Introducing Summative Progress Testing in Radiology Residency: Little Change in Residents' Test Results After Transitioning from Formative Progress Testing.

INTRODUCTION: Educational effects of transitioning from formative to summative progress testing are unclear. Our purpose was to investigate whether such transitioning in radiology residency is associated with a change in progress test results. METHODS: We investigated a national cohort of radiology residents (N > 300) who were semi-annually assessed through a mandatory progress test. Until 2014, this test was purely formative for all residents, but in 2014/2015, it was transitioned (as part of a national radiology residency program revision) to include a summative pass requirement for new residents. In 7 posttransitioning tests in 2015-2019, including summatively and formatively tested residents who followed the revised and pre-transitioning residency program, respectively, we assessed residents' relative test scores and percentage of residents that reached pass standards. RESULTS: Due to our educational setting, most posttransitioning tests had no residents in the summative condition in postgraduate year 4-5, nor residents in the formative condition in year 0.5-2. Across the 7 tests, relative test scores in postgraduate year 1-3 of the summative resident group and year 3.5-4.5 of the formative group differed significantly (p < 0.01 and p < 0.05, respectively, Kruskal-Wallis test). However, scores fluctuated without consistent time trends and without consistent differences between both resident groups. Percentage of residents reaching the pass standard did not differ significantly across tests or between groups. DISCUSSION: Transitioning from formative to summative progress testing was associated with overall steady test results of the whole resident group in 4 post-transitioning years. We do not exclude that transitioning may have positive educational effects for resident subgroups.

Three-dimensional ultrasonography of the breast; An adequate replacement for MRI in neoadjuvant chemotherapy tumour response evaluation? - RESPONDER trial.

BACKGROUND: Accurate measurement of tumour response during and after neoadjuvant chemotherapy (NAC) is important and may influence treatment decisions in invasive breast cancer patients. Breast MRI forms the gold standard but is more burdensome, time consuming and costly. In this study response measurement was done with 3-D ultrasound by Automated Breast Volume Scanner (ABVS) and compared to breast MRI. Moreover, patient satisfaction with both techniques was compared. METHODS AND MATERIALS: A single-institution, prospective observational pilot study evaluating tumour response by ABVS in addition to breast MRI (standard care) was performed in 25 invasive breast cancer patients receiving NAC. Tumour response was evaluated comparing longest tumour diameters as well as tumour volumes at predefined time points using Bland-Altman analysis. Volume measurements for breast MRI were obtained using a fully immersive virtual reality system (a Barco I-Space) and V-Scope software. Same software was used to obtain ABVS volume measurements using an in-house developed desktop VR system. Inter- and intra-observer agreement was evaluated by Intraclass Correlation Coefficient (ICC). RESULTS: Twenty-five patients were eligible for baseline measurement, 20 for a mid-NAC response evaluation, and five for a post-NAC response evaluation. MRI and ABVS showed absolute concordance in 73% of patients for the mid-NAC evaluation, with a 'good' correlation for the difference in longest diameter measurement (ICC 0.73, p < 0.01) as compared to baseline assessment. Concerning difference in volume measurement in the mid-NAC response evaluation showed a 'fair' correlation (ICC 0.52, p < 0.01) and in the post-NAC response evaluation an 'excellent' correlation (ICC 0.98, p < 0.01). 'Excellent' inter- and intra-observer agreement was found (ICC 0.88, p < 0.01) with comparable limits of agreement (LOA) for observer 1 and 2 in both diameter and volume measurement. Patient satisfaction was higher for ABVS compared to breast MRI, 93% versus 12% respectively. CONCLUSION: ABVS showed 'good' correlation with MRI tumour response evaluation in breast cancer patients during NAC with 'excellent' inter- and intra-observer agreement. ABVS has patients' preference over breast MRI and could be considered as alternative to breast MRI, in case results on an on-going prospective trial confirm these results (NTR6799).

Breast and Tumour Volume Measurements in Breast Cancer Patients Using 3-D Automated Breast Volume Scanner Images.

BACKGROUND: The resection volume in relation to the breast volume is known to influence cosmetic outcome following breast-conserving therapy. It was hypothesised that three-dimensional ultrasonography (3-D US) could be used to preoperatively assess breast and tumour volume and show high association with histopathological measurements. METHODS: Breast volume by the 3D-US was compared to the water displacement method (WDM), mastectomy specimen weight, 3-D MRI and three different calculations for breast volume on mammography. Tumour volume by the 3-D US was compared to the histopathological tumour volume and 3-D MRI. Relatedness was based on the intraclass correlation coefficient (ICC) with corresponding 95% confidence interval (95% CI). Bland-Altman plots were used to graphically display the agreement for the different assessment techniques. All measurements were performed by one observer. RESULTS: A total of 36 patients were included, 20 and 23 for the evaluation of breast and tumour volume (ductal invasive carcinomas), respectively. 3-D US breast volume showed 'excellent' association with WDM, ICC 0.92 [95% CI (0.80-0.97)]. 3-D US tumour volume showed a 'excellent' association with histopathological tumour volume, ICC 0.78 [95% CI (0.55-0.91)]. Bland-Altman plots showed an increased overestimation in lager tumour volumes measured by 3-D MRI compared to histopathological volume. CONCLUSIONS: 3-D US showed a high association with gold standard WDM for the preoperative assessment of breast volume and the histopathological measurement of tumour volume. 3-D US is an patient-friendly preoperative available technique to calculate both breast volume and tumour volume. Volume measurements are promising in outcome prediction of intended breast-conserving treatment.

Resident and Faculty Attitudes Toward the Dutch Radiology Progress Test as It Transitions from a Formative to a Summative Measure of Licensure Eligibility.

BACKGROUND: Progress testing, a regularly administered comprehensive test of a complete knowledge domain, usually serves to provide learners feedback and has a formative nature. OBJECTIVE: Our study aimed to investigate the acceptability of introducing a summative component in the postgraduate Dutch Radiology Progress Test (DRPT) among residents and program directors in a competency-based training program. METHODS: A 15-item questionnaire with 3 items on acceptability of summative postgraduate knowledge testing, 7 on acceptability of the summative DRPT regulations, 4 on self-reported educational effects, and 1 open comment item was distributed nationally among 349 residents and 81 radiology program directors. RESULTS: The questionnaire was filled out by 330 residents (95%) and 48 (59%) program directors. Summative postgraduate knowledge testing was regarded as acceptable by both groups, but more so by program directors than residents. The transition toward summative assessment in the DRPT was received neutrally to slightly positively by residents, while program directors regarded it as an improvement and estimated the summative criteria to be lighter and less stressful than did residents. The residents' self-reported educational effects of summative assessment in the DRPT were limited, whereas program directors expected a greater end-of-training knowledge improvement than residents. CONCLUSIONS: Both residents and program directors support summative postgraduate knowledge testing, although it is more accepted by program directors. Residents receive summative radiological progress testing neutrally to slightly positively, while program directors generally value it more positively than residents. Directors should be aware of these different perspectives when introducing or developing summative progress testing in residency programs.

Fourteen years of progress testing in radiology residency training: experiences from The Netherlands.

OBJECTIVES: To describe the development of the Dutch Radiology Progress Test (DRPT) for knowledge testing in radiology residency training in The Netherlands from its start in 2003 up to 2016. METHODS: We reviewed all DRPTs conducted since 2003. We assessed key changes and events in the test throughout the years, as well as resident participation and dispensation for the DRPT, test reliability and discriminative power of test items. RESULTS: The DRPT has been conducted semi-annually since 2003, except for 2015 when one digital DRPT failed. Key changes in these years were improvements in test analysis and feedback, test digitalization (2013) and inclusion of test items on nuclear medicine (2016). From 2003 to 2016, resident dispensation rates increased (Pearson's correlation coefficient 0.74, P-value <0.01) to maximally 16 %. Cronbach´s alpha for test reliability varied between 0.83 and 0.93. The percentage of DRPT test items with negative item-rest-correlations, indicating relatively poor discriminative power, varied between 4 % and 11 %. CONCLUSIONS: Progress testing has proven feasible and sustainable in Dutch radiology residency training, keeping up with innovations in the radiological profession. Test reliability and discriminative power of test items have remained fair over the years, while resident dispensation rates have increased. KEY POINTS: • Progress testing allows for monitoring knowledge development from novice to senior trainee. • In postgraduate medical training, progress testing is used infrequently. • Progress testing is feasible and sustainable in radiology residency training.

TUmor-volume to breast-volume RAtio for improving COSmetic results in breast cancer patients (TURACOS); a randomized controlled trial.

BACKGROUND: Cosmetic result following breast conserving surgery (BCS) for cancer influences quality of life and psychosocial functioning in breast cancer patients. A preoperative prediction of expected cosmetic result following BCS is not (yet) standard clinical practice and therefore the choice for either mastectomy or BCS is still subjective. Recently, we showed that tumour volume to breast volume ratio as well as tumour location in the breast are independent predictors of superior cosmetic result following BCS. Implementation of a prediction model including both factors, has not been studied in a prospective manner. This study aims to improve cosmetic outcome by implementation of a prediction model in the treatment decision making for breast cancer patients opting for BCS. METHODS/DESIGN: Multicentre, single-blinded, randomized controlled trial comparing standard preoperative work-up to a preoperative work-up with addition of the prediction model. Tumour volume to breast volume ratio and tumour location in the breast will be used to predict cosmetic outcome in invasive breast cancer patients opting for BCS. Three dimensional (3D)-ultrasonography will be used to measure the tumour volume to breast volume ratio needed for the prediction model. Sample size was estimated based on a 14% improvement in incidence of superior cosmetic result one year after BCS (71% in the control group versus 85% in the intervention group). Primarily cosmetic outcome will be evaluated by a 6-member independent panel. Secondary endpoints include; (1) patient reported outcome measured by BREAST-Q, EORTC-QLQ-C30/BR23 and EQ-5D-5 L (2) cosmetic outcome as assessed through the BCCT.core software, (3) radiation-induced reaction (4) surgical treatment performed, (5) pathological result and (6) cost-effectiveness. Follow-up data will be collected for 3 years after surgery or finishing radiotherapy. DISCUSSION: This randomized controlled trial examines the value of a preoperative prediction model for the treatment-decision making. It aims for a superior cosmetic result in breast cancer patients opting for BCS. We expect improvement of patients' quality of life and psychosocial functioning in a cost-effective way. TRIAL REGISTRATION: Prospectively registered, February 17th 2015, at 'Nederlands Trialregister - NTR4997 '.

Surgical validation of unenhanced helical computed tomography in acute appendicitis.

BACKGROUND: Surgery for pain in the right lower quadrant of the abdomen remains a clinical dilemma. This prospective study assessed the accuracy of preoperative unenhanced helical computed tomography (CT) in the evaluation of patients with suspected acute appendicitis. METHODS: One hundred and three adult patients with suspected acute appendicitis underwent unenhanced helical CT of the abdomen. Subsequently, all patients underwent laparoscopic inspection of the abdominal cavity by a surgeon who was blinded to the diagnosis suggested by CT. Patients underwent appropriate surgical therapy accordingly. Follow-up was at least 6 weeks. RESULTS: Appendicitis was diagnosed by CT in 83 patients (80.6 per cent). Acute appendicitis was identified during laparoscopy in 87 patients (84.5 per cent). Prospective interpretation of CT images yielded a sensitivity of 95.4 per cent and a specificity of 100 per cent for the diagnosis of acute appendicitis. There were four false-negative scans. In 12 of 20 patients without signs of appendicitis on CT, the scan established the presence of other pathology. At operation no additional pathology was observed in this group and all other diagnoses proved to be correct. CONCLUSION: Plain helical CT in patients with suspected acute appendicitis provides an accurate diagnosis without the disadvantages of contrast enhancement.

Plaque area increase and vascular remodeling contribute to lumen area change after percutaneous transluminal angioplasty of the femoropopliteal artery: an intravascular ultrasound study.

OBJECTIVE: The aim of the study was to assess the change in lumen area (LA), plaque area (PLA), and vessel area (VA) after percutaneous transluminal angioplasty (PTA) of the femoropopliteal artery. METHODS: This was a prospective study. Twenty patients were studied with intravascular ultrasound (IVUS) immediately after PTA and at follow-up examination. Multiple corresponding IVUS cross-sections were analyzed at the segments that were dilated by PTA (ie, treated sites; n = 168), including the most stenotic site (n = 20) and the nondilated segments (ie, reference sites; n = 77). RESULTS: At follow-up examination, both the PLA increase (13%) and the VA decrease (9%) resulted in a significant LA decrease (43%) at the most stenotic sites (P =.001). At the treated sites, the LA decrease (15%) was smaller and was caused by the PLA increase (15%). At the reference sites, the PLA increase (15%) and the VA increase (6%) resulted in a slight LA decrease (3%). An analysis of the IVUS cross-sections that were grouped according to LA change (difference >/=10%) revealed a similar PLA increase in all the groups: the type of vascular remodeling (VA decrease, no change, or increase) determined the LA change. At the treated sites, the LA change and the VA change correlated closely (r = 0.77, P <.001). At the treated sites, significantly more PLA increase was seen in the IVUS cross-sections that showed hard lesion or media rupture (P <.05). No relationship was found between the presence of dissection and the quantitative changes. CONCLUSION: At the most stenotic sites, lumen narrowing was caused by plaque increase and vessel shrinkage. Both the treated sites and the reference sites showed a significant PLA increase: the type of vascular remodeling determined the LA change at follow-up examination. The extent of the PLA increase was significantly larger in the IVUS cross-sections that showed hard lesion or media rupture.

Intravascular ultrasound and histology in in vitro assessment of iliac artery angioplasty.

PURPOSE: Intravascular ultrasound (IVUS) was used to assess in vitro the morphologic and quantitative effects of balloon angioplasty (PTA) of the iliac artery. METHODS: Forty human iliac arteries (>/= 30% area stenosis) were studied with IVUS in vitro before and after PTA and the findings were validated with histology. RESULTS: The sensitivity of IVUS for dissection was 74% and for media rupture 59%. The incidence of vascular damage was higher when the whole segment was analyzed rather than the target site alone. Dissections occurred at the thinnest region of the plaque, unrelated to plaque calcification. Following PTA, quantitative changes at the target site were greater compared with the overall data derived from all cross-sections. The increase in lumen area was caused solely by an increase in vessel area. CONCLUSIONS: IVUS is sensitive in detecting dissections, which occurred irrespective of calcification at the thinnest region of the plaque. The increase in lumen area after PTA was caused by stretching of the vessel.

Response of renal and femoropopliteal arteries to Palmaz stent implantation assessed with intravascular ultrasound.

PURPOSE: To establish the processes responsible for late lumen loss in renal and femoropopliteal Palmaz stents using intravascular ultrasound (IVUS). METHODS: The first 7 consecutive patients treated with stents for renal (n = 4) and femoropopliteal (n = 3) arterial occlusive disease were studied with IVUS immediately after angiographically successful stent placement (< 10% residual stenosis) and periodically during follow-up. Images of both stent edges and the most stenotic site inside the stent at followup were matched to the same cross sections captured immediately after stent placement for quantitative analysis. RESULTS: Late lumen loss in renal artery stents at 5 to 34 months was considerably less than in femoropopliteal stents (17% versus 62%, respectively). In the renal location, late lumen loss (3.0 +/- 1.3 mm2) was due to neointimal hyperplasia, whereas stent area remained unchanged (3% decrease). Late lumen loss (7.4 +/- 8.2 mm2) in femoropopliteal stents was due to neointimal hyperplasia and stent area reduction (26%). Overall, in both types of arteries, neointimal development and stent area reduction were larger at the most stenotic site than at the stent edges. CONCLUSIONS: These data suggest that there may be differences between renal and femoropopliteal arteries in the extent of hyperplastic response to stents.

Comparison of angiography and intravascular ultrasound before and after balloon angioplasty of the femoropopliteal artery.

PURPOSE: To compare angiographic and intravascular ultrasound (IVUS) data before and after balloon angioplasty (PTA) of the femoropopliteal artery. METHODS: Qualitative and quantitative analyses were performed on corresponding angiographic and IVUS levels obtained from 135 patients. RESULTS: IVUS detected more lesions, calcified lesions, and vascular damage than angiography. Sensitivity of angiography was good for the presence of a lesion (84%), moderate for eccentric lesions (53%) and for vascular damage (52%), and poor for calcified lesions (30%). The increase in angiographic diameter stenosis was associated with a decrease in lumen area and increase in percentage area stenosis on IVUS. CONCLUSIONS: Angiography is less sensitive than IVUS for detecting lesion eccentricity, calcified lesions, and vascular damage. Presence of a lesion and amount of plaque were underestimated angiographically. Only before PTA was good agreement found between angiographic diameter stenosis and lumen size on IVUS.

Discrepancy between stent deployment and balloon size used assessed by intravascular ultrasound.

OBJECTIVES: This study was designed to assess the discrepancy in stent deployment seen on intravascular ultrasound and its relation to the balloon size selected for stent delivery. DESIGN: Prospective study. MATERIALS AND METHODS: The study group comprised 27 patients treated using a stent (n = 18) or stent-graft combination (n = 9). Following angiographically optimal stent deployment (< 10% residual stenosis) intravascular ultrasound was used to compare the smallest intra-stent lumen area with measurements at both stent edges and the lumen area of the proximal and distal reference sites. RESULTS: In 14 of the 27 stents the intra-stent dimension was the same as the dimension of the stent edge (difference < or = +/- 10%). Of the remaining stents the intra-stent dimension was smaller (difference > 10%) than the proximal stent edge in seven stents (range 11-39%), smaller than the distal stent edge in three stents (range 11-20%) and smaller than both stent edges in three stents (range 12-37%). Both in patients treated with a stent or stent-graft combination, the resulting smallest intra-stent lumen area was smaller than the balloon size used (mean difference 32% and 42%, respectively) and smaller than the mean lumen area of the reference sites (mean difference 25% and 23%, respectively). CONCLUSION: This intravascular ultrasound study shows a discrepancy between intra-stent lumen area, the area of the stent edges and the balloon size used.

Stent remodeling contributes to femoropopliteal artery restenosis: an intravascular ultrasound study.

This case report describes the status of femoropopliteal artery stents after intervention documented with intravascular ultrasound compared with the changes seen at follow-up. To treat an extensive dissection after balloon angioplasty, a 57-year-old man underwent placement of seven adjacent Palmaz stents. At 5-month follow-up, an angiographic and intravascular ultrasound examination revealed four distinct stenotic lesions (> or = 50%) at stent junctions. Intravascular ultrasound images obtained during the initial stent placement were compared with the corresponding images obtained at follow-up. A distinction was made between changes seen at stent junctions and stent edges (n = 8), those seen within each stent (n = 7), and those in the nonstented sections proximally and distally (n = 3). Intravascular ultrasound examination established that both intimal hyperplasia and stent area reduction (stent remodeling) resulted in lumen area reduction. The extent of the changes seen at the stent junctions were greater than that of changes seen within the stents: lumen area reduction, 67% versus 23%; stent area reduction, 26% versus 11%; and intimal hyperplasia, 10.8 versus 3.3 mm2; respectively. Changes in the nonstented sections were minimal (< 2%). The stent edge seen at the adductor canal showed elliptical deformation. Thus there is a higher risk of restenosis at the stent junctions. In addition to intimal hyperplasia, stent remodeling contributes to restenosis.

Remodeling of atherosclerotic coronary arteries assessed with intravascular ultrasound in vitro.

This study investigated remodeling in human coronary arteries with intravascular ultrasound. We conclude that regression analysis performed by Glagov et al and adopted by others is reproducible but is unable to discern shrinkage of the vessel area.

Intravascular sonographic evaluation of iliac artery angioplasty: what is the mechanism of angioplasty and can intravascular sonography predict clinical outcome?

OBJECTIVE: The purpose of this study was to establish the arterial responses of the iliac artery after percutaneous transluminal angioplasty (PTA), using intravascular sonography, and to correlate intravascular sonography parameters with clinical outcome. SUBJECTS AND METHODS: The study included 21 patients studied with intravascular sonography before and after PTA of the iliac artery. Distinction was made between intravascular sonography cross sections collected from the common iliac and those from the external iliac artery. First, qualitative and quantitative intravascular sonography data obtained at the most stenotic site were compared with data derived from all corresponding cross sections of the dilated segment. Second, the predictive value of intravascular sonography parameters for the patient outcome was assessed. RESULTS: The free lumen and media-bounded areas seen in the common iliac artery were larger than those seen in the external iliac artery. Qualitative and quantitative effects of PTA observed with intravascular sonography on the two types of artery were not different. Vascular damage occurred in 81% of the patients. The frequency of vascular damage at the most stenotic site was slightly lower than in each dilated segment studied. The reduction in area stenosis after intervention was associated with an increase in the free lumen and media-bounded areas, whereas the plaque area reduced only slightly. The increase in the free lumen and media-bounded areas and the decrease in the plaque area at the most stenotic site after intervention were larger than the mean values. Qualitative data seen with intravascular sonography at the most stenotic site before and after intervention were not predictive of the patient outcome. In patients with an uneventful outcome after intervention, the free lumen area measured at the most stenotic site after PTA was larger and the area stenosis was smaller than in patients with a failure. CONCLUSION: This study of intravascular sonography established that although the common iliac artery is larger than the external iliac artery, the qualitative and quantitative effects of PTA in both types of artery were similar. The size of the free lumen area and the degree of stenosis seen with intravascular sonography after PTA at the most stenotic site may be predictive of a patient outcome.