A 15-Year Analysis of International Medical Graduates Matching Into Diagnostic Radiology Residency Programs in the United States

RATIONALE AND OBJECTIVES

To analyze the trends in international medical graduates (IMGs) matching into diagnostic radiology residency programs in the United States (US).

MATERIALS AND METHODS

The National Resident Match Program data was accessed for years 2005-2020 and diagnostic radiology residency-specific data was extracted for US MD, osteopathic (DO), and IMG applicants. IMGs were categorized into US-citizen IMGs and non-US citizen IMGs per the National Residency Match Program. Variables collected for each year included the number of positions, number of applicants in each group, positions filled/unfilled, and fill rate of each group. Additional data for some years included USMLE Step 1 score, United States Medical Licensing Examination (USMLE) Step 2 clinical knowledge (CK) score, number of research experiences, number of abstracts/publications, and additional degrees obtained. Trends were analyzed using simple linear regression model and p value <0.05 was considered significant.

RESULTS

The number of diagnostic radiology residency programs increased from 203 (2006) to 212 (2020). The total number of diagnostic radiology residency positions increased from 1011 (2006) to 1113 (2020), with the peak of 1145 in 2014. The overall "match rate," that is, proportion of positions filled to positions available, increased from 96.4% (2006) to 97.3% (2020), with a brief decline to 86.7% in 2015. Among the filled positions, the proportion filled by US medical school graduates significantly declined from 89.7% (2006) to 69.2% (2020) (p < 0.001), and the proportion of positions filled by osteopathic seniors and graduates significantly increased from 2.2% (2006) to 15.1% (2020; p < 0.001). The proportion of US IMGs increased from 3.2% (2006) to 5.4% (2020), while the proportion of non-US IMGs increased from 4.4% (2006) to 9.4% (2020), with overall IMG match rate increased significantly from 7.6% to 14.9% (p = 0.009). The mean Step 1 scores of US IMGs and non-US IMGs were 238 and 237.3, and the mean Step 2 CK scores were 241.67 and 241, respectively. Cumulatively over the study period, a total of 736 US IMGs and 1051 non-US IMGs have matched into diagnostic radiology residency.

CONCLUSION

There is an increasing proportion of IMGs, especially the non-US citizen IMGs, matching into US radiology residency programs in the last decade. Diagnostic radiology remains a competitive specialty evidenced by average USMLE scores higher than national average and research experiences of matched candidates.

A Late Presentation of COVID-19 Vaccine-Induced Myocarditis

With the introduction of the coronavirus disease 2019 (COVID-19) mRNA vaccines, the incidence of severe infection has significantly decreased. While the vaccines have been shown to be effective and safe, there have been few case reports of acute myocarditis within 3-5 days following the second dose of the vaccine. We report a case of an elderly man who presented with acute-onset chest pain after three months of receiving the second dose of the mRNA vaccine. He was found to have acute myocarditis on cardiac magnetic resonance imaging (CMRI), which was attributed to exposure to the COVID-19 vaccine in the absence of any other risk factors. Our patient demonstrated quick resolution of symptoms and was discharged within 72 hours. We review the literature and summarize published case reports on COVID-19 vaccine-associated myocarditis. The present case report provides new evidence regarding the possible subacute presentation of myocarditis post-COVID-19 vaccine, and further highlights the favorable outcome in this newly described clinical entity.

Coronary-Cameral Fistula, Thebesian Veins, and Anomalous Coronary Vein on Cardiac Computed Tomography

A 63-year-old female with a history of hypertension presented with progressively worsening shortness of breath. She underwent a cardiac catheterization and was found to have prominent Thebesian veins as well as anomalous connections between the proximal right coronary artery and the right ventricle. Cardiac computed tomography was ordered for further evaluation and showed a coronary fistula to the right ventricular outflow tract confirming the diagnosis of a coronary-cameral fistula (CCF). CCF are rare congenital anomalous communications that occur between coronary arteries and a cardiac chamber. They are usually an incidental finding and patients are rarely symptomatic. As the use of coronary computed tomography angiography is rapidly expanding, the detection of CCF will likely increase in the general population.

Imaging After Locoregional Therapy for Hepatocellular Carcinoma With Emphasis on LIRADS Treatment Response Assessment Criteria

The Liver Imaging Reporting and Data System (LI-RADS) is a set of algorithms designed to provide a standardized, comprehensive framework for the interpretation of surveillance and diagnostic imaging in patients at high risk for hepatocellular carcinoma. LI-RADS is the result of a multidisciplinary collaboration between radiologists, hepatologists, hepatobiliary surgeons and pathologists and has recently been incorporated into the practice guidelines for the American Association for the Study of Liver Diseases (AASLD) and made congruent with the Organ Procurement and Transplantation Network (OPTN) criteria. This manuscript illustrates the common ultrasound, computed tomography, and magnetic resonance imaging appearances of hepatocellular carcinoma and describes how these findings can be properly categorized using the LI-RADS system.

Imaging After Locoregional Therapy for Hepatocellular Carcinoma with Emphasis on LIRADS Treatment Response Assessment Criteria

Radiologists play an essential role in assessing hepatocellular carcinoma treatment response and help guide further clinical management of patients. Interpretation of treatment response after locoregional therapy is challenging. The post-treatment imaging findings vary and depend on the type of treatment, the degree of treatment response, time interval after treatment and several other factors. Given the widespread use of local-regional therapies, understanding the appearance of treated lesions has become crucial to allow for a more accurate interpretation of post-treatment imaging. Several response criteria including the recently introduced Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) are currently used to assess treatment response. This review article describes the imaging assessment of HCC treatment response after several locoregional therapies using various response assessment criteria, emphasizing the LI-RADS treatment algorithm.

Meshy business: MRI and ultrasound evaluation of pelvic floor mesh and slings

Pelvic floor disorders are a complex set of conditions including but not limited to stress urinary incontinence and pelvic organ prolapse that generally affect older and multiparous women. Of the several surgical options available for treatment of these conditions, synthetic mid-urethral slings for stress urinary incontinence and vaginal mesh for pelvic organ prolapse are amenable to imaging evaluation by ultrasound and magnetic resonance imaging techniques. Ultrasound can evaluate the sub- and immediate peri-urethral portions of sling due to its ability to differentiate synthetic material from native tissues with real-time imaging, while MRI is able to better depict the global pelvic floor anatomy and assess the more distant components of mesh and slings material. Given the high prevalence of pelvic floor disorders and complications after surgical repair, it is important that radiologists familiarize themselves with normal and abnormal imaging findings after these procedures. This article provides a review of the spectrum of imaging findings in patients after pelvic floor repair with synthetic mid-urethral slings and vaginal mesh.

Diagnostic Radiology Residency Program Director Workforce in the United States: A Descriptive Analysis

PURPOSE

To investigate and describe the demographics, academic background, and scholarly activity of Diagnostic Radiology (DR) residency program directors in the United States.

METHODS

A list of all DR residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and corresponding program directors (PD) was obtained from ACGME website. Information about each PD was obtained from publicly available sources including program websites, Healthgrades and Doximity. Demographic and academic data including age, sex, educational background, subspecialty, tenure, interval between residency completion and appointment as PD, terms served, additional degrees, academic rank, prior leadership positions and metrics of scholarly activity were recorded. Nonparametric statistics including Mann-Whitney U and Kruskal-Wallis tests were applied to compare differences between groups. Results are considered statistically significant at p < 0.05.

RESULTS

A total of 197 PDs were included in the study of which 139 (70.6%) were male. Average age of PDs was 47.56 years (SD 8.29, median 45, range 35-77). There was no significant difference in median age of male vs female PDs (45 vs 44.5, p = 0.655). Majority of PDs attended American medical schools (181/197, 91.9%), and 16/197 attended international medical schools. Nine PDs received DO degrees (9/197, 4.6%). Academic rank was available for 137 PDs, of which 4 (2.9%) were instructors, 63 (46.0%) were assistant professors, 47 (34.3%) were associate professors and 23 (16.8%) were professors. Fellowship information was available for 183 PDs, of which the most common subspecialties were neuroradiology (24.5%), musculoskeletal radiology (15.8%), abdominal radiology (10.3%), and interventional radiology (9.8%). Female PDs had a significantly higher median publications (13.5 vs 6.0, p = 0.003), median citations (133 vs 37, p = 0.19) and median h-index compared to male PDs (6 ± 3, p = 0.005).

CONCLUSION

Radiology PDs are mostly males who graduated from US allopathic medical schools. Female PDs had significantly higher scholarly metrics compared to male PDs. Twenty three percent PDs were appointed in the last 1 year.

Variability in utilization and techniques of pelvic floor imaging: findings of the SAR pelvic floor dysfunction disease-focused panel

Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.

Pelvic floor imaging with MR defecography: correlation with gynecologic pelvic organ prolapse quantification

PURPOSE

Pelvic organ prolapse (POP) is assessed differently by gynecologists and radiologists. It is clinically staged by physical examination using the POP-Q (Pelvic Organ Prolapse Quantification) system and radiologically staged by modalities such as by Magnetic Resonance Defecography (MRD). The purpose of this study was to correlate the two methods of staging pelvic organ prolapse for each pelvic compartment by comparing correlative anatomic points and differences in technique. This understanding will help synthesize information from two different perspectives and bridge the gap between multiple specialists who participate in the care of patients with complex pelvic floor disorders.

METHODS

A retrospective single institution study comparison of patients who underwent both dynamic magnetic resonance pelvic floor imaging and pelvic organ prolapse quantification (POP-Q) at our medical center was done. Two urogynecologists performed the POP-Q and one fellowship-trained radiologist interpreted the MRD and both staged pelvic organ prolapse independently.

RESULTS

A total of 280 patients underwent magnetic resonance imaging (MRI) of the pelvic floor from 1/2013 to 12/2017, of whom 68 met our inclusion criteria. When compared to POP-Q, MRI has strong, moderate, and weak correlation for quantification of anterior, middle, and posterior compartment prolapse, respectively. POP-Q measurements Aa, Ba, C, and D are analogous to true pelvic anatomical landmarks which are directly and consistently measurable by MRI, hence accounting for the better correlation in anterior and middle compartments when compared to measurements Ap and Bp which do not correlate with true anatomical landmarks, and hence can explain the weak correlation for posterior compartment prolapse.

CONCLUSION

When comparing POP-Q to MRI, anterior and middle compartment prolapse have better correlation than posterior compartment prolapse. Inherent differences that exist in technique and anatomic landmarks used for staging pelvic organ prolapse by clinical exam and imaging criteria account for this. MRD, however, still provides anatomic details on static images, real time simultaneous overview of multi-compartmental prolapse, characterizes contents of cul-de-sac hernias and rectal evacuation on dynamic imaging. Corroborative information derived from both methods of staging organ will result in optimum patient care.

MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging

PURPOSE

To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR).

METHODS

An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus.

RESULTS

The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%.

CONCLUSION

We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.

Revisiting the Spleen—An Imaging Review of the Common and Uncommon Splenic Pathology

The spleen is the largest lymphatic organ and is responsible for both hematological and immunological functions. Several common etiologies such as trauma, developmental variants, infectious/inflammatory conditions, and benign and malignant lesions can occur in the spleen. The role of imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in diagnosing these conditions continues to evolve. The main objective of this review article is to illustrate the role of imaging in identifying the common and uncommon pathology of the spleen.

Comprehensive Review of Abdominopelvic Mesenchymal Tumors With Radiologic Pathologic Correlation and Update on Current Treatment Guidelines-Part 2

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features, and treatment options available helps the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft-tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.

Comprehensive Review of Abdominopelvic Mesenchymal Tumors with Radiologic Pathologic Correlation and Update on Current Treatment Guidelines - Part 1

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features and available treatment options will help the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.

Imaging of Abnormal Air in the Abdomen and Pelvis

The presence of abnormal air collection on an imaging study is quite often the reason as well as the solution to a diagnostic dilemma. The purpose of this review article is to develop an understanding of anatomical localization and determine etiology of abnormal air collections in the abdomen and pelvis. Abnormal air collections are commonly encountered on imaging studies on a daily basis, and this article will help familiarize the interpreting radiologist with the pathophysiology of these collections and help solve various diagnostic challenges and avoid potential pitfalls.

Magnetic Resonance Imaging of Rectal Cancer

High-resolution magnetic resonance imaging (MRI) plays a pivotal role in the pretreatment assessment of primary rectal cancer. The success of this technique depends on obtaining good-quality high-resolution T2-weighted images of the primary tumor, orthogonal to rectal lumen. The goal of magnetic resonance staging is to identify patients who will benefit from neoadjuvant therapy prior to surgery to minimize postoperative recurrence and planning of optimal surgical approach. MRI also facilitates optimal identification of important prognostic factors, which improves both treatment selection and posttreatment follow-up. The objective of this article is to review the existing literature and provide a concise update on various aspects of rectal cancer imaging, discuss the current role of advanced imaging techniques such as diffusion-weighted and perfusion imaging in the evaluation of rectal cancer, and to assess response to therapy.

Hepatic Inflammatory Pseudotumor—A Diagnostic Challenge: A Case Report and Review of Literature

Inflammatory pseudotumor (IPT) is a rare lesion of unknown origin, characterized by proliferation of fibrous connective tissue and invasion of inflammatory cells. Although benign, it has the propensity to mimic malignant masses given its nonspecific symptoms and imaging manifestations. We present a case of hepatic IPT with variable interpretation on different imaging modalities, called as abscess on computed tomography (CT) and neoplasm on ultrasound and magnetic resonance imaging (MRI), thus posing a diagnostic dilemma. Hence it is important to recognize this as a distinct clinical entity and include it in the differential of liver masses with atypical imaging findings.

LI-RADS: a conceptual and historical review from its beginning to its recent integration into AASLD clinical practice guidance

The Liver Imaging Reporting and Data System (LI-RADS^®) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver observations in individuals at high risk for hepatocellular carcinoma (HCC). LI-RADS is supported and endorsed by the American College of Radiology (ACR). Upon its initial release in 2011, LI-RADS applied only to liver observations identified at CT or MRI. It has since been refined and expanded over multiple updates to now also address ultrasound-based surveillance, contrast-enhanced ultrasound for HCC diagnosis, and CT/MRI for assessing treatment response after locoregional therapy. The LI-RADS 2018 version was integrated into the HCC diagnosis, staging, and management practice guidance of the American Association for the Study of Liver Diseases (AASLD). This article reviews the major LI-RADS updates since its 2011 inception and provides an overview of the currently published LI-RADS algorithms.

White paper of the Society of Abdominal Radiology hepatocellular carcinoma diagnosis disease-focused panel on LI-RADS v2018 for CT and MRI

The Liver Imaging and Reporting Data System (LI-RADS) is a comprehensive system for standardizing the terminology, technique, interpretation, reporting, and data collection of liver imaging with the overarching goal of improving communication, clinical care, education, and research relating to patients at risk for or diagnosed with hepatocellular carcinoma (HCC). In 2018, the American Association for the Study of Liver Diseases (AASLD) integrated LI-RADS into its clinical practice guidance for the imaging-based diagnosis of HCC. The harmonization between the AASLD and LI-RADS diagnostic imaging criteria required minor modifications to the recently released LI-RADS v2017 guidelines, necessitating a LI-RADS v2018 update. This article provides an overview of the key changes included in LI-RADS v2018 as well as a look at the LI-RADS v2018 diagnostic algorithm and criteria, technical recommendations, and management suggestions. Substantive changes in LI-RADS v2018 are the removal of the requirement for visibility on antecedent surveillance ultrasound for LI-RADS 5 (LR-5) categorization of 10-19 mm observations with nonrim arterial phase hyper-enhancement and nonperipheral "washout", and adoption of the Organ Procurement and Transplantation Network definition of threshold growth (≥ 50% size increase of a mass in ≤ 6 months). Nomenclatural changes in LI-RADS v2018 are the removal of -us and -g as LR-5 qualifiers.

Gossypiboma of Axilla: Imaging Pitfalls on Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography

18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) has become the standard of care in staging, restaging, and response assessment of various malignancies including malignant melanoma. However, nonspecific uptake of FDG can occur in infectious and inflammatory conditions and can mimic a tumor. We present here a case of gossypiboma of the axillary region with FDG uptake detected in a patient with malignant melanoma of the upper extremity and discuss the potential pitfalls of this entity on FDG-PET/CT.

Cardiovascular complications of multiple myeloma in the elderly

INTRODUCTION

Multiple myeloma is a malignant neoplasm characterized by plasma cell proliferation in blood and bone marrow. Approximately two-thirds of the patients with multiple myeloma are >65 years at the time of diagnosis. Patients in this age group often have co-existing cardiovascular diseases. Areas covered: The presence of multiple myeloma adds to the malady by direct deposition of amyloid protein in the heart or via toxicity of chemotherapeutic agents. Cardiac contractile dysfunction, arrhythmias and thromboembolic disorders are the main issues in the management of elderly patients with multiple myeloma. Expert commentary: Assessment of cardiac risk and functional status requires careful evaluation by history, physical examination and imaging studies such as echocardiography and magnetic resonance imaging. The management of cardiovascular disorders in the presence of multiple myeloma is difficult and poses a challenge for the internist, the oncologist, and the cardiologist alike. This review is an overview of the problem of cardiovascular risk in and management of elderly patients with multiple myeloma.

Malignant Triton Tumor (Malignant Peripheral Nerve Sheath Tumor With Rhabdomyoblastic Differentiation) Occurring in a Vascularized Free Flap Reconstruction Graft

Malignant peripheral nerve sheath tumor (MPNST) is a rare form of sarcoma arising from Schwann cells or pluripotent cells of the neural crest. Malignant triton tumor (MTT) is a subtype of MPNST with a component of malignant rhabdomyoblasts in addition to malignant Schwann cells. MPNST and MTT are both aggressive malignancies that most commonly arise from large deep neurofibromas in patients with neurofibromatosis type 1 (NF-1). However, sporadic non-NF-1 cases of MTT have also been reported in the literature. We present a case of a 50-year-old African American male with no stigmata of NF-1 who developed a large mass in a free flap on the right calf. The free flap had been placed by plastic surgery 15 years previously following open right tibial and fibular fractures associated with a large soft tissue defect. Biopsy of the enlarging mass, followed by wide surgical excision, confirmed the pathology to be MTT. Although the development of a high-grade soft tissue sarcoma has been previously reported as a late complication of radiation therapy following free flap reconstructions, we believe this is the first reported case of sarcomatous transformation arising in a vascularized, free muscle transfer.

Magnetic Resonance Enterography (MRE): The role of imaging in the management of adult patients with Crohn's disease

Crohn's disease, an inflammatory bowel disease with devastating complications, often requires frequent imaging to detect active disease and its complications. Endoscopy, which is the gold standard for diagnosis, is contraindicated in come patients and has limited role in detecting deep submucosal/mesenteric disease, mid small bowel disease and intra-abdominal complications. Magnetic Resonance Enterography (MRE) has evolved as a complimentary non-invasive, radiation free, high resolution imaging modality in evaluating these patients, with clinical studies haveing shown MRE to help in the diagnosis and follow up of these patients. Its major advantage over CT Enterography is the absence of radiation.

Evaluation of Myocardial Strain in Patients With Amyloidosis Using Cardiac Magnetic Resonance Feature Tracking

PURPOSE

To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis.

MATERIALS AND METHODS

CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed.

RESULTS

There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P < 0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal.

CONCLUSION

Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Clinical orthopedic examination findings in the lower extremity: correlation with imaging studies and diagnostic efficacy

The lower-extremity anatomy is complex and normal function is dependent on intact osteochondral, musculotendinous, and ligamentous structures. Injury may result in pain and functional limitation. Specific clinical tests are used to help isolate and define the pathoanatomy; however, their terminology may be confusing to the radiologist and the diagnostic value of these tests may not be well understood. This article presents an algorithmic approach to evaluation of the hip, knee, and ankle to improve the radiologist's understanding of lower-extremity physical examination. Knowledge of test terminology, clinical utility, and diagnostic accuracy will improve clinical and radiologic correlation. The article reviews the common clinical tests used to evaluate the lower extremity and provides an algorithm to establish a clinical examination road map and rapidly review the clinical utility and study hierarchy of a particular test. The sensitivity and specificity of the clinical tests and magnetic resonance (MR) imaging are reviewed because these parameters vary, and an understanding of the diagnostic utility of both the clinical and imaging tests is important in accurately formulating a definitive diagnosis. The structured algorithmic approach to lower-extremity examination described here, knowledge of test jargon, and familiarity with the diagnostic accuracy of the clinical and MR imaging examinations may help the radiologist focus image search patterns and provide detailed and clinically relevant reports. Online supplemental material is available for this article.

Clinical orthopedic examination findings in the upper extremity: correlation with imaging studies and diagnostic efficacy

Different orthopedic tests are used to evaluate internal derangements of joints. Radiologic examinations like magnetic resonance (MR) imaging are ordered on the basis of results of these tests to narrow the clinical diagnosis and formulate a treatment plan. Although these tests are clinically useful, the test terminology can be confusing and the significance of the tests not clearly understood. This article helps explain the clinical jargon of tests performed for the major joints of the upper extremity and their proper use and diagnostic value in conjunction with MR imaging. The article presents a structured algorithmic approach to explain the tests. For each joint, a hierarchy of clinical tests is performed, starting with general observation and range of motion, followed by more specific tests tailored to evaluate individual or grouped anatomic structures. MR imaging findings and clinical tests complement each other in making a final diagnosis. However, because of the varied sensitivity and specificity of the clinical tests and MR imaging, it is important to be familiar with their diagnostic value before making clinical decisions. Knowledge of clinical jargon and the proper use and diagnostic value of orthopedic tests can aid in interpretation of radiologic images by focusing search patterns, thus allowing comprehensive evaluation and optimized reporting. It also enhances communication with the orthopedist, thereby helping maintain continuity of care. Online supplemental material is available for this article.

Preserving the educational value of call in a diagnostic radiology residency program

PURPOSE

Our study was designed to determine residents' opinions of the advantages, disadvantages and educational value of a traditional "Tandem Call" (TC) model as compared to night float (NF). Because TC is more representative of adult learning principles and constructivist theory, we hypothesized that resident satisfaction and educational outcomes would demonstrate a preference for, and the educational efficacy of, the TC model.

METHODS

We surveyed all residents in a university-based radiology residency on their opinions of TC and its educational value. Aggregate data from annual Graduate Medical Education Committee institutional surveys (2008-2012) and annual radiology alumni surveys (2009-2012) were reviewed as measures of satisfaction with TC. Performance on the ABR oral exam was a proxy for educational outcome. Quality data for the year of study and prior years in which TC was in effect were reviewed as a measure of patient safety.

RESULTS

The great majority of respondents attributed confidence/competence on call and added value to their education directly to TC. A majority believed that teamwork required for TC facilitated more positive relationships among residents and more peer teaching. Most said that they would not prefer NF. Almost all believed indirect supervision with attending backup aided in developing confidence in performance. Quality data confirmed a low number of discrepancies between preliminary resident and final attending reads.

CONCLUSIONS

TC provides a more consistent call experience throughout residency than NF. TC is valued by residents, facilitates retrieval-based learning and development of independence and efficiency, and parallels essential elements of team-based learning. Quality data suggests that lack of 24-hour attending supervision is not detrimental to patient safety.

Diabetic myonecrosis: likely an underrecognized entity

Diabetic myonecrosis is a rare complication of long-standing diabetes mellitus that presents as acute onset of swelling and pain of the affected muscles. The differential diagnosis includes cellulitis/pyomyositis, necrotizing fasciitis, neoplasm, and deep venous thrombosis (DVT). Missed diagnoses can lead to unnecessary invasive diagnostic procedures and inappropriate treatment. The diagnosis is established by the clinical presentation and findings on magnetic resonance imaging (MRI) scan. A 30-year-old African-American man presented with a painful mass affecting the medial aspect of the right thigh for several months. Initial laboratory studies showed white blood cell count of 8800 cells/mm(3), D-dimer value of 0.55 µg/mL, HgBA1c level of 15.1%, glucose level of 352 mg/dL, erythrocyte sedimentation rate of 22 mm/h, and C-reactive protein level of 222 mg/L. An MRI scan was obtained, and diabetic myonecrosis was diagnosed and treated. One year later, the patient had similar symptoms of pain in the contralateral thigh. Repeat workup and MRI scan were obtained. The MRI abnormalities originally seen in the right thigh 1 year earlier were present in the left thigh, with complete resolution of the abnormalities seen in the right thigh. Treatment with bed rest and analgesics resulted in symptom resolution. Patients with diabetic myonecrosis typically have no fever, normal white blood cell count, mildly increased erythrocyte sedimentation rate, and elevated C-reactive protein level in 50% of cases. They lack the radiologic signs of fascial enhancement or well-defined, rim-enhancing collections that are seen in necrotizing fasciitis and pyomyositis/abscess. The onset of severe pain and the lack of mass effect on imaging differentiate diabetic myonecrosis from tumor-like conditions such as vascular malformations or soft tissue tumors. Normal D-dimer levels and ultrasound Doppler examination of the extremity help to rule out DVT. The typical MRI scan findings and clinical presentation can lead to the diagnosis of diabetic myonecrosis, allowing the physician to avoid invasive tests, such as muscle biopsy, and to reassure patients that this condition is self-limiting with appropriate treatment.

MR imaging findings in diabetic muscle infarction

Diabetic muscle infarction is a rare, often unrecognized complication seen in patients with poorly controlled Diabetes Mellitus. The diagnosis is often missed and leads to unnecessary invasive investigations and inappropriate treatment. The patients usually present with unilateral thigh pain and swelling. MRI typically demonstrates diffuse swelling and increased T2 signal intensity within the affected muscles. The condition is self-limiting and is treated conservatively with bed rest and analgesics. Recurrences have been reported in the same or contralateral limb. We report a case of diabetic muscle infarction with spontaneous resolution of symptoms and imaging abnormality with recurrence on the contralateral side.

Preoperative MRA for Patient Selection in Free Fibula Flap: Is a Venous Phase Indicated?

Objectives:

We present our institutional experience with dynamic time-resolved magnetic resonance angiography (DTR MRA) with delayed venous imaging for free fibula flap (FFF) patient selection. We sought to (1) determine the sensitivity of the test for vascular anomalies predisposing to limb-threatening complications and (2) assess the impact of the venous phase findings in patient selection.

Methods:

Retrospective review of 46 patients considered for mandibular reconstruction with FFF in an academic tertiary setting from 2009-2012. A DTR MRA was performed preoperatively in all cases. Both imaging and physical examination findings were used to determine patient eligibility for the procedure.

Results:

Thirteen patients (28.2%) had findings on DTR MRA excluding flap harvesting from the preferred leg, with atherosclerosis (n = 8) and anatomic variations (n = 4) being the most common findings. Eight of these patients (61.5%) underwent harvesting from the opposite leg, while 5 underwent reconstruction with a different bony flap. Only 2 of these 13 patients (15.3%) had physical examination findings excluding reconstruction with FFF. DTR MRA was significantly more likely to detect potentially limb threatening vascular anomalies than physical examination ( P = .004). There was 1 patient with an anomaly on delayed venous imaging (asymptomatic deep venous thrombosis–thrombophlebitis) which excluded flap harvesting from the affected leg. Both arterial phase imaging and physical examination were normal in this patient.

Conclusions:

DTR MRA is significantly more sensitive than physical examination in detecting limb-threatening anatomic variations and vascular pathology prior to FFF reconstruction. The venous phase allows identification of oligosymptomatic venous anomalies that, while uncommon, may predispose to significant morbidity. These findings justify routine use of this imaging modality.

Preoperative Peroneal Perforator Mapping with Dynamic Time-Resolved Magnetic Resonance Angiography

Objectives:

Dynamic time-resolved magnetic resonance angiography (DTR MRA) is a novel imaging algorithm that allows for better visualization of small-caliber vessels when compared with standard MRA. We sought to estimate the technique sensitivity when compared with intraoperative findings.

Methods:

Retrospective review of 25 patients undergoing reconstruction with free fibula flap at an academic tertiary setting from 2009 to 2013. Preoperative DTR MRA was performed in all cases. Two radiologists performed blind reviews of the images and their findings were compared with surgical descriptions of the perforator anatomy.

Results:

Surgical exploration identified 32 perforators while DTR MRA identified 45 vessels. The technique confirmed the presence of perforators in 22 out of 23 patients with at least one perforator, and their absence in 1 out of 2 patients who had a negative exploration. There was a significant correlation in the number of perforators identified clinically and radiologically in each case ( P = .005). Twenty-seven perforators were localized to their correct anatomic location by the technique, yielding a sensitivity of 84.4% and a specificity of 16.7%. Ten out of the 18 vessels incorrectly identified by this technique were located within 30 mm of a confirmed perforator.

Conclusions:

DTR MRA is a highly sensitive technique for determining the presence and location of cutaneous perforators in patients undergoing reconstruction with free fibula flap. The majority of the false-positive findings corresponded to vessels located within 30 mm of a confirmed perforator; we hypothesize that they could represent distal branching patterns presenting radiologically as separate entities. These results compare favorably to perforator mapping with standard MRA techniques.

Integrated residency training leading to radiology and nuclear medicine board certification: the Arkansas experience

The pool of qualified nuclear medicine (NM) physicians is declining as fewer choose to enter the specialty. In June 2012, we began developing an integrated categorical residency training position satisfying the requirements of both the American Board of Radiology (ABR) and the American Board of Nuclear Medicine (ABNM). Termed "NuRad," this was listed and filled in the 2013 NRMP match. We found it to be more attractive to qualified applicants than our traditional, three year NM residency. This approach may play a significant role in the future in ensuring the training of physicians expert in NM and molecular imaging.

Radiology resident recruitment: A study of the impact of web-based information and interview day activities

RATIONALE AND OBJECTIVES

Residency recruitment is a critical and expensive process. A program's Web site may improve recruitment, but little is known about how applicants use program sites or what constitutes optimal content. The importance of an interview day and interactions with a program's residents has been described, but candidate preferences for various activities and schedules have not been widely reported. We investigated contemporary use and perceived utility of information provided on radiology program Web sites, as well as preferences for the interview day experience.

MATERIALS AND METHODS

Using an anonymous cross-sectional survey, we studied 111 candidates who were interviewed between November 1, 2012 and January 19, 2013 for a diagnostic radiology residency position at our institution. Participation in this institutional review board-approved study was entirely voluntary, and no identifying information was collected. Responses were sealed and not analyzed until after the match.

RESULTS

A total of 70 candidates returned a completed survey (63% response rate). Optimal content considered necessary for a "complete" Web site was identified. The most important factor in deciding where to apply was geographical connection to a program. "AuntMinnie" was the most popular source of program information on social media. Candidates overwhelmingly preferred one-on-one faculty interviews but had no preference between a Saturday and weekday schedule. The ideal interview experience should include a "meet and greet" with residents off campus and a personal interview with the program director. The overall "feel" or "personality" of the program was critical to a candidate's rank order decision.

CONCLUSIONS

Our findings offer insight into what factors make programs appealing to radiology applicants. This information will be useful to medical educators engaged in career counseling and recruitment.

MR evaluation of rectal cancer: current concepts

Magnetic resonance imaging has become more frequently utilized for staging, preoperative planning, and post-neoadjuvant evaluation of rectal cancer. It offers detailed resolution of the layers of the rectal wall, visualization of the mesorectal fascia, and identification of locoregional nodal involvement. Many advances have been made since the original protocols and include the use of phased-array coils, orthogonally obtained images and 3-dimensional sequences, the use of diffusion-weighted and perfusion protocols to better evaluate the tumor before and after neoadjuvant therapy, and the development of techniques to better evaluate metastatic nodes. Magnetic resonance imaging shows similar accuracy to endorectal ultrasound when staging and offers a less invasive technique that is not limited by patient discomfort or decreased luminal size. This article is meant to provide an update on the recent advances in rectal cancer imaging while addressing the controversial issues that exist in staging, technique, and imaging protocol.

Radiology education 2.0--on the cusp of change: part 2. eBooks; file sharing and synchronization tools; websites/teaching files; reference management tools and note taking applications

Increasing use of smartphones and handheld computers is accompanied by a rapid growth in the other related industries. Electronic books have revolutionized the centuries-old conventional books and magazines markets and have simplified publishing by reducing the cost and processing time required to create and distribute any given book. We are now able to read, review, store, and share various types of documents via several electronic tools, many of which are available free of charge. Additionally, this electronic revolution has resulted in an explosion of readily available Internet-based educational resources for the residents and has paved the path for educators to reach out to a larger and more diverse student population.

Radiology education 2.0--on the cusp of change: part 1. Tablet computers, online curriculums, remote meeting tools and audience response systems

We are in the midst of an evolving educational revolution. Use of digital devices such as smart phones and tablet computers is rapidly increasing among radiologists who now regularly use them for medical, technical, and administrative tasks. These electronic tools provide a wide array of new tools to the radiologists allowing for faster, more simplified, and widespread distribution of educational material. The utility, future potential, and limitations of some these powerful tools are discussed in this article.

Intermittent torsion of accessory hepatic lobe: An unusual cause of recurrent right upper quadrant pain

An accessory lobe of the liver is a rare congenital anomaly that can undergo torsion and present as an acute surgical emergency. It is rarely diagnosed preoperatively. We report the preoperative utility of CT scan and MRI in the diagnosis and surgical planning of a case of intermittent accessory hepatic lobe torsion.