Evaluating the effect of NPO status on mucosal coating during double contrast barium esophagrams.

INTRODUCTION: Current guidelines for double contrast barium esophagography studies (BAS) suggest that patients should be nil per os (NPO) prior to completing BAS for optimal esophageal coating, although the time required varies between practices and institutions. It is believed that consumption of food or water disrupts the ability for thick barium contrast to properly coat the esophageal mucosa. Exams that are rescheduled for this reason can lead to delays in care, without substantial evidence that NPO status truly affects esophageal mucosal coating for these exams with current barium mixtures. OBJECTIVE: The study aims to identify the necessity, or lack thereof, of standard NPO protocol in patients undergoing BAS, in effort to prevent unnecessary procedural delay. MATERIALS AND METHODS: This study is an IRB-approved HIPAA-compliant study of 370 consecutive adult patients (115 male/255 female, mean age 55) who underwent BAS at our institution from January to June of 2022. Patients were divided into two groups: < 4 h NPO (n = 334), and ≥ 4 h NPO (n = 36). Four abdominal radiologists blinded to NPO interval independently reviewed a random sample of approximately 92 patients (91-94) and graded esophageal coating on a 4-point-scale with 1 being insufficient coating and 4 being optimal coating. RESULTS: No significant statistical difference in mean esophageal coating score was found between the ≥ 4 h NPO cohort (3.04 ± SD 0.78) and the < 4 h NPO cohort (2.97 ± SD 0.70; P = 0.54). Subset analysis of patients who were NPO for < 2 h (n = 9) also showed no significant difference in mean esophageal coating score (3.11 ± SD 0.6; P = 0.92), compared to the standard ≥ 4 NPO status. CONCLUSION: Non-adherence to standard NPO protocol prior to BAS studies did not result in a significant difference in esophageal coating when compared to traditional preprocedural fasting of 4 or more hours.

Magnetic resonance imaging in the evaluation and management of acute pancreatitis: a review of current practices and future directions.

Acute pancreatitis is a condition marked by inflammation of the pancreas and surrounding tissues. While the majority of cases of acute pancreatitis are mild, a minority of severe cases are the primary contributors to the morbidity and mortality attributed to this condition. Retroperitoneal morphologic changes can be detected by utilization of various imaging modalities, and their accurate evaluation is crucial for effective management. Acute pancreatitis is commonly diagnosed using computed tomography (CT). However, there are certain clinical scenarios where magnetic resonance imaging (MRI) may have superiority over CT. In particular, MRI is useful in cases where patients cannot receive iodinated CT contrast, or where there is a need to investigate the underlying cause of acute pancreatitis. Additionally, MRI can be utilized to evaluate ductal disconnection and guide interventions for necrotic collections. The unique features of MRI can be particularly useful, including its ability to provide superior contrast resolution and to offer greater functional information through techniques such as diffusion-weighted imaging. The aim of this review is to discuss the MRI assessment of individuals with acute pancreatitis. Additionally, the recent advances in MRI for evaluation of acute pancreatitis will also be introduced.

Eye Motion Tracking for Medical Image Interpretation Training.

INTRODUCTION: The significance of Eye Motion Tracking in aiding learners in training search patterns, pattern recognition, and efficiently using their gaze in terms of time and scanning distribution has been highlighted in the USAF Pilot Training Next initiative. METHODS: The innovation described further builds on this concept in the realm of medical imaging and the provision of real-time feedback of eye direction and gaze duration. RESULTS: This real-time indicator enables the trainer to adapt verbal queueing of the trainee in a personalized manner to improve knowledge transfer, and to increase the confidence of the trainer and trainee in the competency of the trainee. The initial experiment data set included bone radiographs, digital subtraction angiograms, and computed tomography images. DISCUSSION: Preliminary results and formative feedback from participants was encouraging with expert viewers able to use Eye Motion Tracking to successfully guide novice readers through search and gaze protocol patterns of the medical images.

Dual-Energy Computed Tomography: Technological Considerations.

Compared to conventional single-energy CT (SECT), dual-energy CT (DECT) provides additional information to better characterize imaged tissues. Approaches to DECT acquisition vary by vendor and include source-based and detector-based systems, each with its own advantages and disadvantages. Despite the different approaches to DECT acquisition, the most utilized DECT images include routine SECT equivalent, virtual monoenergetic, material density (eg, iodine map), and virtual non-contrast images. These images are generated either through reconstructions in the projection or image domains. Designing and implementing an optimal DECT workflow into routine clinical practice depends on radiologist and technologist input with special considerations including appropriate patient and protocol selection and workflow automation. In addition to better tissue characterization, DECT provides numerous advantages over SECT such as the characterization of incidental findings and dose reduction in radiation and iodinated contrast.

Redesign of the American Board of Radiology Diagnostic Radiology Certifying Examination.

On April 13, 2023, the American Board of Radiology (ABR) announced plans to replace the current computer-based diagnostic radiology (DR) certifying examination with a new oral examination to be administered remotely, beginning in 2028. This article describes the planned changes and the process that led to those changes. In keeping with its commitment to continuous improvement, the ABR gathered input regarding the DR initial certification process. Respondents generally agreed that the qualifying (core) examination was satisfactory but expressed concerns regarding the computer-based certifying examination's effectiveness and impact on training. Examination redesign was conducted using input from key groups with a goal of effectively evaluating competence and incentivizing study behaviors that best prepare candidates for radiology practice. Major design elements included examination structure, breadth and depth of content, and timing. The new oral examination will focus on critical findings as well as common and important diagnoses routinely encountered in all diagnostic specialties, including radiology procedures. Candidates will first be eligible for the examination in the calendar year after residency graduation. Additional details will be finalized and announced in coming years. The ABR will continue to engage with interested parties throughout the implementation process.

The Impact of the Dobbs Decision on Diagnostic Radiology Applicants, Residents, and Program Directors.

In the Dobbs decision the United States Supreme Court overturned Roe v. Wade, returning the issue of abortion to the states. To date, there is little published data on the impact this might have on where future residents choose to pursue graduate medical education. We investigated the potential effects of the resultant varied political landscape of abortion care access laws with respect to influence on the selection of prospective diagnostic radiology training programs by medical students, comparing application rates for the 2022 recruitment cycle to the prior 4 years across a geographically diverse group of 22 academic and community sites across the United States. We provide strategies for program directors to consider in dealing with topics related to this continually evolving issue as it pertains to resident recruitment and retention.

PET/MRI for evaluation of patients with pancreatic cancer.

Pancreatic cancers are the third leading cause of cancer-related death in the USA and outcomes remain poor despite improvements in imaging and treatment paradigms. Currently, computed tomography (CT) and magnetic resonance imaging (MRI) are frequently utilized for staging and restaging of these malignancies, but positron emission tomography (PET)/CT can play a role in troubleshooting and improve whole-body staging. PET/MRI is a novel imaging modality that allows for simultaneous acquisition of PET and MRI images, leading to improved image quality and potential increased sensitivity. Early studies suggest that PET/MRI may play a larger role in pancreatic cancer imaging in future. This manuscript will briefly discuss current imaging approaches to pancreatic cancer and outline existing evidence and published data supporting the use of PET/MRI for pancreatic cancers.

Exploratory analysis of mesenteric-portal axis CT radiomic features for survival prediction of patients with pancreatic ductal adenocarcinoma.

OBJECTIVE: To develop and evaluate task-based radiomic features extracted from the mesenteric-portal axis for prediction of survival and response to neoadjuvant therapy in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: Consecutive patients with PDAC who underwent surgery after neoadjuvant therapy from two academic hospitals between December 2012 and June 2018 were retrospectively included. Two radiologists performed a volumetric segmentation of PDAC and mesenteric-portal axis (MPA) using a segmentation software on CT scans before (CTtp0) and after (CTtp1) neoadjuvant therapy. Segmentation masks were resampled into uniform 0.625-mm voxels to develop task-based morphologic features (n = 57). These features aimed to assess MPA shape, MPA narrowing, changes in shape and diameter between CTtp0 and CTtp1, and length of MPA segment affected by the tumor. A Kaplan-Meier curve was generated to estimate the survival function. To identify reliable radiomic features associated with survival, a Cox proportional hazards model was used. Features with an ICC ≥ 0.80 were used as candidate variables, with clinical features included a priori. RESULTS: In total, 107 patients (60 men) were included. The median survival time was 895 days (95% CI: 717, 1061). Three task-based shape radiomic features (Eccentricity mean tp0, Area minimum value tp1, and Ratio 2 minor tp1) were selected. The model showed an integrated AUC of 0.72 for prediction of survival. The hazard ratio for the Area minimum value tp1 feature was 1.78 (p = 0.02) and 0.48 for the Ratio 2 minor tp1 feature (p = 0.002). CONCLUSION: Preliminary results suggest that task-based shape radiomic features can predict survival in PDAC patients. KEY POINTS: • In a retrospective study of 107 patients who underwent neoadjuvant therapy followed by surgery for PDAC, task-based shape radiomic features were extracted and analyzed from the mesenteric-portal axis. • A Cox proportional hazards model that included three selected radiomic features plus clinical information showed an integrated AUC of 0.72 for prediction of survival, and a better fit compared to the model with only clinical information.

Disruptive Behavior: Impact on Diversity, Equity, and Inclusion (DEI) in Radiology, From the AJR Special Series on DEI.

Radiology has recognized the need to increase the diversity of its workforce for decades; however, women and people of color remain disproportionately underrepresented. A welcoming and inclusive environment is essential to physician recruitment and retention, but disruptive behavior in the workplace can be a barrier to achieving this goal. Disruptive behavior can be overt or subtle, can be intentional or inadvertent, and can occur in different settings throughout a radiologist's career, including during patient care, among colleagues, from department leadership, and even from professional societies. The purpose of this article is to provide an overview of where a radiologist may encounter disruptive behaviors, the impact that such behaviors can have on the physician's and practice's well-being, and tips for how to address and mitigate these behaviors in the future.

Patient Engagement with Online Portals and Online Radiology Results.

The purpose of this study was to examine patient portal enrollment and the usage with a specific focus on the utilization of on-line radiology reports by patients. Oracle SQL (Austin, TX, USA) queries were used to extract portal enrollment data over a 13-month period from March 1, 2017 through March 31, 2018 from the hospital system's EMR. Patient enrollment was collected as was patient information including basic demographics and utilization patterns. For enrolled patients, interaction within the portal with the "Radiology" work tab (RADTAB) was used as a surrogate for review of radiology results. As a comparator, interaction within the portal with the "Laboratory" work tab (LABTAB) was used as a surrogate for review of laboratory results. Statistical analysis on the data was performed using Chi-squared, Student's t-test, Logistic regression and multivariate analysis where appropriate. The population for analysis included 424,422 patients. Overall, 138,783 patients (32.7%) were enrolled in the portal. Patients enrolled in the portal were older (P < 0.0001), female (P < 0.0001) and Caucasian (P < 0.0001). Patients enrolled in the portal had higher levels of educational attainment (p < 0.0001), higher annual household income (P < 0.0001), and more outpatient clinic visits (P < 0.0001). The proportion of enrolled patients that interacted with the LABTAB (47.2%) was significantly higher than those that interacted with the RADTAB (27.1%) (P < 0.0001; Table 2). Patients that utilize the portal are more likely to utilize the Laboratory tab than the Radiology tab, and demographic differences do not account for this difference in usage. Further investigation is needed to better understand the reasons for the differing usage trends of Laboratory and Radiology tabs.

Accelerated Fellowships Applicable Across all Subspecialty Areas of Diagnostic Radiology as a Catalyst for Academic Recruitment.

RATIONALE AND OBJECTIVES: To build a sustainable faculty development program based on potential acceleration of all subspecialty fellowships types into the PGY 5 year. MATERIALS AND METHODS: Single center experience in programmatic change to enhance faculty recruitment. Diagnostic Radiology (DR) residents apply to subspecialty fellowships per SCARD Fellowship Embargo Guidelines. Based on projected faculty hiring needs, internal candidates are vetted and agree to enter an accelerated fellowship. The commitment is two years: the PGY5 senior year schedule prioritizes rotations in the subspecialty area while fulfilling requirements of all DR graduates, including call. Accelerated fellows (AF) participate in junior faculty development and concentrated mentoring. A subsequent instructor faculty year within our department is required to ensure professional maturity and provides financial remuneration greater than PGY 6 fellowships. RESULTS: From July 1, 2018, to June 30, 2022, 34 trainees have graduated from our DR program, and 32 have gone through the process of securing fellowships. Over this interval, our DR program has matched 7-9 residents per year. Up to four early specialization positions consisting of 2 Early Specialization in Interventional Radiology (ESIR), and 2 Early Specialization in Nuclear Medicine (ESNM), per year, are available. Over four years of the program, 8 residents participated in standard early specialization opportunities: 5 ESIR, and 3 ESNM. These 8 residents were excluded from consideration for AFs. Two additional residents declined fellowships, leaving 22 seeking standard fellowships for PGY 6 year. 6 (27%) of those were approached as potential AFs; 3 (50%) agreed to and completed the 24-month process. 2 of 3 (67%) continue to serve on faculty after the required instructor year. CONCLUSION: The novel concept of early specialization outside of ESIR and ESNM presents an opportunity to tailor the PGY 5 DR year to increase recruitment to academic faculty positions.

Same day barium esophagography and high-resolution manometry during the COVID-19 pandemic.

PURPOSE: Double contrast barium esophagography (BAS) and high-resolution manometry (HRM) are traditionally performed on separate days to allow for pre-procedural fasting. In an effort to minimize COVID-19 exposure and improve appointment efficiency with required pre-procedure testing, we permitted same day HRM prior to BAS. Our study aimed to evaluate the adequacy of barium mucosal coating with same day HRM prior to BAS compared to BAS alone. METHODS: We performed a retrospective pilot cohort study including 14 patients undergoing same day HRM prior to BAS and 20 patients undergoing BAS alone over an 8-month interval during the COVID-19 pandemic. Three abdominal imaging subspecialty-trained radiologists blindly reviewed the images and graded adequacy of esophageal coating on a 4-point scale with a score of 1 representing inadequate coating and 4 representing optimal coating. RESULTS: For the cohort studied thus far, the mean grade of the HRM and BAS group was 3.17 with a standard deviation of 0.66. The mean grade of the BAS alone group was 3.13 with a standard deviation of 0.79. There was no statistical difference in the adequacy of esophageal coating between the two groups (p-value 0.97). CONCLUSION: Same day HRM prior to BAS has no detrimental effect on barium mucosal coating compared to BAS alone. Though created to limit patient exposures during the COVID pandemic, same day BAS and HRM may prevent delays in care and improve convenience towards improved patient-centered care beyond the pandemic.

Meeting Faculty Development Needs: Review of Current Resources and Opportunities for Program Development.

This paper will review faculty development focus and programming at the early, mid and late career stages. Topics covered include challenges at each career stage, institutional and national programming currently available for the needs of faculty at that stage, and suggested best practices for development of new career focus and potential programs for each stage.

Affecting Change: Enhancing Feedback Interactions with Radiology Trainees.

Feedback is a critical part of the learning process and is a valuable tool to empower adult learners. Modern feedback theory places the learner at the center of the feedback encounter. Individual and institutional barriers to effective giving and receiving of feedback can be overcome through education and attention to the form and content of feedback. We review the elements of effective feedback and address issues of framing, environmental, and social factors which aid in providing psychological safety and trust, as necessary elements to create a culture of feedback in radiology training programs. We provide practical strategies to empower learners with the necessary skills to solicit, receive, and reflect on feedback.

Assessing the Impact of Structured Reports for Fluoroscopic Double-Contrast Barium Esophagrams.

Fluoroscopic barium swallow examinations are a commonly performed radiologic study in the evaluation of dysphagia. These studies remain essential in the diagnostic work-up despite the increasing utilization of endoscopy, but current residents are often less experienced with fluoroscopy. Structured reporting has been demonstrated to improve comprehensiveness of reports in multiple settings, but has not been evaluated for barium swallow examinations. A retrospective review identified patients who underwent barium swallow examinations pre-structured reporting in 2017 and followed a multidisciplinary proposal for and adoption of an optional structured report in 2020. Reports were assessed for comprehensiveness by evaluating presence/absence each element (total of 10 elements). Differences in report elements between groups and multiple subgroups was performed utilizing a Mann-Whitney U test. χ2 tests were also utilized to evaluate inclusion of each individual element of the report. A total of 487 reports from 2020 and 757 reports from 2017 were analyzed. Certain elements showed substantial differences in reporting, with greater than 90% of structured reports including them, but much lower numbers including them in non-structured reports from 2017 and 2020. Reports generated in 2020 had a statistically significant increase in report elements included when compared to 2017 (p < 0.01). This statistically significant increase was also observed in comparison of structured reports and non-structured reports from either period (p < 0.01). Adoption of structured reporting for fluoroscopic barium swallow examinations led to significant increase in report comprehensiveness and should be considered after a multidisciplinary approach to development.

Disposable point-of-care portable perfusion phantom for quantitative DCE-MRI.

PURPOSE: To develop a disposable point-of-care portable perfusion phantom (DP4) and validate its clinical utility in a multi-institutional setting for quantitative dynamic contrast-enhanced magnetic resonance imaging (qDCE-MRI). METHODS: The DP4 phantom was designed for single-use and imaged concurrently with a human subject so that the phantom data can be utilized as the reference to detect errors in qDCE-MRI measurement of human tissues. The change of contrast-agent concentration in the phantom was measured using liquid chromatography-mass spectrometry. The repeatability of the contrast enhancement curve (CEC) was assessed with five phantoms in a single MRI scanner. Five healthy human subjects were recruited to evaluate the reproducibility of qDCE-MRI measurements. Each subject was imaged concurrently with the DP4 phantom at two institutes using three 3T MRI scanners from three different vendors. Pharmacokinetic (PK) parameters in the regions of liver, spleen, pancreas, and paravertebral muscle were calculated based on the Tofts model (TM), extended Tofts model (ETM), and shutter speed model (SSM). The reproducibility of each PK parameter over three measurements was evaluated with the intraclass correlation coefficient (ICC) and compared before and after DP4-based error correction. RESULTS: The contrast-agent concentration in the DP4 phantom was linearly increased over 10 min (0.17 mM/min, measurement accuracy: 96%) after injecting gadoteridol (100 mM) at a constant rate (0.24 ml/s, 4 ml). The repeatability of the CEC within the phantom was 0.997 when assessed by the ICC. The reproducibility of the volume transfer constant, Ktrans , was the highest of the PK parameters regardless of the PK models. The ICCs of Ktrans in the TM, ETM, and SSM before DP4-based error correction were 0.34, 0.39, and 0.72, respectively, while those increased to 0.93, 0.98, and 0.86, respectively, after correction. CONCLUSIONS: The DP4 phantom is reliable, portable, and capable of significantly improving the reproducibility of qDCE-MRI measurements.

CT Radiomic Features of Superior Mesenteric Artery Involvement in Pancreatic Ductal Adenocarcinoma: A Pilot Study.

Background Current imaging methods for prediction of complete margin resection (R0) in patients with pancreatic ductal adenocarcinoma (PDAC) are not reliable. Purpose To investigate whether tumor-related and perivascular CT radiomic features improve preoperative assessment of arterial involvement in patients with surgically proven PDAC. Materials and Methods This retrospective study included consecutive patients with PDAC who underwent surgery after preoperative CT between 2012 and 2019. A three-dimensional segmentation of PDAC and perivascular tissue surrounding the superior mesenteric artery (SMA) was performed on preoperative CT images with radiomic features extracted to characterize morphology, intensity, texture, and task-based spatial information. The reference standard was the pathologic SMA margin status of the surgical sample: SMA involved (tumor cells ≤1 mm from margin) versus SMA not involved (tumor cells >1 mm from margin). The preoperative assessment of SMA involvement by a fellowship-trained radiologist in multidisciplinary consensus was the comparison. High reproducibility (intraclass correlation coefficient, 0.7) and the Kolmogorov-Smirnov test were used to select features included in the logistic regression model. Results A total of 194 patients (median age, 66 years; interquartile range, 60-71 years; age range, 36-85 years; 99 men) were evaluated. Aside from surgery, 148 patients underwent neoadjuvant therapy. A total of 141 patients' samples did not involve SMA, whereas 53 involved SMA. A total of 1695 CT radiomic features were extracted. The model with five features (maximum hugging angle, maximum diameter, logarithm robust mean absolute deviation, minimum distance, square gray level co-occurrence matrix correlation) showed a better performance compared with the radiologist assessment (model vs radiologist area under the curve, 0.71 [95% CI: 0.62, 0.79] vs 0.54 [95% CI: 0.50, 0.59]; P < .001). The model showed a sensitivity of 62% (33 of 53 patients) (95% CI: 51, 77) and a specificity of 77% (108 of 141 patients) (95% CI: 60, 84). Conclusion A model based on tumor-related and perivascular CT radiomic features improved the detection of superior mesenteric artery involvement in patients with pancreatic ductal adenocarcinoma. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Do and Kambadakone in this issue.

Factors Influential in the Selection of Radiology Residents in the Post-Step 1 World: A Discrete Choice Experiment.

OBJECTIVES: Reporting of United States Medical Licensing Examination Step 1 results will transition from a numerical score to a pass or fail result. We sought an objective analysis to determine changes in the relative importance of resident application attributes when numerical Step 1 results are replaced. METHODS: A discrete choice experiment was designed to model radiology resident selection and determine the relative weights of various application factors when paired with a numerical or pass or fail Step 1 result. Faculty involved in resident selection at 14 US radiology programs chose between hypothetical pairs of applicant profiles between August and November 2020. A conditional logistic regression model assessed the relative weights of the attributes, and odds ratios (ORs) were calculated. RESULTS: There were 212 participants. When a numerical Step 1 score was provided, the most influential attributes were medical school (OR: 2.35, 95% confidence interval [CI]: 2.07-2.67), Black or Hispanic race or ethnicity (OR: 2.04, 95% CI: 1.79-2.38), and Step 1 score (OR: 1.8, 95% CI: 1.69-1.95). When Step 1 was reported as pass, the applicant's medical school grew in influence (OR: 2.78, 95% CI: 2.42-3.18), and there was a significant increase in influence of Step 2 scores (OR: 1.31, 95% CI: 1.23-1.40 versus OR 1.57, 95% CI: 1.46-1.69). There was little change in the relative influence of race or ethnicity, gender, class rank, or clerkship honors. DISCUSSION: When Step 1 reporting transitions to pass or fail, medical school prestige gains outsized influence and Step 2 scores partly fill the gap left by Step 1 examination as a single metric of decisive importance in application decisions.