COVID-19 Radiology Preparedness, Challenges & Opportunities: Responses From 18 Countries.

PURPOSE: Radiology departments around the world have been faced with the challenge to adapt, and recover to the COVID-19 pandemic. This study is part of a worldwide survey of radiologists' responses to COVID-19 in 18 different countries in Africa, Asia, Europe, and Latin America. The purpose of this study is to analyze the changes made in international radiology departments and practices in response to the pandemic. METHODS: The 18-item survey was sent via email from April to May 2020 to radiologists in Africa, Asia, Europe, and Latin America to assess their response to COVID-19. Our survey included questions regarding imaging, workforce adjustments, testing availability, staff and patient safety, research and education, and infrastructure availability. RESULTS: Twenty-eight survey responses were reviewed. Of the 28 respondents, 42.9% have shortages of infrastructure and 78.6% responded that COVID-19 testing was available. Regarding the use of Chest CT in COVID-19 patients, 28.6% respondents used Chest CT as screening for COVID-19. For staff safety, interventions included encouraging use of masks in patient encounters, social distancing and PPE training. To cope with their education and research mission, radiology departments are doing online lectures, reducing the number of residents in rotations, and postponing any non-urgent activities. CONCLUSION: In conclusion, there are disparities in infrastructure, research, and educational initiatives during COVID-19 which also provides opportunity for the global radiology community to work together on these issues.

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.

Lessons Learned From the COVID-19 Response in a Major New York City Hot Zone.

The COVID-19 pandemic had significant impact on radiology departments across the United States. Radiology departments have adjusted to the effects of the pandemic. This article presents the changes made by the Radiology department at the Montefiore Medical Center (MMC) of the Albert Einstein College of Medicine located in the Bronx, New York City which is one of the major hot spots of the COVID-19 pandemic.

Early detection of deep vein thrombosis in patients with coronavirus disease 2019: who to screen and who not to with Doppler ultrasound?

PURPOSE: Aim of the study is to evaluate the incidence of DVT in COVID-19 patients and its correlation with the severity of the disease and with clinical and laboratory findings. METHODS: 234 symptomatic patients with COVID-19, diagnosed according to the World Health Organization guidelines, were included in the study. The severity of the disease was classified as moderate, severe and critical. Doppler ultrasound (DUS) was performed in all patients. DUS findings, clinical, laboratory's and therapeutic variables were investigated by contingency tables, Pearson chi square test and by Student t test and Fisher's exact test. ROC curve analysis was applied to study significant continuous variables. RESULTS: Overall incidence of DVT was 10.7% (25/234): 1.6% (1/60) among moderate cases, 13.8% (24/174) in severely and critically ill patients. Prolonged bedrest and intensive care unit admission were significantly associated with the presence of DVT (19.7%). Fraction of inspired oxygen, P/F ratio, respiratory rate, heparin administration, D-dimer, IL-6, ferritin and CRP showed correlation with DVT. CONCLUSION: DUS may be considered a useful and valid tool for early identification of DVT. In less severely affected patients, DUS as screening of DVT might be unnecessary. High rate of DVT found in severe patients and its correlation with respiratory parameters and some significant laboratory findings suggests that these can be used as a screening tool for patients who should be getting DUS.

A New Era of Extended Time Window Acute Stroke Interventions Guided by Imaging.

Ischemic stroke is one of the most debilitating and deadliest conditions worldwide. Intravenous t-PA is the current standard treatment within 4 hours after onset of symptoms. Recent randomized controlled trials have demonstrated the efficacy of neurointerventional intra-arterial treatment in acute ischemic stroke. About 20% of acute ischemic stroke are classified as wake-up strokes, which falls out of the conventional treatment time window. New evidence suggests that some patients with longer time from symptom onset (up to 24 hours) may benefit from thrombectomy, probably in part due to variations in collateral circulation among individual patients. Advanced imaging can play a crucial role in identifying patients who could benefit from endovascular intervention presenting within extended treatment time windows. In this article, we review the advanced imaging algorithm for ischemic stroke workup in the multiple studies published to date and summarize the results of the clinical trials for late ischemic stroke that can be clinically useful.

Creating 3D models from Radiologic Images for Virtual Reality Medical Education Modules.

Virtual Reality (VR) is a powerful tool that has increasingly being used by medical field in recent years. It has been mainly used surgical training in particular laparoscopic procedures. VR can be used for the teaching of anatomy. The aim of the study is to show application of transforming 2D radiologic images into 3D model by using thresholding and segmentation and import into VR interface at an affordable cost. Four anatomy modules are created with inputs to control the rotational and translational movement of 3D models in the virtual space. These movements allow users to explore 3D models by using head tilt and gaze input. 3D models of the Circle of Willis, Vertebral Aneurysm, Spine, and Skull are rendered in the user's field of view at runtime. VR is constructed to have many potentials uses in radiology education. Visualization of 3D anatomic structures in a virtual environment give another tool for teaching to students and patients about anatomy of the body. Four anatomy modules described here demonstrate example user interaction patterns best suited for viewing contexts. Instead viewing stacked 2D images or 3D models confined to desktop applications, virtual reality increases user interactivity of education. An intuitive understanding of anatomic structures in 3D space enhances the learning experience for medical students, residents, and patients we are treating.

Imaging in neurointerventional stroke treatment: review of the recent trials and what your neurointerventionalist wants to know from emergency radiologists.

Stroke is one of the leading causes of death and disability worldwide. Standard treatment for stroke is intravenous (IV) injection of tissue plasminogen activator (t-PA) rapidly after symptom onset. However, there are limitations of IV t-PA treatment, such as a short time window for administration and risk for hemorrhage. Recent trials have demonstrated the benefit of endovascular treatment when added to standard treatment to improve outcomes for patients. Advanced imaging was utilized in some trials to identify patients with proximal intracranial occlusion to target for endovascular reperfusion therapy, and to exclude patients with large infarct cores or poor collateral circulation who would not be expected to benefit from intervention. This article summarizes the use of imaging in recent stroke trials in details, provides a stroke imaging protocol, and provides tips which radiologists should know to help their neurointerventionalists.

Evaluation of medical physics training in radiology residency in 67 countries.

PURPOSE: The main aim of medical physics training in radiology residency is to have appropriate and safer imaging of patients and safety of personnel. The need to have adequate coverage of medical physics and radiation safety in curricula of radiology residency is well perceived, but it is not known how far it is implemented in practice. METHODS: We have analysed the data from 67 countries on medical physics teaching and assessment of residents in radiology programs, considering differences between countries in function of their human development index (HDI). RESULTS: The results indicate that teaching of medical physics by radiologists rather than by medical physicists is very common and there is relationship with the developmental status of a country. The majority of countries with very high HDI used a written test (69%) for medical physics topics, often in combination with other subjects (63%). Further, there is lack of direct involvement of medical physicists during the examination phase of residents. Geographically, it can be seen that Latin American countries in particular lack involvement of medical physicists during both the teaching and examination phase. CONCLUSION: The lack of adequate involvement of medical physicists in training and in the formal examination of radiology residents in both developed and developing countries is a matter of concern with likely implications on patient and staff safety.

Brain MRI Features of CSF Human Immunodeficiency Virus Escape.

BACKGROUND AND PURPOSE: HIV infection of the central nervous system (CNS) is a nearly universal feature of untreated systemic HIV infection. While combination antiretroviral therapy (ART) that suppresses systemic infection usually suppresses CNS (CNS) HIV infection, exceptions have been reported with discordance between CSF and blood HIV RNA concentrations such that CSF demonstrates higher HIV concentrations than blood, referred to as CSF HIV escape. Rarely, CSF HIV escape presents with neurological symptoms, called neurosymptomatic escape. METHODS: In this report, we describe the MRI findings in 6 patients with neurosymptomatic escape who were identified at our institution. RESULTS: MR imaging suggests an encephalitis possibly evolving from a distinct HIV subpopulation within the CNS. A major difference between primary HIV infection and the current case series is that untreated HIV encephalitis usually occurs in the setting of late disease and a low CD4 whereas CSF Escape develops in setting of a higher CD4, as well as more robust immune and inflammatory responses. Our findings show a burden and distribution of white matter signal abnormalities atypical for patients adherent to ART and that differs from that seen in untreated HIV encephalitis and leukoencephalopathy. Moreover, these patients may also demonstrate perivascular enhancement, a finding not previously reported in the CSF HIV escape literature. CONCLUSION: Recognition of these imaging characteristics-patchy subcortical white matter intensities and a perivascular pattern of enhancement-may be helpful in recognition and, along with other clinical information and CSF findings, in diagnosis of neurosymptomatic escape.

Radiology education in Europe: Analysis of results from 22 European countries.

AIM: To assess the state of radiology education across Europe by means of a survey study. METHODS: A comprehensive 23-item radiology survey was distributed via email to the International Society of Radiology members, national radiological societies, radiologists and medical physicists. Reminders to complete the survey were sent and the results were analyzed over a period of 4 mo (January-April 2016). Survey questions include length of medical school and residency training; availability of fellowship and subspecialty training; number of residency programs in each country; accreditation pathways; research training; and medical physics education. Descriptive statistics were used to analyze and summarize data. RESULTS: Radiology residency training ranges from 2-6 years with a median of 5 years, and follows 1 year of internship training in 55% (12 out of 22) European countries. Subspecialty fellowship training is offered in 55% (12 out of 22) European countries. Availability for specialization training by national societies is limited to eight countries. For nearly all respondents, less than fifty percent of radiologists travel abroad for specialization. Nine of 22 (41%) European countries have research requirements during residency. The types of certifying exam show variation where 64% (14 out of 22) European countries require both written and oral boards, 23% (5 out of 22) require oral examinations only, and 5% (1 out of 22) require written examinations only. A degree in medical physics is offered in 59% (13 out of 22) European countries and is predominantly taught by medical physicists. Nearly all respondents report that formal examinations in medical physics are required. CONCLUSION: Comparative learning experiences across the continent will help guide the development of comprehensive yet pragmatic infrastructures for radiology education and collaborations in radiology education worldwide.

Diagnostic Performance of Brain MRI in Immune Reconstitution Inflammatory Syndrome.

BACKGROUND AND PURPOSE: Central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS) significantly negatively impacts the human immunodeficiency virus (HIV)-infected population on combination antiretroviral therapy (cART). We sought to determine the diagnostic performance of several magnetic resonance imaging (MRI) features for CNS-IRIS in a cohort of HIV+ patients recently started on cART. METHODS: Our radiologic database was searched from January 2003 to September 2014 retrospectively for patients diagnosed with HIV and worsening symptoms on cART. A total of 20 patients with HIV were identified; patients were classified as having CNS-IRIS on the basis of established clinical criteria (8 patients; 12 age- and sex-matched controls). Brain MR images were obtained at a single post-cART timepoint during hospitalization for acute neurologic deterioration and blindly interpreted by two experienced neuroradiologists for the presence of four variables: intrinsic T1 hyperintensity, marginal reduced diffusion, and marginal enhancement or perivascular enhancement. RESULTS: Although each individual finding showed moderate predictive accuracy, the combination of MR findings demonstrated good test characteristics: sensitivity 88% (confidence interval [CI] 62-98), specificity 79% (58-93), positive predictive value 71% (44-90%), and negative predictive value 83% (CI 52-98%). In addition, this final diagnosis demonstrated good predictive accuracy, area under curve .78 (CI .63-.91), and moderate inter-reader agreement, κ = .55. CONCLUSIONS: Our findings suggest that although each individual MR finding shows only moderate diagnostic performance, the combined assessment of experienced neuroradiologists has good predictive accuracy. The absence of any described MRI findings makes the diagnosis of CNS-IRIS highly unlikely.

Rosai-Dorfman Disease Isolated to the Thoracic Epidural Spine.

Rosai-Dorfman disease is a rare benign histiocytic disease that infrequently presents in the spine. We report a case of Rosai-Dorfman disease isolated to the epidural thoracic spine in a 26-year-old male. To our knowledge, this is the 15th reported case of isolated spinal disease and only the fourth case of isolated thoracic epidural disease. Given its rarity as well as non-specific symptoms and imaging findings, Rosai-Dorfman disease is often not considered and misdiagnosed on imaging studies. To help improve awareness of Rosai-Dorfman spinal disease, we review the literature and discuss the epidemiology, clinical presentation, imaging features, and treatment considerations for this condition.