The Sonographic Stenosis Index: A New Specific Quantitative Measure of Transplant Hepatic Arterial Stenosis.

OBJECTIVES: This study evaluates the sensitivity and specificity of stenosis index (SI), which accounts for the entire spectral Doppler waveform, to detect significant transplant hepatic arterial stenosis. MATERIALS AND METHODS: In this institutional review board-approved, HIPAA compliant study, we retrospectively analyzed 69 patients who had catheter angiography for suspected transplant hepatic arterial stenosis (THAS) between January 2006 and December 2010; all patients had Doppler ultrasound within 30 days before angiography. Patients with angiographic stenosis requiring intervention were considered positive for THAS. Stenosis index was calculated from each patient's spectral Doppler ultrasound images by obtaining the ratio of the area under the high-frequency signal to low-frequency signal in the spectral Doppler. Resistive index (RI) and pulsatility index (PI) were also calculated. Receiver operator curve analysis was performed and the area under the curve (AUC) was compared among the three metrics. RESULTS: Forty-eight of 69 patients had THAS by angiography requiring intervention; 21patients had no angiographic evidence of THAS. SI was significantly different (P < .001) between patients with THAS (SI = 1.04 ± 0.20) and those without THAS (SI = 1.39 ± 0.30). Stenosis index had an AUC of 0.86 for detecting THAS, which was significantly higher than that from RI (AUC = 0.68, P = .038 for the comparison) and PI (AUC = 0.70, P = .029). For SI < 1.35, the sensitivity for THAS was 94% and specificity was 52%. For RI < 0.5, the sensitivity was 96% and the specificity was 29%. CONCLUSIONS: Stenosis index is more accurate than the resistive index and the pulsatility index for detecting transplant hepatic artery stenosis.

Vertebral Artery Transection in Nonpenetrating Trauma: A Series of 4 Patients.

Blunt cerebrovascular injury is a common and potentially devastating consequence of nonpenetrating trauma to the head and neck. The degree of injury ranges from minimal intimal disruption to complete transection with free extravasation. Although blunt carotid transection has been well characterized in clinical reports and radiologic studies, the computed tomographic angiography (CTA) features of blunt vertebral artery transection have not been well described. We report a series of 4 patients presenting to our level I trauma center with blunt vertebral artery transection, with an emphasis on their CTA imaging findings at presentation and their respective clinical courses. A brief review of the pertinent literature is provided.

Hepatocellular carcinoma in the noncirrhotic liver.

OBJECTIVE: Hepatocellular carcinomas (HCCs) that arise in noncirrhotic livers have several histologic and biochemical features that distinguish them from HCCs occurring in the setting of cirrhosis. Because the presentation, management, and prognosis of these entities are distinct, the accurate preoperative characterization of these lesions is of great clinical significance. We review the pathogenesis, imaging appearance, and clinical implications of noncirrhotic HCCs as they pertain to the clinical radiologist. CONCLUSION: HCCs that develop in noncirrhotic patients have distinct etiologic, cytogenetic, histopathologic, and clinical features. Despite a larger tumor burden at the time of HCC diagnosis, noncirrhotic patients with HCC have better overall survival and disease-free survival than cirrhotic patients with HCC. Knowledge of the precise clinical and imaging features of this entity and of other diagnostic considerations for the noncirrhotic liver is essential for improved patient care.

Multimodality imaging of diseases of the duodenum.

The duodenum is a unique segment of intestine, occupying both intra and extra-peritoneal locations. There is a wide spectrum of abnormalities of the duodenum that range from congenital anomalies to traumatic, inflammatory, and neoplastic entities. The duodenum may be overlooked on cross-sectional imaging due to its location and small size. Duodenal pathologies may, therefore, be missed or wrongly diagnosed. Knowledge about duodenal pathologies and optimal imaging techniques can increase diagnostic yield and permit optimal patient management. Conventionally, the duodenum was evaluated with upper GI studies on fluoroscopy; however, endoluminal evaluation is better performed with endoscopy. Additionally, a broad array of cross-sectional imaging modalities permits comprehensive assessment of the duodenum and surrounding viscera. While endoscopic sonography is increasingly used to locally stage duodenal malignancies, MDCT remains the primary modality widely used in the detection and characterization of duodenal abnormalities. MRI is used as a "problem solving" modality in select conditions. We present a comprehensive review of duodenal abnormalities with an emphasis on accurate diagnosis and management.

Arterial closure device to achieve hemostasis in children following percutaneous femoral arterial puncture.

BACKGROUND: Percutaneous arterial closure devices have increasingly entered clinical practice to assist in achieving femoral arterial access site hemostasis. Prior studies have demonstrated the safety and efficacy of several arterial closure devices in adults. OBJECTIVE: To evaluate the efficacy of using an arterial closure device in children. MATERIALS AND METHODS: A retrospective review of all children (defined as younger than 18 years) undergoing device-assisted closure of their percutaneous femoral arterial access site was conducted. Patient demographics, the clinical indications for use of the arterial closure device and pre-procedural laboratory parameters were noted. The accessed common femoral artery diameter and largest procedural sheath size were recorded. The technical success rate for device deployment and rates of immediate and delayed complications including hemorrhage, access site or retroperitoneal hematoma, access site infection, arterial thromboembolism, pseudoaneurysm or arteriovenous fistulae were documented. RESULTS: Between June 2009 and June 2011, an arterial closure device was deployed with intent to achieve hemostasis in percutaneous femoral arterial access punctures in 38 consecutive children. The mean common femoral artery diameter was 0.70 ± 0.13 cm. Device deployment was technically successful in 37/38 (97.4%) procedures. There was a single complication (2.6%), a small access site hematoma. No other immediate or delayed complications occurred. CONCLUSION: The use of a percutaneous arterial closure device can be an efficacious method for achieving immediate femoral arterial access site hemostasis with few complications in children who have undergone percutaneous femoral arterial access procedures.

Imaging of granulomatous fibrosing mediastinitis.

OBJECTIVE: The purpose of this article is to review and illustrate the pathogenesis, natural history, imaging features, and treatment of granulomatous fibrosing mediastinitis. CONCLUSION: Granulomatous fibrosing mediastinitis is an infiltrative disorder characterized by encasement of the mediastinal viscera; in most cases in the United States, it represents an idiosyncratic immune response to histoplasma. Familiarity with the various imaging features of fibrosing mediastinitis is important for prompt and accurate diagnosis as well as for planning and guiding surgical and less-invasive treatments.

Imaging of the diaphragm: anatomy and function.

The diaphragm is the primary muscle of ventilation. Dysfunction of the diaphragm is an underappreciated cause of respiratory difficulties and may be due to a wide variety of entities, including surgery, trauma, tumor, and infection. Diaphragmatic disease usually manifests as elevation at chest radiography. Functional imaging with fluoroscopy (or ultrasonography or magnetic resonance imaging) is a simple and effective method of diagnosing diaphragmatic dysfunction, which can be classified as paralysis, weakness, or eventration. Diaphragmatic paralysis is indicated by absence of orthograde excursion on quiet and deep breathing, with paradoxical motion on sniffing. Diaphragmatic weakness is indicated by reduced or delayed orthograde excursion on deep breathing, with or without paradoxical motion on sniffing. Eventration is congenital thinning of a segment of diaphragmatic muscle and manifests as focal weakness. Treatment of diaphragmatic paralysis depends on the cause of the dysfunction and the severity of the symptoms. Treatment options include plication and phrenic nerve stimulation. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.322115127/-/DC1.

Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis.

BACKGROUND: Because the surgical management of perforated appendicitis remains controversial, percutaneous catheter drainage (PCD) has gained favor for managing periappendiceal abscess in hemodynamically stable children. OBJECTIVE: To determine the safety and effectiveness of PCD in children with perforated appendicitis and to identify any variables of prognostic value. MATERIALS & METHODS: We retrospectively evaluated clinical data and imaging features for 33 children undergoing PCD for periappendiceal abscess from October 2006 to February 2010. Those with preprocedural CT studies were assigned to one of three risk categories based on imaging features. RESULTS: Appendectomy was successfully postponed for all patients. Our technical success rate was 87.9%, with three recurrences (two requiring repeat drainage, one managed conservatively) and one possible complication (enterocutaneous fistula formation). Children with large and diffuse abscesses had a 50% rate of technical failure, which was significantly increased when compared to children with large but localized abscesses (P < 0.028). Extraluminal appendicolith, extraluminal gas, leukocytosis, ileus/obstruction and procedural variables were not reliable predictors of outcome. CONCLUSION: PCD can be effective for managing perforated appendicitis in children. Children with large and ill-defined abscess might be at increased risk for complication or recurrence.

Transfer patient imaging: a survey of members of the American Society of Emergency Radiology.

When trauma patients are transferred from outside hospitals, the receiving clinicians often consult their local radiologists for definitive interpretations of outside examinations (IOE). Such requests introduce a host of logistical, medicolegal, and financial concerns related to quality control and resource utilization. We surveyed 701 members of the American Society of Emergency Radiology to elucidate these concerns. We found that the majority of emergency departments still rely on compact disks for conveyance of outside images; hard film and network transfers were minor mechanisms for most respondents. Sixty-nine percent of the respondents indicated that radiologist reports accompany fewer than 25 % of all transferred imaging studies; of the reports that do arrive, most are unverified preliminary reads. There is considerable variability in billing practices and reimbursement patterns for radiologic second opinions; 68 % of the respondents do not know how often their IOEs are reimbursed. Suboptimal communication between community hospitals and referral centers may result in duplicated efforts and inconsistent quality of medical imaging studies. Further investigation into the role of radiology trainees in the handling of outside studies is also highly recommended.

Burnout in Radiology.

Burnout is a psychological syndrome that arises in the setting of prolonged work-related stress. Although its specific manifestations are highly variable, the core features of burnout include emotional exhaustion, callousness or apathy towards patients or peers, and feelings of personal inadequacy. Burnout can have profound consequences for the affected physician, his or her patients, and the health care system at large. Increased rates of substance abuse, depression, and suicide have been linked to physician burnout, as have medical errors and lapses in patient safety. Disruptive workplace behaviors, such as presenteeism (which is reduced productivity due to physical or emotional dysfunction), absenteeism (which is nonparticipation in work), high employment turnover, and early retirement also have been linked to physician burnout and depression. In this article, we review causes, preventive measures and possible solutions for physician burnout.

Design and implementation of handheld and desktop software for the structured reporting of hepatic masses using the LI-RADS schema.

RATIONALE AND OBJECTIVES: The Liver Imaging Reporting and Data System (LI-RADS) can enhance communication between radiologists and clinicians if applied consistently. We identified an institutional need to improve liver imaging report standardization and developed handheld and desktop software to serve this purpose. MATERIALS AND METHODS: We developed two complementary applications that implement the LI-RADS schema. A mobile application for iOS devices written in the Objective-C language allows for rapid characterization of hepatic observations under a variety of circumstances. A desktop application written in the Java language allows for comprehensive observation characterization and standardized report text generation. We chose the applications' languages and feature sets based on the computing resources of target platforms, anticipated usage scenarios, and ease of application installation, deployment, and updating. RESULTS: Our primary results are the publication of the core source code implementing the LI-RADS algorithm and the availability of the applications for use worldwide via our website, http://www.liradsapp.com/. The Java application is free open-source software that can be integrated into nearly any vendor's reporting system. The iOS application is distributed through Apple's iTunes App Store. Observation categorizations of both programs have been manually validated to be correct. The iOS application has been used to characterize liver tumors during multidisciplinary conferences of our institution, and several faculty members, fellows, and residents have adopted the generated text of Java application into their diagnostic reports. CONCLUSIONS: Although these two applications were developed for the specific reporting requirements of our liver tumor service, we intend to apply this development model to other diseases as well. Through semiautomated structured report generation and observation characterization, we aim to improve patient care while increasing radiologist efficiency.

Internal versus external moonlighting by radiology trainees: differences in roles and responsibilities.

RATIONALE AND OBJECTIVES: Recent survey data have suggested that the paid extracurricular activities of radiology trainees (known as "moonlighting") are more diverse than has been previously recognized. The purpose of this study is to examine these activities in further detail and to assess for differences between clinical duties performed at institutions affiliated with residents' training programs ("internal moonlighting") versus those performed at unaffiliated institutions ("external moonlighting"). MATERIALS AND METHODS: Electronic survey data were collected from trainee members of the Association of University Radiologists regarding their extracurricular clinical work, with an emphasis on their responsibilities when working in institutions that are affiliated with their training program versus work done in unaffiliated institutions. Descriptive and analytic statistics were used to examine these data. RESULTS: Survey respondents represented 61 unique institutions (of 173 Association of University Radiologists member-programs, a 35% institutional response rate). Trainees engage in moonlighting activities at nearly three-fourths of these programs. Although the incidence of duty hour violations appears to be low ("probably" or "definitely" occurring at three of 44, or 7%, of represented programs with moonlighting trainees), these violations go largely undocumented. Residents participating in external moonlighting were significantly more likely to provide final interpretations of diagnostic imaging studies when compared with residents moonlighting internally (odds ratio 13.84, P < .05). Of the 27 programs with residents that moonlight externally, five respondents (19%) indicated that their external moonlighting duties include the unsupervised performance of invasive procedures. There were no reports of unsupervised procedures performed by trainees moonlighting internally. CONCLUSIONS: Many resident physicians view moonlighting as a highly desirable, or even financially necessary, component of their clinical training. Although external moonlighting may be a useful means of garnering additional experience and income, certain ethical and medicolegal implications must be considered. The moonlighting trainee should seek opportunities for extracurricular work that do not compromise patient safety or the trainee's own long-term professional interests. Department administrators might facilitate this process by providing opportunities for internal moonlighting, while simultaneously developing competency-based systems for assessing trainee readiness for progressive clinical independence.

Transfer patient imaging: current status, review of the literature, and the Harborview experience.

Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described.

The emotional wellness of radiology trainees: prevalence and predictors of burnout.

RATIONALE AND OBJECTIVES: Burnout is a complex phenomenon characterized by emotional exhaustion, social detachment, and feelings of low personal achievement. In this study, we aim to establish the prevalence of burnout among radiology trainees and to explore the factors influencing its development. MATERIALS AND METHODS: Survey data were collected from 266 trainee members of the Association of University Radiologists to assess financial status, attitudes toward money and compensation, and burnout symptomology. Descriptive and inferential statistics were used to analyze these data. RESULTS: Most radiology residents reported high levels of personal achievement but routine symptoms of emotional exhaustion and depersonalization. Although increasing levels of household debt were correlated with symptoms of depersonalization and lower reported quality of life, we found that the subjective financial experience was a more reliable indicator of emotional well-being. Specifically, higher subjective self-assessments of financial strain were the best predictors of symptoms of depersonalization (P < .0001), emotional exhaustion (P < .0001), and lower self-reported quality of life (P < .0001). Additionally, residents with recent moonlighting activity reported higher levels of personal achievement (P < .05), lower levels of emotional exhaustion (P < .05), and greater quality of life (P < .05) when compared to non-moonlighters. CONCLUSIONS: The unique nature of radiology training could mean that traditional assumptions regarding the development of trainee burnout do not necessarily apply. Finances may be an underappreciated influence on resident burnout, and subjective feelings of financial scarcity could outweigh the impact of objective indebtedness. Further study is needed to ensure that the emotional well-being of radiology trainees is optimally supported.

The nature and scope of moonlighting by radiology trainees.

RATIONALE AND OBJECTIVES: The practice of moonlighting by trainees is a longstanding controversy; however, the resident point of view remains distinctly underrepresented in the radiology literature. We report the resident perspective on the moonlighting practices of radiology trainees. METHODS: Survey data were collected from resident members of the Association of University Radiologists representing 84 training programs in the United States to assess their routine and extracurricular clinical responsibilities. Descriptive statistics were used to analyze these data. RESULTS: Moonlighting is practiced by radiology trainees at nearly three-fourths of the programs represented in this survey. Interpreting diagnostic imaging (85.5%) and monitoring contrast administrations (72.6%) are the most common duties performed. Twenty-one percent of moonlighting trainees perform procedures (excluding diagnostic fluoroscopy) in their extracurricular positions; of these, most (61.5%) are without attending supervision. Most trainees that moonlight spend 1 to 10 hours weekly doing so while averaging a 59-hour workweek at their primary jobs. CONCLUSIONS: The clinical duties of moonlighting trainees may be more diverse than has been previously recognized. Although major discrepancies between overnight radiology trainee interpretations and attending final interpretations have been shown to be infrequent, the consequences of trainees performing procedures and monitoring adverse contrast reactions without attending supervision are unknown. The financial and professional benefits of moonlighting must be weighed against the potential for harm. Our data suggest that most moonlighting radiology trainees operate within the Accreditation Council for Graduate Medical Education-mandated 80-hour weekly work limit; the mandatory 8-hour break between shifts and 24-hour continuous duty limit may pose logistical challenges.