Radiology Fellows Research Articles

Percutaneous Transluminal Angioplasty Balloon Inflation with Syringes: Who Needs an Inflator?

High pressures are important in percutaneous transluminal angioplasty, particularly in hemodialysis access. Although many operators rely on commercially available inflators, small syringes can deliver high pressures, which might make inflators unnecessary. Recently introduced polycarbonate (PC) syringes may allow higher pressure delivery than traditional polypropylene (PP) ones, so the present study was performed to determine predictors of inflation pressures achievable with various syringe designs. Forty-two subjects participated: 12 residents, 12 interventional radiology fellows, 12 interventional radiology attending physicians, and six others. Each subject made three attempts to deliver maximum pressure with use of a calibrated gauge for each syringe type (1-, 3-, 5-/6-, 10-, and 20-mL PP and PC syringes). A control experiment was conducted to assess fatigue effects. Age, sex, grip strength measured on a dynamometer, and physical parameters (height, weight, body mass index [BMI]) were collected for each participant. Pressures of 40 atm or greater were achieved by more than 90% of subjects with 1-mL PC syringes (mean, 47 atm +/- 7 [SD]). Female subjects generated lower mean pressures with every syringe type (P value range, <.0001 to .025); this effect was least pronounced with 1-mL PC syringes. Grip strength was highly correlated with pressure generation across syringe types. Control experiments showed no significant fatigue effect. With rare exceptions, age, BMI, level of training, height, and weight did not correlate with pressure generation. Irrespective of sex, grip strength, and BMI, 1-mL PC syringes can be used to generate pressures in excess of 40 atm. High correlation between grip strength and pressure generation may make it possible to predict the pressure an individual can generate with any syringe size or design.

Differentiation of a Femoral Hernia from an Inguinal Hernia on Isotropic Multidetector-Row CT (MDCT): the Benefit of Inguinal Ligament Coronal-Oblique Images

Purpose: This study was designed to evaluate the diagnostic value of the use of inguinal ligament coronal-oblique CT images in the differentiation of femoral hernias from inguinal hernias. Materials and Methods: A total of 32 patients (with 11 femoral hernias and 21 inguinal hernias) underwent CT imaging. All of the examinations were performed with a 16multidetector row CT (MDCT) scanner with contrast enhancement, and transverse sections, coronal sections and coronal-oblique CT images were reformed along an imaginary inguinal ligament plane. Two independent observers retrospectively evaluated the CT scans. Image analysis was first performed with only transverse and coronal images. A second analysis was then performed with transverse, coronal and coronal-oblique images. Results: The mean angle difference between coronal and coronal-oblique CT images was 8.0 degrees (range, 0-22 degrees). A radiologist correctly diagnosed the presence of a femoral hernia in nine (82%) of 11 patients and a radiology fellow correctly diagnosed the presence of a femoral hernia in seven (64%) of 11 patients in the first session. Both of the reviewers made the correct diagnosis in all patients in the second session. For inguinal hernias, both reviewers correctly diagnosed all patients during both sessions. The coronal-oblique CT images were the most valuable images for the evaluation of the relationship between hernias of the neck and inguinal ligament. Conclusion: Inguinal ligament coronal-oblique CT images can provide additional diagnostic value in the evaluation of groin hernias.

The meniscofibular ligament: An MRI study

Aim To describe the appearances and determine the prevalence of the meniscofibular ligament (ligamentum fibulare-MFibL) on MRI of the knee. Subjects and methods Retrospective observational review of 160 knee MRI studies (152 patients) which was performed for a variety of clinical presentations over a period of 31 months. The images were assessed independently by two musculoskeletal radiology Fellows. Results The MFibL was optimally visualised on far lateral sagittal oblique fat suppressed PDW FSE images. The MFibL appeared as a curvilinear or straight, hypointense band of variable thickness extending between the inferior margin of the posterior third of the lateral meniscus and the fibular head. The ligament was demonstrated in 42.5% ( n = 68) of the total knee MRI studies, but this prevalence increased to 63% (56/88) in the presence of fluid in the posterolateral corner of the joint. Conclusion The MFibL is commonly seen on far lateral fat suppressed oblique sagittal PD weighted MR images, particularly in the presence of fluid in the posterolateral corner, and should be recognised as a normal structure in the posterolateral corner of the knee.

Simulation in Training: One-year Experience Using an Efficiency Index to Assess Interventional Radiology Fellow Training Status

To compare objective fellow and expert efficiency indices for an interventional radiology renal artery stenosis skill set with the use of a high-fidelity simulator. The Mentice VIST simulator was used for three different renal artery stenosis simulations of varying difficulty, which were used to grade performance. Fellows' indices at three intervals throughout 1 year were compared to expert baseline performance. Seventy-four simulated procedures were performed, 63 of which were captured as audiovisual recordings. Three levels of fellow experience were analyzed: 1, 6, and 12 months of dedicated interventional radiology fellowship. The recordings were compiled on a computer workstation and analyzed. Distinct measurable events in the procedures were identified with task analysis, and data regarding efficiency were extracted. Total scores were calculated as the product of procedure time, fluoroscopy time, tools, and contrast agent volume. The lowest scores, which reflected efficient use of tools, radiation, and time, were considered to indicate proficiency. Subjective analysis of participants' procedural errors was not included in this analysis. Fellows' mean scores diminished from 1 month to 12 months (42,960 at 1 month, 18,726 at 6 months, and 9,636 at 12 months). The experts' mean score was 4,660. In addition, the range of variance in score diminished with increasing experience (from a range of 5,940-120,156 at 1 month to 2,436-85,272 at 6 months and 2,160-32,400 at 12 months). Expert scores ranged from 1,450 to 10,800. Objective efficiency indices for simulated procedures can demonstrate scores directly comparable to the level of clinical experience.

Should Vascular Surgeons be Trained in Endovascular Techniques? – An Observational Study

The aim of this study was to determine if there is a satisfactory cover for interventional radiology and whether vascular surgeons have received sufficient training in endovascular techniques. This was an observational study based on questionnaires sent to radiology and vascular trainers and vascular trainees in England. A total of 50 NHS trusts were chosen randomly to take part in the study and 320 questionnaires were sent out with an overall consultant response rate of 57%. Of vascular consultants in the study group, 53% have had experience in endovascular procedures. Overall, 87% felt that there were not enough radiologists to fulfil the demand and 64% would like further training in endovascular procedures. In addition, 69% would like to be involved in a vascular rota without the general component. Similarly, 81% of radiologists felt that the demand was not being met, as emergency interventional radiology cover was not available on most nights in 65% of the trusts. Of responders, 72% would not object to training of vascular trainees in interventional work and 43% would be happy to be involved in training. Some 33% would accept a vascular trainee for 1 year. Integrated fellowship in vascular surgery and interventional radiology has been implemented and tested in a number of centres in the US. This approach could be implemented in some of the larger vascular units in the UK.

Seyed Abdolmajid Rooholamini

It can only be said of a few men that their accomplishments in their medical careers helped progress the practice and knowledge of medicine in their native country, but Seyed...

Validation of percutaneous nephrostomy (PCN) performed using the PercMentor® simulator.

INTRODUCTION: The traditional method of acquiring procedural skills is by apprenticeship and involves an extensive period of training with patients. Model-based and virtual reality simulation is gaining interest as alternative training, allowing repetitive practice in a low-risk, trainee focused and safe environment. The objective of this study was to prospectively validate percutaneous nephrostomy (PCN) training using the PercMentor® simulator. The study concentrated on assessing construct validity (the ability of the training system to differentiate trainees according to their clinical experience) and on getting experts opinion on the training modality. MATERIALS AND METHODS: 4 groups of 10 medical doctors each participated in the study :1) novices, 2) radiology residents, 3) radiology fellows and 4) board certified invasive radiologists. Following a structured introduction to the procedure and to the simulation system, each participant performed the following tasks: 1) recognition of anatomic structures without fluoroscopy, 2) and with fluoroscopy, 3) calices recognition with fluoroscopy, 4) balloon puncturing, and 5) 2 clinical PCN free training tasks. Evaluation parameters included: time to task completion, fluoroscopy time, contrast volume used, and the number of balloons punctured over a 5 minute period. At the end of the training participants were asked to fill in a subjective questionnaire regarding the training modality. RESULTS: Construct validity of task performance was demonstrated in most parameters. Time to task completion in the recognition of the spleen without fluoroscopy in groups 1), 2), 3) and 4) was 109±61, 56±28, 28±15, 18±7 (mean±SD) seconds, respectively (F(3,36)=8.3, p<0.00); and with fluoroscopy 103±42, 56±42, 32±20, 22±10 seconds, respectively. The total time for calices recognition was 337±105, 241±58, 154±37, and 117±37 seconds (F(3,36)=12.8, p<0.00). Time to task completion of the first free PCN task was 175±27, 187±76, 99±38, 36±24 seconds (F(3,35)=22.8, p<0.00), and for the second free PCN task 103±40, 101±64, 41±14, 30±17 seconds (F(3,36)=9.7, p<0.00). Contrast material volume used in the first task was 42±13, 44±22, 21±9, 9±6 ml (F(3,36)=14.8, p<0.00) and for the second task 22±9, 16±6, 9±9, 9±5 ml. The number of balloons punctured over 5 minutes period was 4±1, 5±1, 6±1, 7±0. The board certified radiologists recommended using the simulator as a teaching tool for residents in invasive radiology (mean score of 6 on a 1–6 scale), and indicated that the imaging achieved by the simulation system is similar to real imaging (score 5±1). The experts indicated that the catheters used are not fully similar to real catheters and that the haptic of working with the simulation system not fully resembles the haptic of human tissues (both scored as 3±1). CONCLUSION: In this study construct validity of the simulation training system was demonstrated and experts recommended its use for training of fellows in invasive radiology. This information is crucial for the validation of the training system but the benefits of training using the simulation system on actual clinical performance remains to be proved.

Funding for Graduate Medical Education

The education of radiology residents and fellows is a vitally important but costly process. This paper reviews the most common methods of funding graduate medical education. The majority of graduate medical education in the United States is funded by Medicare, but there are caps on the number of trainees allowed, and the government is cutting payments. Academic medicine, particularly academic radiology, is at a point of crisis today if new methods to provide additional support are not found.

Vascular and Interventional Radiology Training: A Perspective from the Association of Program Directors in Interventional Radiology

INTERVENTIONAL Radiology fellowship training has undergone rapid evolution since the Accreditation Council for Graduate Medical Education (ACGME) began accrediting programs in 1991. Until recently, the Society of Interventional Radiology (SIR) was the main resource for assisting with program development. However, as our specialty matured, it became evident that a more formalized connection between programs was needed.

“Whatever happened to the class of 2000?” An outcome survey of potential interventional radiologists

To find out what final career choices were made by trainee doctors who had indicated a strong interest in pursuing a career in interventional radiology and to establish the reasons behind their final career choice. Eighty-eight doctors who attended a meeting in 2000 designed to promote interventional radiology as a career were questioned as to whether the meeting influenced their potential career choices and then further surveyed via postal questionnaire 5 years later to find out their eventual career choices. Of the 88 doctors who attended, 56 were radiology trainees and 32 were training in either medical or surgical specialties. There were 25 women and 63 men. Five years after the meeting, six are now interventional radiologists (6.8%) though four of these are still in a 6th year interventional radiology fellowship. A further 12 (13.6%) are systems based, predominantly diagnostic radiologists with an interest in intervention. Thirty-two (43.2%) are diagnostic radiologists who undertake little or no therapeutic intervention. Of the 32 non-radiologists who attended the meeting only three entered radiology and are still in training. Interventional radiology is a popular initial career choice amongst trainee doctors. However, only a small number eventually pursue the specialty. If the manpower shortage of interventional radiologists is to be addressed, there needs to be improvements in training, accreditation, career opportunities and working conditions.

Electronic Evaluation Systems for Radiology Residency and Fellowship

Electronic evaluation systems are becoming more commonplace in radiology residencies. This article describes the authors' experience in the development of such a system and a method that a residency program or graduate medical education office could use to evaluate commercially available programs.

MRI of Meniscal Lesions: Soft-Copy (PACS) and Hard-Copy Evaluation Versus Reviewer Experience

The purpose of our study was to compare diagnostic performance, reviewer confidence, and time requirements in the MRI diagnosis of meniscal tears for three types of reviewers and two types of image documentations (PACS vs hard copies). An experienced musculoskeletal radiologist (reviewer 1), a fellow in musculoskeletal radiology (reviewer 2), and a junior staff member in orthopedic surgery (reviewer 3) evaluated MR images displayed on PACS monitors and hard copies independently and in a blinded fashion with regard to the presence or absence of meniscal tears. Seventy-one patients (mean age, 45.4 years; range, 16-80 years) were consecutively included if they had undergone both MRI of the knee and arthroscopy within 4 months. Arthroscopy was the standard of reference. Evaluation time and the reviewer's confidence in his or her diagnosis (Visual Analogue Scale, possible values of 0-100) were determined. Accuracies, sensitivities, and specificities in diagnosing meniscal tears were 80-87%, 63-85%, and 87-93% for soft copies and 82-85%, 64-76%, and 87-94.0%, respectively, for hard copies. Intrareviewer differences between PACS and hard copies were not significant for any of the three reviewers (McNemar tests). Reviewer 3 was less sensitive but more specific in the diagnosis of meniscal tears than reviewers 1 and 2. This difference was significant for both the PACS and hard copies. The reviewers' confidence in their diagnoses and evaluation times were not significantly different for PACS and hard copies (analysis of variance with Bonferroni post hoc analysis). Differences in the diagnostic performance of suspected meniscal tears depend on reviewer experience rather than on the type of documentation.

On Judging Book Covers

I have always looked young for my age. The older I get, the less annoying this becomes but it still gets irritating sometimes. Like two nights ago, while buying groceries with my 6-year-old son, I was carded buying light beer (for about the thousandth time). Considering I could drink legally in 1984 (and drank illegally for several years before that), I have been dealing with this for over 20 years. Same thing happens at work. Every July, new interns or medical students who wander into our section ask me where they can find an interventional radiology (IR) fellow or attending. I can't count the number of times I've had would-be-savvy patients demand that the first-year resident perform the procedure because he or she looked older than me. My usual reply is, “Well, if that's what you really want-OK.” Incidentally, saying this usually makes me feel much better for some reason.

Fellowship Directors’ Perceptions of the 2005 NRMP Radiology Fellowship Match 1

The aim of the study is to gauge radiology fellowship directors' experiences with the fellowship application process and perceptions of the National Resident Matching Program Radiology Fellowship Match, as well as compare these perceptions with those of senior residents. An electronic survey was sent to 291 members of the Association of Program Directors in Radiology. Responses were compared directly with an earlier survey of senior residents who participated in the same cycle of the Fellowship Match. Sixty-seven respondents participated in the survey. Based on our estimates of the total number of US-based radiology subspecialty fellowship programs, this represents between 15.3% (67/438) and 24.2% (67/277) of all fellowship directors. Approximately three quarters (52/76 directors; 77.6%) participated in the Fellowship Match. Respondents believe that the match process makes the process fairer for all applicants (31/43 respondents; 70.5%) and primarily benefits residents (30/76 respondents; 60.0%), a significant difference compared with senior residents (P < .01). The majority of fellowship directors favor the current calendar and the ability to select internal candidates outside the Match. The majority of respondents believe that programs generally are not abiding by the rules of the Match (22/43 respondents; 51.2%), and at least 15 instances of rule violations were reported. A majority of fellowship directors favor continuing the Match in some form (26/42 respondents; 61.9%). Although there are significant differences in perception of the Match process between fellowship directors and senior residents, the majority of fellowship directors favor continuing the Match in some form. Several potential solutions, including explicit declaration of the number of available positions and strict enforcement of Match rules, may help improve the process in the future.

The Radiology Class of 2005: The Fellowship Application Process and Perceptions of the NRMP Fellowship Match

To assess experiences and perceptions of the fellowship application process of the radiology residency class of 2005, including the 2005 National Resident Matching Program (NRMP) Radiology Fellowship Match. An electronic survey composed by the ACR Resident and Fellow Section was completed by 416 senior residents (a 46.9% response rate) enrolled in allopathic radiology residency programs from across the United States. Residents generally agree with the timing of the current fellowship application calendar in the spring of the third year of residency. Respondents were divided over the issue of permitting internal candidates to fill positions outside of the match, although the majority felt that the process influences both applicants and programs to favor their own institutions to avoid the match process. Residents support requiring fellowship programs to declare the number of positions being filled through the match before applications are due (72.6%) or before rank lists are due (79.8%). Residents noted match rule violations, which threaten to undermine residents' confidence in the process. Residents were split over the future of the match: 23.1% favored continuing the match in its current form, 28.8% favored continuing the match with modifications, and 34.4% favored discontinuing the match entirely. Although the NRMP Fellowship Match was created to improve and standardize the fellowship application process, and although a majority of residents support continuing the match in some form, there are areas of concern, including adherence to the letter and spirit of the match rules, which must be addressed to galvanize support among residents in the future and ensure a fair process for fellowship applicants.

The Radiology Class of 2005: Postresidency Plans

To examine the postresidency plans of the radiology residency class of 2005, including influences on and trends in the decision to pursue subspecialty fellowship training after residency. An electronic survey composed by the ACR Resident and Fellow Section was completed by 416 senior residents (a 46.9% response rate) enrolled in allopathic radiology residency programs from across the United States, representing approximately 41.2% of the entire residency class. Eighty-seven percent (95% confidence interval 83.8% to 90.2%) of respondents plan to do fellowships immediately after residency, representing an increasing number, compared with published figures from the 1990s. Increasing age at the completion of residency was independently and significantly correlated with the decision not to pursue a fellowship. There has been a shift in the most popular fellowships, with an increased interest in musculoskeletal radiology fellowships and decreased interest in interventional radiology. Among residents not pursuing immediate fellowship training, the most common plans were private practice positions (48.1%), military obligations (22.2%), and nighthawk positions (9.3%). An increasing number of residents are electing to pursue subspecialty training after the completion of residency. Close monitoring of the postresidency plans of current residents may portend important trends in education, residency training, and changes in the radiology workforce.

SOS: Can We Save Pediatric Radiology?

SOS: Can We Save Pediatric Radiology?

WE-E-E-611-06: Resources-Handouts

Purpose: To present resources available to Medical Physicists who teach Diagnostic Radiological Physics to Radiology Residents. Method and Materials: Web and published materials are listed. Links to web sites and web-published documents are included. Results: There are many on-line and printed Educator's Resources that are useful to a Medical Physicist in teaching Diagnostic Radiological Physics to Radiology Residents and Fellows. This handout describes some of the printed resources and provides URLs to on-line resources. Printed resources include AAPM Report ♯64 “A Guide to the Teaching of Clinical Radiological Physics to Residents in Diagnostic and Therapeutic Radiology”. On-line resources include the resources on the AAPM web site, the web sites of other professional organizations, and the work-in-progress of AAPM Task Group ♯115. Conclusion: Improved Educator's resources for Diagnostic Radiological Physics instruction of Radiology Residents are available and will continue to be expanded.

Solitary pulmonary nodule diagnosis on CT: Results of an observer study 1

To investigate the performance of observers with different levels of experience in distinguishing between benign and malignant solitary pulmonary nodules (SPN) on CT, and to determine the effects on interpretation of three different conditions: image data alone, the addition of clinical data, and the addition of output from a computer-aided diagnosis (CAD) system. 28 thin-section CT datasets of SPNs with proven diagnoses (15 malignant and 13 benign) were used to measure observer performance. Readers were categorized according to their experience and read the cases in random order. For each case readers were asked to assign a level of confidence on a scale from 0.0-1.0 (0.0 benign, 1.0 malignant) for the diagnosis of the nodule. Each reader scored the cases based on review of image data alone (phase 1), then with limited clinical data (phase 2), and finally with CAD output (phase 3). To assess performance, multiple reader multiple case (MRMC) receiver operating characteristic (ROC) analysis was used. 2 thoracic radiologists, 1 thoracic radiology fellow, 2 nonthoracic radiologists, and 3 radiology residents read the cases. The average area under the ROC curve for all readers (A(z)) at each stage was 0.68, 0.75, and 0.81, for image data alone, with clinical data, and with CAD output respectively. The difference in performance between phases (2 and 3) and (1 and 3) was significantly different (P = 0.018 and P = 0.020). However, the difference between phases (1 and 2) was not significantly different (P = 0.155). Diagnostic performance increased significantly with the addition of CAD output. With further validation CAD output may play a significant role in SPN management.

Interventional Neuroradiology is Dead! Long Live Endovascular Therapy!

Radiology, regardless of its technique and area, is a diagnostic specialty. Thus, patients treated by interventional radiologists are not hospitalized in radiology departments and are not under the physical, legal and financial responsibility of therapeutic radiologists. If there is a debate on interventional neuroradiology therapy is or should be organized, it is because these treatments go against radiology's primary goal, the diagnosis of disease, and this opposition is becoming increasingly apparent. Indeed, after twenty years of ambiguity about the radiologist's therapeutic status, we are coming to a time of change. Why this prolonged uncertainty? Up until recently, the therapeutic activity of most centers was negligible compared to their diagnostic activity. In addition, potentially dangerous diagnostic procedures, such as cerebral angiography, were done by the same operators and in the same angiography suites as the therapeutic procedures. As long as their diagnostic activities were proportionally more important than their therapeutic ones, the operators could call themselves radiologists and did not need to reflect on the consequences of their therapeutic role. The proportion has now shifted and the radiologist's role, diagnostician versus therapist, needs to be clarified. MRI and CT-scans have evolved, and the need for diagnostic cerebral angiography has disappeared or will disappear shortly. At the same time, the development of endovascular implants has multiplied the number of endovascular interventions: cerebral arteriovenous malformations are treated with embolization, as are almost all intracranial aneurysms, while atherosclerotic stenosis is treated by angioplasty, etc. These procedures are carried out in angiography suites, the sole purpose of which is now therapeutic! These procedures imply the following sequence: the operator participates in the diagnostic evaluation, proposes treatment, informs the patient and his/her advocates, obtains consent on the risks and potential complications of the procedure, performs the procedure, follows up after the procedure and prescribes appropriate post-procedure medical treatment, orders the patient's release, writes the hospital summary, sees him/her at follow up visits, is liable and carries insurance. For all purposes and intents, the radiologist treats the patient. This new therapeutic specialty no longer has anything in common with radiology, apart from using X-rays. But X-rays here are only an optical device, used to check the accuracy of the therapeutic aim. By analogy, it may be interesting to note that the radiological checks frequently made during surgery do not transform surgeons into radiology technicians. In the case of interventional neuroradiology, though, this means that patients are treated by radiologists, not therapists, in an area (the radiology suite) dedicated to diagnosis, not to treatment. How confusing for the patients and their advocates! Were we to be patients, wouldn't we prefer being treated by bona fide therapists, i.e. therapists with hospital staff and beds? Conversely, why wouldn't neurologists or neurosurgeons, who already have the hospital staff, beds, and budget, become interventionists, with the risk that our specialty may be dragged down by insufficiently trained operators? And what about our colleagues in training? Are we recruiting therapists among doctors who have chosen, rightly so, to specialize in an area where they are not involved with the patient's actual care, or shouldn't we attempt to choose our colleagues among those who are willing to perform often physically demanding interventions where the actual risk is directly assessable and has severe consequences? For those of us with teaching responsibilities in diagnostic radiology, the main feeling is that we are not holding our end of the bargain: we, therapeutic neuroradiologists, don't know how to make the protons dance and cannot teach diagnostic neuroradiology to the radiology fellows who man our departments. As to our budgets, we have seen little interventional neuroradiology is taken into account in the billing of radiology-related events: there is no strength in this union. Thus, no matter the level, local or national, it may be more realistic to map related health care costs to endovascular therapy departments, rather than keep wondering about the therapeutic activities of a department that performs CT-scans and MRIs. It is time to recognize that like surgery, endovascular therapy is a specialty in itself, deserving angiography suites in lieu of operating rooms and its own hospital beds, hospital personnel and hospital budgets. Our specialty is much closer to surgery than to radiology, and must obtain its independence.