Use of gadolinium chelate to confirm epidural needle placement in patients with an iodinated contrast reaction.

OBJECTIVE: When performing epidural steroid injections for the management of chronic back pain, imaging guidance and a limited epidurogram improve accuracy of needle placement and ensure appropriate delivery of the injectate into the epidural space. We describe our experience using a gadolinium chelate as an alternative contrast agent for limited epidurography in patients with a history of an iodinated contrast reaction. DESIGN: Thirty-eight of 2,067 (1.8%) epidural steroid injections performed in our department over a 25-month period (December 2003-January 2006) employed gadolinium. All injections were performed in the lumbar spine employing a paramedian interlaminar approach. Procedural notes and patient charts were reviewed to evaluate for immediate or delayed complications related to incorrect intrathecal or intravascular needle placement. A retrospective analysis of selected fluoroscopic spot images was performed to evaluate confidence of epidural needle placement; this analysis compared these spot images against those obtained from age- and gender-matched control patients in whom iodinated contrast was used to confirm needle placement. RESULTS: Real-time fluoroscopic guidance permitted confident visualization of an epidurogram at the time of procedure in all 38 cases as documented in the procedural report, and no procedure resulted in a complication due to incorrect needle placement. Retrospective review of fluoroscopic spot images revealed at least moderate confidence of epidural needle placement by both readers in 29/38 cases (76.3%). Fluoroscopic spot images obtained using gadolinium yielded significantly less confidence than images obtained in control patients whose procedures were performed using iodinated contrast (P < 0.01). However, operators were sufficiently confident in needle placement based on real-time fluoroscopic images (not available in our subsequent review) to inject anesthestic in all 38 cases, despite the immediate consequences that could result from intrathecal administration. During the same time period, there were 11/2,067 (0.5%) instances of intrathecal needle placement discovered during attempted epidurography despite the use of fluoroscopy for needle guidance and reliance on loss-of-resistance technique. CONCLUSION: Gadolinium chelate represents a safe and useful alternative contrast agent for confirmation of epidural needle placement in patients with an iodinated contrast allergy.

The impact of professional turf battles on radiology resident education: perspectives from the radiology class of 2005.

PURPOSES: To assess residents' exposure to professional turf battles, via a survey of the radiology residency class of 2005, and to assess perceptions about the causes, solutions, and impact of turf battles on resident education. METHODS: An electronic survey composed by the ACR Resident and Fellow Section was completed by 168 senior residents (a 18.9% response rate) enrolled in allopathic radiology residency programs from across the United States. RESULTS: The majority of respondents (153 of 168, 91.1%) perceive a loss of professional turf from nonradiologists. Areas most often perceived as being affected by lost professional turf were interventional radiology (136/168, 81.0%), cardiothoracic imaging (106 of 168, 63.1%), and ultrasound (88 of 168, 52.4%). The sense of lost professional turf was most often attributed to inadequate residency training in the affected subspecialities (87 of 168, 51.8%). The most commonly cited motivation for ongoing turf battles was reimbursement for diagnostic imaging and image-guided procedures as a motivator for nonradiologists. The majority of residents feel that the most effective ways to counter professional turf battles include the promotion of national physician-training standards for diagnostic imaging and image-guided therapies, the mandatory accreditation of all imaging facilities, and the development of performance standards that providers of imaging services must meet to qualify for reimbursement. CONCLUSIONS: The majority of resident respondents feel that professional turf battles have had a significant impact on their education. Methods recommended to counter professional turf battles mirror recent proposals by the ACR to support mandatory national quality, safety, and training standards for providers of diagnostic imaging.

The radiology class of 2005: postresidency plans.

PURPOSE: To examine the postresidency plans of the radiology residency class of 2005, including influences on and trends in the decision to pursue subspecialty fellowship training after residency. METHODS: An electronic survey composed by the ACR Resident and Fellow Section was completed by 416 senior residents (a 46.9% response rate) enrolled in allopathic radiology residency programs from across the United States, representing approximately 41.2% of the entire residency class. RESULTS: Eighty-seven percent (95% confidence interval 83.8% to 90.2%) of respondents plan to do fellowships immediately after residency, representing an increasing number, compared with published figures from the 1990s. Increasing age at the completion of residency was independently and significantly correlated with the decision not to pursue a fellowship. There has been a shift in the most popular fellowships, with an increased interest in musculoskeletal radiology fellowships and decreased interest in interventional radiology. Among residents not pursuing immediate fellowship training, the most common plans were private practice positions (48.1%), military obligations (22.2%), and nighthawk positions (9.3%). CONCLUSION: An increasing number of residents are electing to pursue subspecialty training after the completion of residency. Close monitoring of the postresidency plans of current residents may portend important trends in education, residency training, and changes in the radiology workforce.

The radiology class of 2005: the fellowship application process and perceptions of the NRMP fellowship match.

PURPOSE: To assess experiences and perceptions of the fellowship application process of the radiology residency class of 2005, including the 2005 National Resident Matching Program (NRMP) Radiology Fellowship Match. METHODS: An electronic survey composed by the ACR Resident and Fellow Section was completed by 416 senior residents (a 46.9% response rate) enrolled in allopathic radiology residency programs from across the United States. RESULTS: Residents generally agree with the timing of the current fellowship application calendar in the spring of the third year of residency. Respondents were divided over the issue of permitting internal candidates to fill positions outside of the match, although the majority felt that the process influences both applicants and programs to favor their own institutions to avoid the match process. Residents support requiring fellowship programs to declare the number of positions being filled through the match before applications are due (72.6%) or before rank lists are due (79.8%). Residents noted match rule violations, which threaten to undermine residents' confidence in the process. Residents were split over the future of the match: 23.1% favored continuing the match in its current form, 28.8% favored continuing the match with modifications, and 34.4% favored discontinuing the match entirely. CONCLUSION: Although the NRMP Fellowship Match was created to improve and standardize the fellowship application process, and although a majority of residents support continuing the match in some form, there are areas of concern, including adherence to the letter and spirit of the match rules, which must be addressed to galvanize support among residents in the future and ensure a fair process for fellowship applicants.