What Do Program and Geographic Preference Signals Signal? A Survey of Diagnostic Radiology and Integrated Interventional Radiology Residency Applicants.

RATIONALE AND OBJECTIVES: As part of the 2022-2023 Diagnostic/Interventional Radiology residency application process, applicants could participate in the ERAS supplemental application, including sending up to six preference signals and three geographic signals. Our goal was to survey Diagnostic Radiology and Integrated Interventional Radiology applicants at two large academic institutions in different geographic locations regarding their perceived impact of program and geographic preference signaling on the application process. METHODS: An anonymous survey was sent to 282 applicants between two academic medical centers asking about their participation in program and geographic preference signaling as well as their perception on its impact on the application process. RESULTS: 105 applicants responded to the survey (37.2% [105/282]). Most applicants (26% [27/102]) received four interviews from signaled programs. When prompted to best describe their sentiments with respect to program signaling (one being most negative and five being most positive), the plurality of applicants reported a positive sentiment of four (36% [37/103]). Applicants that received four to six interviews from signaled programs were significantly more likely to feel positively towards program signaling than those that received one to three interviews (p = 0.01). Geography was the most important deciding factor on which programs to signal for applicants (57% [58/101]). DISCUSSION: Our survey results demonstrate that most applicants felt positively towards program signaling and it increased their odds of receiving interviews from preferred programs, which is consistent with the current literature. CONCLUSION: Program and geographic signaling are relatively new features of the ERAS residency application process and therefore, their effects on the match outcome are still in question. However, our study results indicate that they are perceived positively by most applicants and that they boost their chances in finding their ideal match.

An ASER AI/ML expert panel formative user research study for an interpretable interactive splenic AAST grading graphical user interface prototype.

PURPOSE: The AAST Organ Injury Scale is widely adopted for splenic injury severity but suffers from only moderate inter-rater agreement. This work assesses SpleenPro, a prototype interactive explainable artificial intelligence/machine learning (AI/ML) diagnostic aid to support AAST grading, for effects on radiologist dwell time, agreement, clinical utility, and user acceptance. METHODS: Two trauma radiology ad hoc expert panelists independently performed timed AAST grading on 76 admission CT studies with blunt splenic injury, first without AI/ML assistance, and after a 2-month washout period and randomization, with AI/ML assistance. To evaluate user acceptance, three versions of the SpleenPro user interface with increasing explainability were presented to four independent expert panelists with four example cases each. A structured interview consisting of Likert scales and free responses was conducted, with specific questions regarding dimensions of diagnostic utility (DU); mental support (MS); effort, workload, and frustration (EWF); trust and reliability (TR); and likelihood of future use (LFU). RESULTS: SpleenPro significantly decreased interpretation times for both raters. Weighted Cohen's kappa increased from 0.53 to 0.70 with AI/ML assistance. During user acceptance interviews, increasing explainability was associated with improvement in Likert scores for MS, EWF, TR, and LFU. Expert panelists indicated the need for a combined early notification and grading functionality, PACS integration, and report autopopulation to improve DU. CONCLUSIONS: SpleenPro was useful for improving objectivity of AAST grading and increasing mental support. Formative user research identified generalizable concepts including the need for a combined detection and grading pipeline and integration with the clinical workflow.

Traumatic Cervical Cerebrovascular Injury and the Role of CTA: AJR Expert Panel Narrative Review.

Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt CVI (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.

Blunt splenic injury in adults: Association between volumetric quantitative CT parameters and intervention.

Several ordinal grading systems are used in deciding whether to perform angioembolization (AE) or splenectomy following blunt splenic injury (BSI). The 2018 American Association for the Surgery of Trauma (AAST) Organ Injury Scale incorporates vascular lesions but not hemoperitoneum, which is considered in the Thompson classifier. Granular and verifiable quantitative measurements of these features may have a future role in facilitating objective decision making. The purpose of this study is to compare performance of computed tomography (CT) volumetry-based quantitative modeling to the 1994 and 2018 AAST Organ Injury Scale and Thompson classifier for the following endpoints: decision to perform splenectomy (SPY), and the composite of SPY or AE. Adult BSI patients (age ≥18 years) scanned with dual-phase CT prior to intervention at a single Level I trauma center from 2017 to 2019 were included in this retrospective study (n = 174). Scoring using 2018 AAST, 1994 AAST, and Thompson systems was performed retrospectively by two radiologists and arbitrated by a third. Endpoints included (1) SPY and (2) the composite of SPY or AE. Logistic regression models were developed from segmented active bleed, contained vascular lesion, splenic parenchymal disruption, and hemoperitoneum volumes. Area under the receiver operating characteristic curve (AUC) for ordinal systems and volumetric models were compared. Forty-seven BSI patients (27%) underwent SPY, and 87 patients (50%) underwent SPY or AE. Quantitative model AUCs (0.85­SPY, 0.82­composite) were not significantly different from 2018 AAST AUCs (0.81, 0.88, p = 0.66, 0.14) for both endpoints and were significantly improved over Thompson scoring (0.76, p = 0.02; 0.77, p = 0.04). Quantitative CT volumetry can be used to model intervention for BSI with accuracy comparable to 2018 AAST scoring and significantly higher than Thompson scoring. Prognostic and Epidemiological; Level IV.

CT of Sacral Fractures: Classification Systems and Management.

CT is often performed as part of a whole-body protocol in the setting of polytrauma and is the standard of care for diagnosing and characterizing sacral fractures. These fractures are not uncommon, occurring in conjunction with pelvic ring disruption in approximately 40%-50% of patients. Knowledge of basic functional anatomy and fracture biomechanics is important in understanding sacral fracture patterns, which only rarely result from direct impact. More often, sacral fractures result from an indirect mechanism with fracture lines that propagate along relative lines of weakness, leading to predictable fracture patterns. Each fracture pattern has implications with respect to neurologic injury, spinopelvic stability, management, and potential complications. The authors explore the Denis, Roy-Camille, Isler, Robles, Sabiston-Wing, and shape-based classification systems for sacral fractures. These form the basis of the subsequently discussed unified AOSpine sacral fracture classification, a consensus system developed by spine and orthopedic surgeons as a means of improving and standardizing communication. The AOSpine sacral fracture classification also includes clinical designations for neurologic status and patient-specific modifiers. When a patient is unexaminable owing to obtundation or sedation, CT is an invaluable indirect marker of nerve compression or traction injury. It also plays an important role in visualizing and characterizing the type and extent of any associated soft-tissue injuries that may warrant a delay in surgery or an alternative operative approach. ©RSNA, 2022.

A pilot study of deep learning-based CT volumetry for traumatic hemothorax.

PURPOSE: We employ nnU-Net, a state-of-the-art self-configuring deep learning-based semantic segmentation method for quantitative visualization of hemothorax (HTX) in trauma patients, and assess performance using a combination of overlap and volume-based metrics. The accuracy of hemothorax volumes for predicting a composite of hemorrhage-related outcomes - massive transfusion (MT) and in-hospital mortality (IHM) not related to traumatic brain injury - is assessed and compared to subjective expert consensus grading by an experienced chest and emergency radiologist. MATERIALS AND METHODS: The study included manually labeled admission chest CTs from 77 consecutive adult patients with non-negligible (≥ 50 mL) traumatic HTX between 2016 and 2018 from one trauma center. DL results of ensembled nnU-Net were determined from fivefold cross-validation and compared to individual 2D, 3D, and cascaded 3D nnU-Net results using the Dice similarity coefficient (DSC) and volume similarity index. Pearson's r, intraclass correlation coefficient (ICC), and mean bias were also determined for the best performing model. Manual and automated hemothorax volumes and subjective hemothorax volume grades were analyzed as predictors of MT and IHM using AUC comparison. Volume cut-offs yielding sensitivity or specificity ≥ 90% were determined from ROC analysis. RESULTS: Ensembled nnU-Net achieved a mean DSC of 0.75 (SD: ± 0.12), and mean volume similarity of 0.91 (SD: ± 0.10), Pearson r of 0.93, and ICC of 0.92. Mean overmeasurement bias was only 1.7 mL despite a range of manual HTX volumes from 35 to 1503 mL (median: 178 mL). AUC of automated volumes for the composite outcome was 0.74 (95%CI: 0.58-0.91), compared to 0.76 (95%CI: 0.58-0.93) for manual volumes, and 0.76 (95%CI: 0.62-0.90) for consensus expert grading (p = 0.93). Automated volume cut-offs of 77 mL and 334 mL predicted the outcome with 93% sensitivity and 90% specificity respectively. CONCLUSION: Automated HTX volumetry had high method validity, yielded interpretable visual results, and had similar performance for the hemorrhage-related outcomes assessed compared to manual volumes and expert consensus grading. The results suggest promising avenues for automated HTX volumetry in research and clinical care.

Paraoxonase 1 hydrolysis of EPA-derived lactone impairs endothelial-mediated vasodilation.

Human serum paraoxonase-1 (PON1) is a lactonase that plays a significant role in anti-atherosclerotic high-density lipoprotein (HDL) activity. PON1 is also localized in endothelial cell membranes, where it is enzymatically active and regulates endothelial signals. PON1 has a high specificity for lipophilic lactones and has been shown to hydrolyze and regulate lactone lipid mediators derived from arachidonic polyunsaturated fatty acids (PUFA). Previously, we showed that an arachidonic acid lactone metabolite (AA-L) dose-dependently dilates PON1 gene deletion (PON1KO) mouse mesenteric arteries significantly more than wild-type arteries. In contrast, preincubation with HDL or rePON1 reduced AA-L-dependent vasodilation. Recently we showed that an additional δ-lactone metabolite derived from the eicosapentaenoic acid lactone, 5,6-δ-DiHETE lactone (EPA-L) reduced blood pressure by dilating microvessels of hypertensive rats. However, whether PON1 regulates the activity of the EPA-L lipid mediator is unknown. AIM: To demonstrate that PON1 hydrolyzes EPA-L and to reveal the effect of this hydrolysis on endothelial-dependent vascular dilation. METHODS AND RESULTS: In vascular reactivity experiments, EPA-L dose-dependently dilated PON1KO mouse mesenteric arteries significantly more than wild-type mesenteric arteries. This dilation was not affected by nitric oxide inhibition. PON1 impaired the cellular calcium increase mediated by EPA-L in endothelial cells, though this impairment decreased with PON1 internalization to the cell. CONCLUSION: These findings support that PUFA-lactones are physiological substrates of PON1, and that PON1 activity in the endothelial membrane affects the dilation of microvessels that is induced by these endothelial-derived hyperpolarizing PUFA-lactones.

Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity.

Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications. Online supplemental material is available for this article. ©RSNA, 2022.

Fishing for lipid lactones using selective reaction and characteristic fragmentation pattern.

Extensive research has been invested in developing sensitive methods to identify lipid mediators (LMs) from multiple biological matrices. Previous studies point to the existence of a potential family of lactone-containing metabolites generated from eicosanoid families, isoprostanes, and prostanoid-like compounds that may function as LMs. However, targeted lipidomic studies do not routinely include lactone-containing lipids due to their low ionizability and instability under some common sample preparation conditions. Thus, the discovery of lactone-containing LM is limited. Herein we describe a method for selective identification of lipid lactones from within biological matrices. This method is based on a selective reaction of lactones with 1-(3-aminopropyl)imidazole, followed by cation exchange solid phase extraction and the identification of characteristic fragmentation patterns unique to reaction products of lactones in LC/MS/MS. NMR and LC/MS results indicated that saturated and unsaturated aliphatic ɣ and δ lactone model compounds mixed with human serum were successfully detected. MS/MS analyses of the reaction products revealed a unique pattern for the lactones, resulting from common neutral losses and fragmentation. When applied to esters and free fatty acids, some reaction products were observed. However, these reaction products' MS/MS fragmentation did not match the specific fragmentation of the lactones' reaction products. Confirming that lactones can be detected in a highly selective manner from within complex biological matrices when using the presented method. Thus, the presented method can selectively analyze lactones and may further complement existing lipidomic approaches to discover new LMs.

Online Hide and Seek: Allopathic US Medical Schools' Radiology Education Virtual Presence.

RATIONALE AND OBJECTIVES: To highlight radiology's merits and boost appeal to medical students in the digital era, it is increasingly important for radiology departments to be readily accessible to medical students. We report the results of a multivariate analysis of the virtual presence of radiology medical student education of 152 allopathic United States (US) medical schools, the first report of its kind to the authors' knowledge. We detail eight elements to include when optimizing a radiology medical student education website. METHODS: In August 2020, the Department of Radiology websites at 152 allopathic US medical schools were assessed for the presence of a medical student radiology education website and accessibility of collated information about preclinical and clinical course offerings, radiology interest groups, and outreach initiatives in the form of student radiology mentorship, shadowing, and research opportunities. RESULTS: 65.1% (99/152) of allopathic US medical schools' radiology departments have a dedicated medical student radiology education website, one of which was excluded from further review due to password protected content. 58.2% (57/98) of departmental websites include information about preclinical radiology coursework and 90.8% (89/98) of departments provide information about clinical courses. Details about interest groups were found on 26.5% (26/98) of departmental websites. Information about mentorship and shadowing was identified on less than half of departmental websites. 51% (50/98) of Department of Radiology websites provide information about research opportunities for students. CONCLUSIONS: This study demonstrates that the majority of allopathic US medical schools' radiology departments lack full information of relevance to medical students. To engage today's and tomorrow's medical learners digitally, there is opportunity and need to improve the online availability of information about preclinical and clinical radiology courses, student interest groups, shadowing opportunities, student mentorship, and student research. We detail eight elements to include when optimizing a radiology medical student education website. In most instances, this can be accomplished by revising an existing radiology department website in a manner that engages, educates, and recruits medical students. As a specialty, radiology must expand our digital footprint to reach tomorrow's colleagues and leaders.

Radiology Medical Student Education 2020: Surveys of the Alliance of Medical Student Educators in Radiology and Medical Students.

RATIONALE AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant changes to medical student education by disrupting clinical rotations, licensing exams, and residency applications. To evaluate the pandemic's impact and required modifications of radiology medical student courses, the authors developed and administered surveys to Alliance of Medical Student Educators in Radiology (AMSER) faculty and enrolled medical students. The surveys requested feedback and insight about respondents' experiences and innovations. MATERIALS AND METHODS: Anonymous twenty-question and seventeen-question surveys about the pandemic's impact on medical student education were distributed via email to AMSER members and medical students. The surveys consisted of multiple choice, ranking, Likert scale, and open-ended questions. Differences in the Likert score agreement was performed using one-sided Wilcoxon-Mann-Whitney tests. Survey data were collected using SurveyMonkey (San Mateo, California). This study was IRB exempt. RESULTS: The AMSER survey indicated 96% of institutions cancelled medical student courses and 92% resumed with virtual courses, typically general radiology. A total of 64% of faculty enjoyed online teaching, although 82% preferred on-site courses. A total of 62% of students felt an online radiology course was an excellent alternative to an on-site rotation, although 27% disagreed. A total of 69% of students who completed both on-site and online courses preferred the on-site format. Survey-reported innovations and free response comments have been collated as educational resources. CONCLUSION: Faculty were able to adapt radiology courses to the online environment utilizing interactive lectures, self-directed learning, flipped classroom sessions, and virtual readouts, which were effective for student respondents. Hybrid rotations with on-site and online elements may offer the best of both worlds.

A new search pattern for emergency breast exams: the clinical picture.

Distinct breast diseases are readily diagnosed by clinical and ultrasound appearance that radiologists and sonographers may encounter in emergency room and urgent care patient presentations. While it may be impractical or impossible for the on-call emergency radiologist to examine a patient with breast complaints, radiologists can and should adopt the practice pattern to routinely seek out the clinical photographs in the patient's medical record while interpreting breast examinations. Imaging should be interpreted in the context of both the history and the physical findings. Sonographers play important roles in the documentation of visual inspection findings, in addition to performing high quality targeted ultrasound where applicable. This pictorial offers resources to emergency radiologists and sonographers that facilitate rapid accurate diagnosis of ten distinct breast diseases.

The Effect of Virtual Interviews and Social Media on Applicant Decision-Making During The 2020-2021 Resident Match Cycle.

RATIONALE AND OBJECTIVES: The COVID-19 pandemic significantly altered the residency application and interview process. Due to social distancing concerns, residency programs have had to virtually showcase their program to applicants, many utilizing social media. Similarly, applicants have had to devise novel ways of assessing "goodness of fit", one of the top factor's applicants use when ranking programs (1). Whether or not these attempts made an impact on an applicant's decision-making process has yet to be determined. MATERIALS AND METHODS: Residency candidates interviewing for a diagnostic and/or interventional radiology residency position at our institution completed an online survey. The goal of the survey was to assess the potential influence of virtual interviews, social media, and virtual events on an applicant's decision to apply to, interview at, and rank residency programs. RESULTS: 78/156 (50%) candidates completed the survey. Thirty-five percent reported applying to more programs and 58% reported accepting more interviews than they would have if interviews were not virtual. Forty-two percent reported that social media played a vital role during the application season and 71% reported using social media to learn more about the program. Sixty-nine percent attended a virtual open house, 57% of whom reported that attending the open house influenced their decision to apply to a program. Sixty-three percent reported that attending a virtual reception influenced a program's ranking. CONCLUSION: Social media has had a growing role in the medical community, and the COVID-19 pandemic likely accelerated an inevitable shift in residency program "branding" and how applicants perceive overall "goodness of fit".

Postoperative Computed Tomography for Facial Fractures.

In order for a radiologist to create reports that are meaningful to facial reconstructive surgeons, an understanding of the principles that guide surgical management and the hardware employed is imperative. This article is intended to promote efficient and salient reporting by illustrating surgical approaches and rationale. Hardware selection can be inferred and a defined set of potential complications anticipated when assessing the adequacy of surgical reconstruction on postoperative computed tomography for midface, internal orbital, and mandible fractures.

You'll see it when you know it: granulomatous mastitis.

Granulomatous mastitis (GM) is an under-recognized and under-diagnosed disease. Patients with GM often present to the emergency room with a painful breast mass, nipple retraction, and skin changes. This pictorial essay will review the clinical presentation and imaging appearance of GM, BI-RADS reporting parameters, differential diagnoses, and diagnostic challenges posed by this disease. Early and accurate diagnosis is essential, as misdiagnosis can result in repeated core biopsies, leading to fistulae and sinus tract formation. A classic history and typical sonographic appearance allow the emergency radiologist to confidently make this diagnosis.

Evolution of the Interventional Radiology (IR) Pathway-Various Changes and Interrelation to Diagnostic Radiology (DR).

Interventional radiology continues to evolve into a more robust and clinically dynamic specialty underpinned by significant advancements in training, education, and practice. This article, prepared by members of the 2020-2021 Association of University Radiologists' task force of the Radiology Research Alliance, will review these developments, highlighting the evolution of interventional radiology pathways with attention to growing educational differences, interrelation to diagnostic radiology training, post-training practice patterns, distribution of procedures and future trends, amongst other key features important to those pursuing a career in interventional radiology as well as those in practice.

A virtual emergency: learning lessons from remote medical student education during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic resulted in the cancelation of traditional on-site clinical rotations for medical students across the country. Radiology educators have had to rapidly adapt to a new, virtual educational landscape. We describe our experience restructuring a Trauma and Emergency Radiology Elective to an online format and present survey data obtained from students who completed the course. METHODS: This elective is a 4-week course offered to third and fourth year medical students at a large Level 1 Trauma Center. Changes to the traditional rotation included assigning an increased number of self-study educational resources, independent review of unknown cases using a virtual workstation, and online interactive conferences. At the conclusion of each block, students were asked to complete post-course feedback surveys. RESULTS: Thirteen students enrolled in this online course; 92% submitted post-course surveys. Students strongly agreed that the course was clinically relevant, with accessible, engaging material (average score, 4.92/5), and 91.7% of students were very likely to recommend this rotation to others. Students reported improved post-course confidence in ordering and interpreting imaging studies. A majority (60%) of students who had previously taken an on-site course would have preferred a course that combined traditional and online learning elements. CONCLUSIONS: The success of our online rotation highlights the merits of self-directed learning and flipped-classroom techniques. Many of the principles incorporated into this course could be applied and/or modified to increase medical student engagement when students return to the hospital.

Training Radiology Residents, Bloom Style.

Bloom's Taxonomy, an integral component of learning theory since its inception, describes cognitive skill levels in increasing complexity (Remember, Understand, Apply, Analyze, Evaluate, and Create). Considering Bloom's Taxonomy when writing learning objectives and lecture material, teaching residents at the workstation and creating multiple choice questions can increase an educator's effectiveness. The incorporation of higher Bloom levels aids in cultivating critical thinking skills vital to image interpretation and patient care, and becomes increasingly important as the radiologist's role evolves with the continued development of artificial intelligence. Following established tenets of multiple choice question writing, involving trainees in the question writing process, and incorporating audience response systems into lectures are all strategies in which higher Bloom level skills can be accomplished.

Auditing RadExam: Employing Psychometrics to Improve Exam Quality.

INTRODUCTION: RadExam is a question item and exam database jointly developed by the Association of Program Directors in Radiology and the American College of Radiology to provide formative resident assessment, offering performance metrics benchmarked against institutional and national resident performance. Beyond resident performance, data is available on question and exam performance. Despite considerable investment in the education and training of its question writers and editors and meticulous attention to current psychometrically validated methods, it was anticipated a minority of exam questions would still perform poorly. Audits were performed to identify these questions, identify reasons for poor performance, and modify or replace so-affected questions. Exam performance was also assessed. METHODS: Two audits were performed, the first after the February-May 2018 RadExam pilot phase, and the second nearly 1 year after the full implementation of RadExam. In each audit, RadExam subspecialty editors evaluated all exam questions and exams using statistical data: question and test number of administrations, question p value, question Discrimination Index (DI), question Bloom's taxonomy learning level, exam P-value, and the number of image-based questions in each exam. Identified questions were modified or removed and replaced. RESULTS: Audit 1 was performed after the administration of 3114 exams comprised of 2520 questions administered across 100 residency programs. Audit 1 identified 617 questions with DI <0.1 and 565 questions with unacceptable P-values, all of which were modified or replaced. Audit 2 was performed after the administration of 16,416 exams, comprised of 2,507 questions. Audit 2 identified 229 questions with DI <0.1 and 290 questions with unacceptable P-values, representing a 49.1% decrease in total flagged questions compared to Audit 1. Statistically significant decreases were seen in questions with both DI and P-values outside of the desired range across nearly all subspecialties. CONCLUSION: The positive impact of our audit system on question and exam performance was reflected in a significant decrease in the number of questions flagged and improved overall exam performance in Audit 2. This illustrates the positive impact of Audit 1.