Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review.

INTRODUCTION: Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs). METHODS: We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery. RESULTS: 77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE. CONCLUSIONS: CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

Diagnosing periprosthetic joint infection.

Aims: The diagnosis of periprosthetic joint infection (PJI) can be challenging as the symptoms are similar to other conditions, and the markers used for diagnosis have limited sensitivity and specificity. Recent research has suggested using blood cell ratios, such as platelet-to-volume ratio (PVR) and platelet-to-lymphocyte ratio (PLR), to improve diagnostic accuracy. The aim of the study was to further validate the effectiveness of PVR and PLR in diagnosing PJI. Methods: A retrospective review was conducted to assess the accuracy of different marker combinations for diagnosing chronic PJI. A total of 573 patients were included in the study, of which 124 knees and 122 hips had a diagnosis of chronic PJI. Complete blood count and synovial fluid analysis were collected. Recently published blood cell ratio cut-off points were applied to receiver operating characteristic curves for all markers and combinations. The area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values were calculated. Results: The results of the analysis showed that the combination of ESR, CRP, synovial white blood cell count (Syn. WBC), and polymorphonuclear neutrophil percentage (PMN%) with PVR had the highest AUC of 0.99 for knees, with sensitivity of 97.73% and specificity of 100%. Similarly, for hips, this combination had an AUC of 0.98, sensitivity of 96.15%, and specificity of 100.00%. Conclusion: This study supports the use of PVR calculated from readily available complete blood counts, combined with established markers, to improve the accuracy in diagnosing chronic PJI in both total hip and knee arthroplasties.

Utility of Blood Cell Ratio Combinations for Diagnosis of Periprosthetic Joint Infection.

Background: Periprosthetic joint infection (PJI) is a serious complication following joint replacement surgery, and its diagnosis can be challenging due to the similarity of symptoms to other conditions and the lack of confirmatory imaging tests. Platelet/mean platelet volume ratio (PVR), platelet/lymphocyte ratio, monocyte/lymphocyte ratio, and neutrophil/lymphocyte ratio have been proposed as potential markers to aid in the diagnosis of PJI. This study aimed to further assess the utility of these blood cell ratio combinations for the diagnosis of PJI. Methods: A retrospective chart review was conducted on patients who presented to a university hospital for evaluation for PJI or underwent aseptic revision surgery. All patients were reviewed for inclusion in the study. Data were collected on several markers, including complete blood counts, synovial fluid white blood cell count, and polymorphonuclear percentage. Receiver operator characteristic curve analysis was used to evaluate the diagnostic capabilities of the markers and marker combinations. Results: The combination of erythrocyte sedimentation rate, C-reactive protein, synovial white blood cell count, and synovial polymorphonuclear percentage, with PVR, had the highest area under the curve of 0.97, with a sensitivity of 94.3% and a specificity of 88.9%, and a positive predictive value of 97.1% and a negative predictive value of 80.0%. Conclusions: This study further supports the use of PVR calculated from complete blood count commonly ordered laboratory values obtained during routine complete blood counts when combined with established serum and synovial markers to increase the diagnostic accuracy for diagnosing PJI.

Who Wants to Learn How to Teach? Perceptions of Radiology Residents and Radiology Teaching Faculty Regarding Resident as Teacher Training.

RATIONALE AND OBJECTIVES: While the ACGME requires Resident as Teacher (RAT) training, curricula in radiology remain limited. Our study was performed to examine radiology residents (RR) and teaching faculty (TF) perceptions about RAT training. MATERIALS AND METHODS: In 2021, anonymous online surveys were administered to all RR (53-item) and to all TF (24-item) of a radiology residency program. Content domains included attitudes about RAT training and learning topics. RESULTS: Response rates were 97% (38/39) for RR and 54% (58/107) for TF. Most RR desired training to become better educators to medical students (MS) (81%) and other residents (83%). Seventy-seven percent of RR reported the importance regarding how to give feedback to other learners, while 94% desired formal training on delivering case presentations. While 94% of RR reported that resident feedback was valuable, only 6% reported always giving feedback to MS. Seventy-two percent of RR did not apply at least some best-practices in their reading room teaching. Fifty-nine percent of RR wanted TF to observe their own teaching skills and provide feedback although 70% reported rarely or never receiving TF feedback. Ninety-three percent of TF reported RR should receive RAT training, while 88% reported that feedback of RR to MS was important. CONCLUSION: RR and TF strongly endorsed the need for RAT training. RR anticipate teaching to be an important part of their careers. We identified learning topics and possible gaps regarding how TF are meeting RR needs, which could inform the development of RAT curricula.

Axillary Adenopathy after COVID-19 Vaccine: No Reason to Delay Screening Mammogram.

Online supplemental material is available for this article.

Tips for Successful Career Transitions in Breast Imaging.

Whether beginning a new career in breast imaging or switching into a different breast imaging practice for personal or professional advancement, a leadership opportunity, a need to relocate geographically, or simply a better opportunity, it is critical to transition between positions as smoothly as possible. Thoroughly reflecting on your career priorities and goals is essential prior to undertaking any career transition. Once the decision has been made to move to a new position, it is imperative to learn about the dynamics of the new practice and practice environment. Here, we provide suggestions on how to hit the ground running when joining a new breast imaging practice.

"What Program Directors Think" V: Results of the 2019 Spring Survey of the Association of Program Directors in Radiology (APDR).

RATIONALE AND OBJECTIVES: The Association of Program Directors in Radiology (APDR) surveys its membership annually on hot topics and new developments in radiology residency training. Here we report the results of that annual survey. MATERIALS AND METHODS: A web-based survey was posed to the APDR membership in the Fall of 2018. Members were asked 43 questions on program staffing, resident education resources/funding, impact of the integrated-Interventional Radiology residency program on Diagnostic Radiology program resources, resident interest in imaging informatics, Accreditation Council for Graduate Medical Education requirements on resident practice habits data reporting, institutional reliance on residents for clinical coverage, teaching format in the post-oral board era, resident conference attendance, confidentiality of the Match rank list, Early Specialization in Interventional Radiology pathway recruitment and selection, Diagnostic Radiology and Interventional Radiology program relationships, independent resident call, pediatric radiology training, diversity and unconscious bias training, and social media in radiology education. RESULTS: Responses were collected electronically, results were tallied using Qualtrics software, and qualitative responses were tabulated or summarized as comments. There were 86 respondents with a response rate of 31.3%. CONCLUSION: Survey result highlights include perceived resident interest in imaging informatics with the vast majority of residency programs offering an informatics curriculum; the provision of resident practice habits data by nearly all residency programs despite lack of clarity surrounding this Accreditation Council for Graduate Medical Education requirement; continued use of case-taking in the post-oral boards era; frequent disclosure of the Match rank list to departmental and hospital administration; low penetration of unconscious bias training in academic radiology; and finally, the successful integration of interventional and diagnostic radiology training programs.

Preserving Radiology Resident Education During the COVID-19 Pandemic: The Simulated Daily Readout.

RATIONALE AND OBJECTIVES: The educational value of the daily resident readout, a vital component of resident training, has been markedly diminished due to a significant decrease in imaging volume and case mix diversity. The goal of this study was to create a "simulated" daily readout (SDR) to restore the educational value of the daily readout. MATERIALS AND METHODS: To create the SDR the following tasks were performed; selection of cases for a daily worklist for each resident rotation, comprising a combination of normal and abnormal cases; determination of the correct number of cases and the appropriate mix of imaging modalities for each worklist; development of an "educational" environment consisting of separate "instances" of both our Picture Archive Communication System and reporting systems; and the anonymization of all of the cases on the worklists. Surveys of both residents and faculty involved in the SDR were performed to assess its effectiveness. RESULTS: Thirty-two residents participated in the SDR. The daily worklists for the first 20 days of the SDR included 3682 cases. An average of 480 cases per day was dictated by the residents. Surveys of the residents and the faculty involved in the SDR demonstrated that both agreed that the SDR effectively mimics a resident's daily work on rotations and preserves resident education during the Coronavirus Disease 2019 crisis. CONCLUSION: The development of the SDR provided an effective method of preserving the educational value of the daily readout experience of radiology residents, despite severe decreases in imaging exam volume and case mix diversity during the Coronavirus Disease 2019 pandemic.

Harnessing the Power of Low-tech Collaborative Learning.

Medical education in the United States has undergone a paradigm shift from passive learning to more interactive student-centered teaching methods. Several digital tools and platforms have been developed to assist educators in creating a high-tech, interactive classroom. However, there are many low-tech ways to engage learners and improve retention by combining collaborative learning techniques and summary exercises. Collaborative learning is an educational approach that involves the coordinated engagement of two or more learners for the purpose of completing a task or solving a problem. Such methods use a student-centered active learning model to promote higher-order cognitive tasks through active engagement in course content. Additionally, summary exercises at the end of a learning activity promote reflection and retention of learned concepts while clarifying content that may have been confusing for the learner. The purpose of this article is to describe the methodology and tips for the implementation of low-tech collaborative learning methods and summary activities into trainee educational activities to create an engaging student-centered learning environment.

Development of Breast Imaging Specific Entrustable Professional Activities Using a Double Delphi Technique.

RATIONAL AND OBJECTIVES: To develop subspecialty-specific entrustable professional activities for breast imaging radiology (EPA-BRs) through the use of a double consensus-driven, validity-enhancing methodology that may be relevant to other subspecialties in radiology and medicine in general. MATERIALS AND METHODS: A six-step methodology was used to develop EPA-BRs via a double Delphi process followed by educational theorist's refinement. Two groups of experts completed each Delphi process: the core group of breast imaging educators and an expert panel of national experts in breast imaging standards and appropriateness. RESULTS: Five EPA-BRs were developed, with eight nested EPA-BRs, one of which is elective. This comprehensive list of EPA-BRs covers the role of a breast imaging radiologist in the care of a patient from detection of breast cancer to post-treatment follow-up. CONCLUSION: A combined modified and classic double Delphi approach can be utilized by other graduate medical education (GME) specialties and subspecialties as a method by which GME education can be transformed into a clinical framework that more closely bridges individual competencies and real-world clinical practice.

Initial Institutional Experience With Cryoablation Therapy for Breast Fibroadenomas: Technique, Molecular Science, and Post-Therapy Imaging Follow-up.

Cryoablation is a safe and effective nonsurgical treatment for breast fibroadenomas (FAs). The treatment response is inversely related to the tumor size, with lesions less than 2 cm showing an optimal response. Ultrasound (US) imaging follow-up of the ablated tumor is recommended at 6-month intervals for 2 years at our institution. Although a decrease in the size of the FA clinically and on US imaging is the expected treatment response, variations can be seen. Knowledge of typical US changes over time is imperative to prevent unnecessary rebiopsy or excision in patients who have undergone cryoablation. We will review the initial patient selection criteria, cryoablation technique, and US findings at regular follow-up intervals after cryoablation of FAs through a series of cases treated at our institution.

Key Ingredients of a Breast Imaging Fellowship-A Recipe for Success.

OBJECTIVE: In 2013, the ACR and Society of Breast Imaging created a curriculum to standardize the knowledge of graduates from breast imaging fellowships. Despite this, however, there remains a need to provide guidance to programs as to how to structure and organize the fellowship. In this article, we review key elements of a breast imaging fellowship to ensure that programs graduate radiologists that are well prepared to practice safely and independently. Such a program would provide a developmental framework using the Dreyfus model of skill acquisition. The training should be comprised of multiple and varied opportunities that promote active learning with appropriate supervision but progressive independence. SUMMARY: A successful fellowship program in breast imaging should embrace developmental milestones to ensure mastery of both basic and complex skills. Organized rotations, regular feedback, structured and self-directed learning activities, and participation in local, regional, and national meetings and organizations contribute to well-rounded graduates.

Video-Based Teaching of Image-Guided Breast Interventions: Stereotactic Core Biopsy Using a Prone Table.

Introduction: The introduction of new technologies and teaching strategies to educate the digital learner creates the potential for a better and more standardized training experience across programs. Thus, we sought to create an instructional video on stereotactic core breast biopsy that simulates best practices and could be readily accessed by training programs to improve and standardize resident education. Methods: At our institution, we use the video and questions as part of a flipped classroom educational activity. Residents are requested to complete the questions at home and watch the video. They then take the posttest questions during the lecture period, at which time the answers are reviewed and there is additional discussion of the procedure. The tests contain both video-related questions and control questions. Results: After viewing the video, there was a 30% mean improvement in the video-related questions compared to a 0% improvement in the control set of questions. Discussion: An instructional video on stereotactic core biopsy was created with associated assessment questions that can be used at any institution for the purposes of improving and standardizing training in breast imaging procedures. This resource can be especially useful for programs where trainees have limited procedure exposure.

Hidradenitis suppurativa: Mammographic and sonographic manifestations in two cases.

Hidradenitis suppurativa is a chronic debilitating disorder of the skin manifested by recurrent, painful, inflammatory, subcutaneous nodules. The lesions occur most commonly in the apocrine-gland-bearing skin sites such as the axillae and inguinal regions; they cause scarring and disfigurement from the formation of multiple abscesses and fistulous tracts within the skin. We report the radiologic manifestations of two cases of hidradenitis suppurativa in women who presented for breast imaging.