Challenges in diagnosis of calcaneal fractures: an examination using the WIDI SIM platform.

INTRODUCTION: The calcaneus is the most commonly fractured tarsal bone. Diagnosis is often challenging due to subtle radiographic changes and requires timely identification to prevent complications, including subtalar arthritis, neurovascular injury, malunion, osteomyelitis, and compartment syndrome. Treatment varies based on fracture type, with non-surgical methods for non-displaced stress fractures and surgical interventions for displaced or intra-articular fractures. METHODS: This study utilized the Wisdom in Diagnostic Imaging Simulation (WIDI SIM) platform, an emergency imaging simulation designed to assess radiology resident preparedness for independent call. During an 8-hour simulation, residents were tested on 65 cases across various imaging modalities of varying complexity, including normal studies. A single, unique case of calcaneal fracture was included within the simulation in four separate years of testing. Cases were assessed using a standardized grading rubric by subspecialty radiology faculty, with errors subsequently classified by type. RESULTS: A total of 1279 residents were tested in five separate years on the findings of calcaneal fractures of 5 different patients. Analysis revealed a consistent pattern of missed diagnoses across all training years, primarily attributed to observational errors. There was limited improvement with training progression as all training years exhibited similar average performance levels. CONCLUSIONS: Calcaneal fractures pose a diagnostic challenge due to their frequent subtle radiographic findings, especially in stress fractures. Simulation-based evaluations using WIDI SIM highlighted challenges in radiology residents' proficiency in diagnosing calcaneal fractures. Addressing these challenges through targeted education and exposure to diverse cases is essential to improve diagnostic accuracy and reduce complications with calcaneal fractures.

An assessment of radiology resident competency in identifying suppurative retropharyngeal lymphadenitis: an examination using the WIDI SIM platform.

BACKGROUND AND PURPOSE: Suppurative retropharyngeal lymphadenitis is a retropharyngeal space infection almost exclusively seen in the young (4-8 years old) pediatric population. It can be misdiagnosed as a retropharyngeal abscess, leading to unnecessary invasive treatment procedures. This retrospective study aims to assess radiology residents' ability to independently identify CT imaging findings and make a definitive diagnosis of suppurative retropharyngeal lymphadenitis in a simulated call environment. MATERIALS AND METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a computer-aided emergency imaging simulation proven to be a reliable method for assessing resident preparedness for independent radiology call. The simulation included 65 cases across various imaging modalities of varying complexity, including normal studies, with one case specifically targeting suppurative retropharyngeal adenitis identification. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. RESULTS: A total of 543 radiology residents were tested in three separate years on the imaging findings of suppurative retropharyngeal lymphadenitis using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Suppurative retropharyngeal lymphadenitis was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 3.5% of radiology residents were able to correctly identify suppurative retropharyngeal lymphadenitis on a contrast-enhanced computed tomography (CT). CONCLUSIONS: Our findings underscore a potential gap in radiology residency training related to the accurate identification of suppurative retropharyngeal lymphadenitis, highlighting the potential need for enhanced educational efforts in this area.

Radiology resident competency in detecting basilar artery occlusion: a simulation-based assessment.

PURPOSE: Basilar artery strokes are rare but can have characteristic imaging findings that can often be overlooked. This retrospective study aims to assess radiology residents' ability to identify CT imaging findings of basilar artery occlusion in a simulated call environment. METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM)-a tested and reliable computer-aided emergency imaging simulation-was employed to assess resident readiness for independent radiology call. The simulations include 65 cases of varying complexity, including normal studies, with one case specifically assessing basilar artery stroke. Residents were presented with a single, unique case of basilar artery occlusion in two separate years of testing and were only provided with non-contrast CT images. Residents' free text responses were manually scored by faculty members using a standardized grading rubric, with errors subsequently classified by type. RESULTS: A total of 454 radiology residents were tested in two separate years on the imaging findings of basilar artery occlusion using the Wisdom in Diagnostic Imaging simulation web-based testing platform. Basilar artery occlusion was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. On average, only 14% of radiology residents were able to correctly identify basilar artery occlusion on non-contrast CT. CONCLUSIONS: Our findings underscore a potential gap in radiology residency training related to the detection of basilar artery occlusion, highlighting the potential need for increased educational efforts in this area.

Imaging of pediatric extragonadal pelvic soft tissue tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

The most common pediatric extragonadal pelvic cancers include germ cell tumors, sacrococcygeal teratomas, and rhabdomyosarcomas (arising from the urinary bladder, prostate, paratesticular tissues, vagina, uterus, and perineum). This paper describes the radiological and nuclear medicine features of these entities and provides consensus-based recommendations for the assessment at diagnosis, during, and after treatment.

Bubbles in the belly: How well do radiology trainees recognize pneumatosis in pediatric patients on plain film?

OBJECTIVES: Pneumatosis intestinalis is a radiographic finding that refers to the presence of gas within the walls of the small or large bowel. This sign is diagnostic in the setting of premature infants with suspected necrotizing enterocolitis. Earlier detection of NEC on X-ray is vital to improve the overall management in these infants. The identification of pneumatosis intestinalis concerning for necrotizing enterocolitis by the "on-call" trainee is critical in the care of the preterm infant. Our objective was to study trainees' ability to identify pneumatosis on an emergent overnight film. METHODS: The Emergent/Critical Care Imaging SIMulation (WIDI SIM) is a strategically designed computer-aided simulation of an emergency imaging experience that has been rigorously tested and proven to be a reliable means for assessing radiology trainee preparedness to competently and independently cover radiology call. One test case each year included requires the trainee to accurately identify pneumatosis on a plain radiograph of the abdomen in a neonate. RESULTS: A total of 463 radiology trainees from 32 distinct training programs across the country were given a case of pneumatosis using the WIDI simulation web-based testing platform. On average only 28% of radiology trainees were able to correctly identify pneumatosis intestinalis on plain film. Although the sample sizes in the upper-level trainees were smaller, those with greater number years of training performed better. CONCLUSIONS: Further training must be given to radiology trainees to accurately recognize pneumatosis and report concerns for necrotizing enterocolitis. ADVANCES IN KNOWLEDGE: This paper is the first to describe and assess the ability of the "on-call" radiology trainee to accurately recognize pneumatosis and report concerns for necrotizing enterocolitis. Our paper includes the largest cohort of radiology trainees evaluated to this date.

Pediatric craniosynostosis computed tomography: an institutional experience in reducing radiation dose while maintaining diagnostic image quality.

BACKGROUND: Children with craniosynostosis may undergo multiple computed tomography (CT) examinations for diagnosis and post-treatment follow-up, resulting in cumulative radiation exposure. OBJECTIVE: To reduce the risks associated with radiation exposure, we evaluated the compliance, radiation dose reduction and clinical image quality of a lower-dose CT protocol for pediatric craniosynostosis implemented at our institution. MATERIALS AND METHODS: The standard of care at our institution was modified to replace pediatric head CT protocols with a lower-dose CT protocol utilizing 100 kV, 5 mAs and iterative reconstruction. Study-ordered, protocol-utilized and radiation-dose indices were collected for studies performed with routine pediatric brain protocols (n=22) and with the lower-dose CT protocol (n=135). Two pediatric neuroradiologists evaluated image quality in a subset (n=50) of the lower-dose CT studies by scoring visualization of cranial structures, confidence of diagnosis and the need for more radiation dose. RESULTS: During the 30-month period, the lower-dose CT protocol had high compliance, with 2/137 studies performed with routine brain protocols. With the lower-dose CT protocol, volume CT dose index (CTDIvol) was 1.1 mGy for all patients (0-9 years old) and effective dose ranged from 0.06 to 0.22 mSv, comparable to a 4-view skull radiography examination. CTDIvol was reduced by 98% and effective dose was reduced up to 67-fold. Confidence in diagnosing craniosynostosis was high and more radiation dose was considered unnecessary in all studies (n=50) by both radiologists. CONCLUSION: Replacing the routine pediatric brain CT protocol with a lower-dose CT craniosynostosis protocol substantially reduced radiation exposure without compromising image quality or diagnostic confidence.

Rate of resident recognition of nonaccidental trauma: how well do residents perform?

BACKGROUND: A resident working under the entrustable professional activity of a graduated independent coverage model must identify nonaccidental trauma and notify clinicians of this concern to facilitate potential removal of the child from harm. The resident's role in identifying child abuse has not previously been studied. OBJECTIVE: The purpose of this study was to assess radiology residents' ability to identify radiographic imaging findings of nonaccidental trauma in a simulated call environment. MATERIALS AND METHODS: The Wisdom in Diagnostic Imaging Emergent/Critical Care Radiology Simulation (WIDI SIM) is a strategically designed computer-aided simulation of an emergency imaging experience that has been rigorously tested and proven to be a reliable means for assessing resident preparedness to competently and independently cover radiology call. The residents are provided with 65 cases of varying difficulty, including normal studies. Those cases include ones that require the resident to accurately identify skeletal findings of nonaccidental trauma. The residents respond using free text that is then scored manually by faculty members utilizing a robust grading rubric. Missed cases are then categorized by observation error and/or interpretative errors. RESULTS: A total of 675 radiology residents were given a case of nonaccidental trauma using the WIDI simulation web-based test platform between 2014 and 2017. Child abuse was consistently underdiagnosed by radiology residents being tested for call readiness irrespective of the numbers of years in training. Correct diagnostic score averages per year ranged from 10% to 79%. In year 1, 71% of residents correctly diagnosed nonaccidental trauma with a total of 101 participants. In year 2, 130 residents participated with only 20% answering correctly. In year 3, there were 201 participants with 79% correctly diagnosing nonaccidental trauma. In year 4, only 10% of 243 residents accurately diagnosed nonaccidental trauma. Residents from various stages of training were tested. Cases used with leading histories provided, accounted for a higher correct call rate. CONCLUSION: Radiology residency programs may be deficient in teaching residents to accurately recognize and report child abuse. This deficiency has potential implications for programs where a radiology attending is not present after hours as it raises the concern that child abuse may be missed by residents taking independent call. These data further question whether graduating radiologists are competent to recognize nonaccidental trauma and demonstrates the need for additional mandatory training during radiology residency.

Full Resolution Simulation for Evaluation of Critical Care Imaging Interpretation; Part 2: Random Effects Reveal the Interplay Between Case Difficulty, Resident Competence, and the Training Environment.

RATIONALE AND OBJECTIVES: To further characterize empirical data from a full-resolution simulation of critical care imaging coupled with post hoc grading of resident's interpretations by senior radiologists. To present results from estimating the random effects terms in a comprehensive mixed (hierarchical) regression model. MATERIALS AND METHODS: After accounting for 9 fixed effects detailed in Part 1 of this paper, we estimated normally distributed random effects, expressed in terms of score offsets for each case, resident, program, and grader. RESULTS: The fixed effects alone explained 8.8% of score variation and adding the random effects increased explanatory power of the model to account for 36% of score variation. As quantified by intraclass correlation coefficient (ICC = 28.5%; CI: 25.1-31.6) the majority of score variation is directly attributable to the case at hand. This "case difficulty" measure has reliability of 95%. Individual residents accounted for much of the remaining score variation (ICC = 5.3%; CI: 4.6-5.9) after adjusting for all other effects including level of training. The reliability of this "resident competence" measure is 82%. Residency training program influence on scores was small (ICC = 1.1%; CI: 0.42-1.7). Although a few significantly high and low ones can be identified, reliability of 73% militates for caution. At the same time, low intraprogram variation is very encouraging. Variation attributable to differences between graders was minimal (ICC = 0.58%; CI: 0.0-1.2) which reassures us that the method of scoring is reliable, consistent, and likely extensible. CONCLUSION: Full resolution simulation based evaluation of critical care radiology interpretation is being conducted remotely and efficiently at large scale. A comprehensive mixed model of the resulting scores reliably quantifies case difficulty and resident competence.

Full Resolution Simulation for Evaluation of Critical Care Imaging Interpretation; Part 1: Fixed Effects Identify Influences of Exam, Specialty, Fatigue, and Training on Resident Performance.

RATIONALE AND OBJECTIVES: To describe our full-resolution simulation of critical care imaging coupled with posthoc grading of resident's interpretations and present results from the fixed effects terms in a comprehensive mixed regression model of the resulting scores. MATERIALS AND METHODS: The system delivered full resolution DICOM studies via clinical-grade viewing software integrated with a custom built web-based workflow and reporting system. The interpretations submitted by participating residents from 47 different programs were graded (scores of 0-10) on a case by case basis by a cadre of faculty members from our department. The data from 5 yearly (2014-2018) cycles consisting of 992 separate 65 case, 8 hour simulation sessions were collated from the transaction records. We used a mixed (hierarchical) statistical model with nine fixed and four random independent variables. In this paper, we present the results from the nine fixed effects. RESULTS: There were 19,916/63,839 (27.0%, CI 26.7%-27.4%) scores in the 0-2 range (i.e., clinically significant miss). Neurological cases were more difficult with adjusted scores 2.3 (CI 1.9-3.2) lower than body/musculoskeletal cases. There was a small (0.3, CI 0.20-0.38 points) but highly significant (p<0.0001) decrease in score for the final 13/65 cases (fifth quintile) as evidence of fatigue during the last hour of an 8 hour shift. By comparing adjusted scores from mid-R1 (quarter 3) to late-R3 (quarter 12) we estimate the training effect as an increase of 2.2 (CI 1.90-2.50) points. CONCLUSION: Full resolution simulation based evaluation of critical care radiology interpretation is being conducted remotely and efficiently at large scale. Analysis of the resulting scores yields multiple insights into the interpretative process.

Against the Overgrowth Hypothesis: Shorter Costal Cartilage Lengths in Pectus Excavatum.

BACKGROUND: Pectus excavatum is a common chest wall deformity with no known cause. A common hypothesis is that in patients with pectus excavatum, there is an overgrowth of costal cartilage relative to healthy individuals. MATERIALS AND METHODS: We obtained radiological curvilinear three-dimensional measurements of the fourth to eighth costal cartilage and associated ribs in 16 patients with pectus excavatum and 16 age- and gender-matched controls between the ages of 6 and 32 y. An analysis of variance was used to compare bone length, cartilage length, and their ratios between patients and controls. RESULTS: Relative to bone length, patients with pectus excavatum overall had shorter costal cartilage lengths (P < 0.001), especially on the left side (P < 0.05). We were unable to localize this observation to specific ribs during post hoc analysis. CONCLUSIONS: This is the first study to empirically test the overgrowth hypothesis of pectus excavatum for ribs 4 through 8. Although we and others have found no evidence to support this hypothesis, we surprisingly found the alternate hypothesis to be true: patients with pectus excavatum tend to have shorter costal cartilages. Future studies should expand on these results with larger sample sizes and consider volumetric measurements longitudinally during thoracic development.

Congenital Pulmonary Artery Anomalies: A Review and Approach to Classification.

Congenital pulmonary artery anomalies are infrequent but given improved prenatal diagnosis and care, and neonatal surgical advances, over the past two decades are not uncommonly encountered by cardiothoracic imagers. An understanding of their etiology, classifications, associated anomalies, and surgical management can be helpful to avoid under or overdiagnosis. Timely diagnosis assisted by familiarity with imaging findings across modalities and recognition of surgical findings allows for medical management and surgical planning for these patients, with more patients reaching adulthood than ever before.

An "accidental" discovery: Incidentally found metanephric adenofibroma in a 5-year-old male trauma patient.

Metanephric adenofibroma is a rare pediatric renal tumor, which should be considered in cases of solid renal lesions that mimic Wilms tumor on both imaging and histology. We present a case of an incidentally found left renal lesion on a trauma computed tomography scan in a 5-year-old male patient. The patient underwent total nephrectomy, and the diagnosis of metanephric adenofibroma was made on histology. Radiologists should consider this entity in the differential for an incidentally found solitary renal mass in a pediatric patient. Prompting the pathologic diagnosis of this entity can spare patients from unnecessary chemotherapy and allow for nephron-sparing surgery.

Can Neonatal Brain MRI be Performed during Active Cooling?

OBJECTIVE: Due to logistical constraints, physicians traditionally delay diagnostic imaging for neonatal hypoxic-ischemic encephalopathy (HIE) until the neonate has completed all 72 hours of therapeutic hypothermia and rewarming. In some cases, neonates may require neuroimaging before 72 hours has passed. STUDY DESIGN: We present a case in which an MRI was acquired during active hypothermia. RESULTS: Upon return to the NICU, Baby X's temperature probe read 33.6 degrees, indicating that hypothermia was likely maintained at the target temperature. CONCLUSION: Active hypothermia is possible during MRI.

Emergent presentation of Langerhans cell histiocytosis in a pediatric patient: Acute cerebellar involvement causing obstructive hydrocephalus requiring posterior fossa decompression.

Langerhans cell histiocytosis (LCH) is a disorder of the monocyte-macrophage system that can be unifocal or systemic. Here, we present a pediatric case who initially presented with osseous LCH but again presented 6 years later emergently with cerebellar symptoms, cerebellar mass and obstructive hydrocephalus. Patient underwent biopsy of the cerebellum which was path proven intracranial LCH.

A Case of Polyarteritis Nodosa Associated with Vertebral Artery Vasculitis Treated Successfully with Tocilizumab and Cyclophosphamide.

Pediatric polyarteritis nodosa is rare systemic necrotizing arteritis involving small- and medium-sized muscular arteries characterized by aneurysmal dilatations involving the vessel wall. Aneurysms associated with polyarteritis nodosa are common in visceral arteries; however intracranial aneurysms have also been reported and can be associated with central nervous system symptoms, significant morbidity, and mortality. To our knowledge extracranial involvement of the vertebral arteries has not been reported but has the potential to be deleterious due to fact that they supply the central nervous system vasculature. We present a case of a 3-year-old Haitian boy with polyarteritis nodosa that presented with extracranial vessel involvement of his vertebral arteries. After thorough diagnostic imaging, including a bone scan, ultrasound, Magnetic Resonance Imaging/Angiography, and Computed Tomography Angiography, he was noted to have vertebral artery vasculitis, periostitis, subacute epididymoorchitis, arthritis, and myositis. He met diagnostic criteria for polyarteritis nodosa and was treated with cyclophosphamide, methylprednisolone, and tocilizumab, which resulted in improvement of his inflammatory markers, radiographic findings, and physical symptoms after treatment. To the authors' knowledge, this is the first report of vertebral artery vasculitis in polyarteritis nodosa as well as successful treatment of the condition using the combination cyclophosphamide and tocilizumab for this condition.