerebrospinal fluid (CSF) confirmed the presence of enterovirus. In the immunocompromised patient with encephalopathy, it is important to consider an enteroviral infection. This case adds to the present body of knowledge about enteroviral infections in immunocompromised hosts.