Strengthening the Clinical Learning Environment by Mandate-Implementing the ACGME Common Program Requirements.

RATIONALE: Three years ago, the Accreditation Council for Graduate Medical Education (ACGME) introduced updated Common Program Requirements in recognition of the need to further promote resident and faculty member well-being and patient safety. The ACGME acknowledged residencies would need time to comply with new requirements. This grace period, however, concluded as of July 1, 2019, and programs now risk citations for failure to implement new requirements. METHODS AND RESULTS: The authors, members of the Association of Program Directors in Radiology Common Program Requirements Ad Hoc committee, developed downloadable resources provided in the Appendix delineating the 2019 Common Program Requirements and offering sample resources as compliant solutions. CONCLUSION: The resources offer a national standardized approach to educating trainees in these essential skills and should be especially helpful to programs with access to fewer resources. In addition to achieving compliance, incorporation of these resources into residency training will ensure the next generation of radiologists are equipped to add value while remaining physically and emotionally healthy.

Metastatic mucinous cystadenocarcinoma of the pancreas presenting as intractable back pain.

An 85-year-old woman presented to the emergency department for evaluation of gradually worsening upper back pain of 3 weeks' duration. Her pain radiated down her right arm and was associated with right arm weakness. She reported visiting pain medicine specialists who administered steroid and lidocaine injections, which failed to improve her symptoms. Initial CT of her chest revealed a large lytic lesion within her posterior right fourth rib extending into her T4 vertebral body. The primary malignancy, a mucinous cystadenocarcinoma of the pancreas, was later found on a CT of the abdomen. The patient was also found to have multiple pulmonary, hepatic and lymphatic metastases from the pancreatic primary tumour.

Endovascular aspiration of a symptomatic free-floating common carotid artery thrombus.

Free-floating thrombi of the common carotid artery (CCA) are a very rare cause of ischemic stroke. To date, only a few reports have been described in the academic literature. Revascularization is indicated due to the risk of thromboembolic disease and hemodynamic-related stroke syndromes. Medical treatment typically includes anticoagulation and, in some circumstances, open surgical thrombectomy is an additional option. Although rarely described in the literature, endovascular thrombectomy is a viable treatment alternative in these patients.

Association of kyphosis and spinal skeletal abnormalities with intrathoracic stomach: a link toward understanding its pathogenesis.

BACKGROUND: Modern-day concepts about the pathogenesis of an intrathoracic stomach include crural diaphragm muscular deterioration, loss of phrenoesophageal ligament integrity, and presence of abdominothoracic pressure gradients. The role of spinal abnormalities has received little attention. Based on clinical observation, we hypothesized that kyphosis and other spinal diseases are components of the pathophysiology of an intrathoracic stomach. STUDY DESIGN: The study population consisted of 98 patients (men, n = 22; women, n = 76; mean age 69.4 years) undergoing operations for type III or IV hiatal hernia with an intrathoracic stomach. Twenty-four age- and gender-matched control patients without hiatal hernia undergoing pulmonary or pleural procedures were used for comparison. Chest radiographs were assessed for spinal abnormalities, including degree of kyphosis, measured from superior T4 to inferior T12 (modified Cobb method), spinal fractures, osteoporosis, and scoliosis. Statistical analyses included two-sample t-test and Fisher's exact test. RESULTS: Patients with intrathoracic stomach had a greater degree of kyphosis than control patients (Cobb angle, 50.2 degrees versus 39.7 degrees; p < 0.001). This difference was most pronounced in women (Cobb angle, 51.7 degrees versus 40.4 degrees; p < 0.001), although the difference in men was not significant (Cobb angle, 45.0 degrees versus 38.1 degrees; p = 0.25). Patients with an intrathoracic stomach had significantly more vertebral fractures (37 of 98 [38%] versus 3 of 24 [13%]; p < 0.05). There was no difference in prevalence of degenerative changes (51 of 98 [52%], versus 13 of 24 [54%]), osteopenia (30 of 98 [31%] versus 6 of 24 [25%]), and scoliosis (27 of 98 [28%] versus 6 of 24 [25%]). CONCLUSION: Patients with an intrathoracic stomach have a higher degree of kyphosis and more vertebral fractures than age- and gender-matched controls. These data suggest that change in spinal curvature can be important in the pathogenesis of the intrathoracic stomach, a growing problem of our aging population.

Multidetector CT of the female pelvis.

In the emergency room setting, multidetector detector CT (MDCT) offers rapid, noninvasive, multiplanar evaluation of female patients who have acute pelvic pain. MDCT has been integrated into several of the major trauma centers, and its use may surpass the use of ultrasound in the trauma evaluation of the pregnant patient. In the nonemergent setting, MDCT can be used to stage gynecologic malignancy and to evaluate tumor recurrence. Multiplanar MDCT has received some acceptance for evaluation of small primary tumor volume and small metastatic implants. MDCT also has a role in the evaluation of pelvic varices and suspected pelvic congestion syndrome.