Splenic trauma in the pediatric patient: the integrated roles of ultrasound and computed tomography.

Seven children who sustained splenic trauma were scanned by ultrasound and computed tomography (CT) or ultrasound and nuclear liver/spleen scan. All patients were managed conservatively and did not need abdominal surgery. On the initial sonogram, the majority of children had multiple areas of both increased and decreased echogenicity. Hematomas were followed to resolution in five of seven children and were usually multiple and hypoechoic prior to complete disappearance. On contrast-enhanced CT scans, areas of splenic hemorrhage appeared as low attenuation. Our small patient population demonstrates that, following an initial CT scan, sonography is helpful for sequential splenic imaging to show when the appearance of the spleen returns to normal. When correlated with the clinical information, such data are helpful to the clinician in determining when a child who has sustained splenic trauma may resume normal activity.

Objectively evaluating student case presentations.

Evaluation and documentation of student performance is of major importance to a radiology elective coordinator. To better assess a variety of aspects of competence and learning, an oral case presentation was included in the final elective evaluation. This article describes the 31-item checklist designed to assess the level of student achievement of the objectives for the oral presentation. In addition to developing this standard evaluation instrument, methodologies were used to increase the validity and reliability of the oral presentation; the examiners were briefed in advance, the checklist included cognitive and noncognitive measures, and a simple grading score was used for each item. Students who received the checklist and written course objectives at the beginning of the elective earned better grades than those students who did not receive the materials. Student evaluations reveal that the oral case presentation as presently organized is felt to be of value.

Constructing pre- and post-tests in a medical student elective.

The importance of evaluating medical student performance has been widely addressed in the medical education literature. Multiple-choice examinations are the preferred method of testing because they are easy to administer and score. Development of parallel or equivalent pre- and post-examinations provides objective information regarding actual knowledge gains by the students during the elective and points to strengths and weaknesses in the elective. This article provides information for developing the parallel multiple-choice questions for effective pre- and post-tests.

Guidelines for writing multiple-choice questions in radiology courses.

Objective evaluation of students frequently includes the utilization of multiple-choice test questions. Due to constraints on faculty time, however, the writing of these questions is usually completed quickly and somewhat haphazardly. The guidelines contained in this article were written to help radiologists produce better test questions for the purpose of improving the evaluation of clerkship students. The guidelines include choosing an item that is worth testing and has one definite answer, asking a single, clearly formulated question, avoiding true-false stems, being concise when writing the question, avoiding the use of negatives in the stem, avoiding using "all of the above" or "none of the above" as a response, avoiding subtle clues toward the keyed answer or away from the distractors, avoiding one-word definitions as responses, and placing the responses in logical or numerical order. A definition of terms used in the educational literature and a discussion of a quantitative evaluation of test questions are included.

First-year medical students' attitudes toward radiology.

To explore the perspectives of entering medical students, a questionnaire was completed anonymously by 171 students in September of their first year of medical school. The authors investigated their attitudes toward radiology relative to other specialties and their perspective concerning which factors would influence their eventual choice of a specialty. Upon entering medical school, 33.3% of the students indicated that they had chosen a specialty, and 7.4% of these students had selected radiology. Radiology was perceived as a well-paid specialty with a pleasant lifestyle. These are factors that were perceived as very important regarding influence on eventual choice of specialty. However, radiology was believed to have an undesirably low level of patient contact and was perceived as not being intellectually exciting. We plan to follow this group of students prospectively through medical school to see whether their attitudes change toward radiology as a career.

Systematic evaluation and increased structure in a radiology elective.

Diagnostic radiology is expanding, playing an increasingly central role in patient care, which heightens the importance of radiology teaching in undergraduate medical education. This study examined the impact of increased structure and systematic evaluation on student performance in a radiology elective. The evaluation protocol included premultiple and postmultiple choice examinations (70 questions each), a film interpretation quiz (ten films, 20 questions), faculty assessment of a student oral case presentation, and student evaluations of the elective experience. The relationships among the evaluation techniques, as well as differences in class level and course ratings were also examined. Two different treatment groups were studied. Group 1 was given general objectives and information regarding availability of recommended resources, including self-learning materials for the elective, didactic seminars, and viewbox exposure. Group 2 was given specific written instructional objectives, a structured schedule for viewing the self-learning materials, and the same seminars and viewbox exposure. The statistically significant higher performance of the structured group suggests that medical students achieve the objectives of an elective better when learning activities are well defined, structured, and systematically evaluated. In addition, those students receiving the structured experience rated the radiology elective more favorably.

Journal publications in radiology education. A review of the literature, 1966-1986.

Published scholarly activity pertaining to radiology education is relatively uncommon compared with an extensive clinical literature. To guide future radiology educational efforts in a time of changing priorities and practice patterns, the authors undertook an in-depth review and analysis of the existing radiology education literature covering the 20-year period from 1966 to 1986. A total of 194 articles was identified via a computerized literature search and manual cross-checking of cited references. Articles pertinent to medical student radiology education (36.6%) or radiology resident education (29.9%) predominated. The majority of published radiology education articles were editorials (35.5%) or expository in nature (49.5%). Surveys (5.1%) and experimental research (8.7%) comprised the balance. Although editorial opinions and personal reflections are important and valuable resources for radiology educators, a substantial lack of empirical research in radiology education exists. Additional knowledge in underdeveloped research areas is essential for future curriculum planning and development in radiology education.

Medical student attitudes toward radiology. A multi-institutional survey.

A questionnaire was administered to 238 students at four institutions before and after a radiology clerkship to evaluate student attitudes regarding radiology as a career, radiologist expertise, and clerkship expectations. There was no statistically significant difference among the clerkships, although they varied in types of experience, geographic location, and size. After the clerkship, the students agreed more strongly that the radiologist should be involved in patient workup, screening of requests, interpretation of emergency room films, and consultations. A significant change in attitude could be identified after the four-week experience, indicating a desire for the radiologist to have a more active role as imaging consultant.

Late results of fundoplication for gastroesophageal reflux in infants and children.

The Nissen fundoplication (NFP) for the management of severe gastroesophageal reflux (GER) in infants and children has become one of the most frequently performed operations in pediatric surgical centers in the United States. Short-term outcome, morbidity, and mortality are consistently favorable in several large series. The long-term success of this procedure is presumed but has not been established objectively. To examine the late results of this operation, 46 infants and children were carefully evaluated more than 5 years after NFP (mean, 6.7 years). Evaluation included parental interview, physical examination, upper gastrointestinal series, and esophageal pH monitoring. The mean age at the time of operation was 4.13 years. Fifty-seven percent of the patients had significant neurologic impairment, and 80% had at least one serious additional medical problem. Twenty-four percent of the children died during the period of follow-up--all but one death related to serious underlying medical problems. Of the 35 survivors, 26 (74.3%) have no symptoms; five (14.3%) have mild symptoms potentially referable to GER that necessitate little if any treatment; four (11.5%) have had symptomatic recurrence of GER necessitating repeat fundoplication. Three of these patients now have no symptoms. Forty-five percent of the patients had at least one postoperative complication. NFP provides efficacious, long-term treatment of GER in infants and children, with acceptable morbidity. Mortality in this group of children is related primarily to associated diseases rather than to GER.

Periventricular cavitations in the first week of life.

Eleven infants were encountered (nine premature, two term) in whom well-defined small periventricular cavitations were found by sonography in the first week of life. The sonographic findings bore remarkable similarity to subependymal pseudocysts in neonates previously described in autopsy specimens. The cavitations, which were identified predominantly along the superolateral aspects of the lateral ventricles, did not evolve in the manner of postnatally acquired periventricular leukomalacia. The location of the cavitations differed from the site of previously reported lesions of posthemorrhagic and postinfectious germinolysis along the medial aspect of the caudothalamic groove. Neurosonologists and neonatologists should be alerted to this finding and encouraged to follow these infants as a separate group to learn whether neurodevelopmental sequelae occur in these children.

Predicting outcome at the knee in juvenile rheumatoid arthritis.

This study was undertaken to correlate long-term severe radiographic changes with clinical profiles in an attempt to identify a group of patients at risk. Knee radiographs of 100 juvenile rheumatoid arthritis (JRA) patients with 1-20 years of follow-up studies were reviewed for changes leading to severe disability. Eighteen children had evidence of destructive changes an average of 4.3 years after onset of JRA. 23 patients had reactive changes superimposed on destructive changes seen 9.7 years after onset of disease. 92% of the children with reactive and destructive knee changes had radiographic evidence of significant JRA at another joint. Polyarticular disease with significant JRA involvement of another joint seems to indicate a group of children at higher risk for destructive and reactive changes at the knee.

Familial cervical dysplasia.

Nine of twelve family members from three generations were affected by an inherited form of cervical vertebral dysplasia. All of the affected people had an abnormality of the first cervical vertebra. Some also had defects of the axis and caudad to it. The mode of transmission of the disorder is autosomal dominant, with apparently complete penetrance and variable expressivity. Two patients had symptoms. One had a passively correctable tilt of the head, with an associated audible clunk and hypoplasia of the left superior facet of the second cervical vertebra. This patient had no local symptoms, neurological involvement, or muscle spasm. In the other patient, suboccipital pain developed. Radiographs revealed an anterior atlanto-occipital dislocation. The symptoms resolved after reduction and arthrodesis. Because of the apparently complete penetrance of this disorder, physicians caring for patients who have this type of congenital malformation of the cervical spine should consider examination of closely related members of the family. Clinical findings such as tilting of the head, torticollis, or limitation of cervical motion suggest that additional evaluation should be done. The examination should include lateral radiographs of the cervical spine in flexion and extension. Three-dimensional computed-tomography reformatting was helpful in demonstrating the complex cervical anatomy in our patients. Patients who have recognized abnormalities should be followed and should be re-examined whenever local or neurological symptoms develop. A magnetic resonance image of the spine in flexion and extension was valuable for identification of the potentially disastrous situation of impending damage to the cord in patients who had instability and evolving symptoms.

Limitations of student evaluations of curriculum.

RATIONALE AND OBJECTIVES: Medical student surveys are used extensively in the development and modification of curriculum. The purpose of this study was to look at medical student surveys of a radiology lecture series, evaluating the accuracy of student perceptions of learning and factors affecting them. MATERIALS AND METHODS: After a "Case of the Week" lecture series, 156 3rd-year medical students returned a survey evaluating the experience with 10 questions on a four-point scale (1 = disagree, 4 = agree very much) and took a clinical competency assessment (CCA) examination with a radiology substation. Survey responses were compared with actual examination performance, analyzed for how overall learning was characterized in specific educational objectives, and evaluated for factors affecting perceived learning. RESULTS: The mean response for perceived CCA examination preparedness was 1.83. The mean radiology station test score was 90.43%. Correlations between student perception of learning and the scoring of focused learning objectives ranged from 0.33 to 0.48 (P < .01). Students responding 1 to items assessing perceived lecture organization, stimulation to read, and interest in the field of radiology had mean scores for perception of overall learning of 2.09-2.44 and mean scores for recommendation of course continuation of 1.68-2.46. Students responding 4 had means of 3.25-3.81 and 3.06-4.0, respectively. CONCLUSION: Student perceptions of the value of curriculum were inaccurate compared with external measures of performance, and students poorly related their general impressions to specific learning objectives. Perceived lecture organization, stimulation to read, and interest in radiology as a specialty affected perceived overall learning and perceived value of the lecture series.

Improvement of faculty teaching performance: efficacy of resident evaluations.

RATIONALE AND OBJECTIVES: We assessed the effects on the perceived quality of faculty teaching of a resident evaluation form that solicits specific comments on faculty strengths and weaknesses. METHODS: An evaluation form was devised that rated faculty on a scale of 1-10 in teaching conference quality, availability, efficiency, and teaching. The form requested constructive comments on faculty strengths and weaknesses. The forms were completed anonymously by residents at all levels. Individual results and means for the department were tabulated and provided to each faculty member in a personal interview. Change in performance was assessed by comparing faculty evaluation scores for 2 consecutive years. RESULTS: The mean faculty scores for teaching conference quality, availability, efficiency, and teaching increased from 7.8, 7.9, 7.9, and 7.7 to 8.1, 8.3, 8.3, and 8.1 in each of the respective areas. The scores of the faculty members who initially received the 10 lowest scores rose to an even greater extent (from 6.2, 6.2, 6.0, and 6.0 to 6.8, 7.4, 7.3, and 6.8 in each of the respective areas), whereas the scores of the faculty members who initially received the 10 highest scores remained relatively constant. CONCLUSION: The perceived quality of certain focused aspects of resident teaching can be modified by use of resident evaluations that solicit specific suggestions for improvement. With appropriate feedback, this is an effective tool for improving the teaching performance of radiology department faculty, particularly those considered to be the weakest teachers.

Medical students' attitudes toward radiology: comparison of matriculating and graduating students.

RATIONALE AND OBJECTIVES: To determine graduating medical students' perceptions of radiology and to document changes in their perceptions since they entered medical school. MATERIALS AND METHODS: A survey questionnaire was distributed to 213 graduating students. Questions were similar to those answered by the same group of students as they entered medical school nearly 4 years earlier. RESULTS: The survey was anonymously completed by 140 students. Seventy percent of students changed their choice of medical specialty since entering medical school. Factors with a major or important influence on specialty choice included intellectual excitement (96%), high patient contact (86%), opportunity for a good family life (72%), and regular hours (57%). Radiology was perceived to be a well-paid (89%), "high-tech" (86%) specialty with a healthy lifestyle (82%), regular hours (99%), and good family life (92%), but it was not perceived to offer high patient contact (1%) and was intellectually exciting to only 33% of students. This perception was unchanged from freshman year. CONCLUSIONS: This 4-year longitudinal study of a medical student class documents surprisingly little change in the perception of radiology throughout medical school. High patient contact and intellectual excitement, both factors of major or important influence on specialty choice, were thought to be lacking in radiology.

Journal publications in radiologic education: a review of the literature, 1987-1997.

RATIONALE AND OBJECTIVES: This study was designed to analyze articles on radiologic education quantitatively and qualitatively, comparing those published in 1987-1997 with those published in 1966-1986. MATERIALS AND METHODS: An initial literature search used four major databases to identify and retrieve articles related to radiologic education. Additional articles were identified through manual cross-checking of references from the original articles. All articles were reviewed by two radiologists as to type of article (editorial, expository, survey, correlational, or experimental, including preexperimental, quasi-experimental, or true experimental), statistics used (inferential or descriptive), educational emphasis (medical student, resident, postgraduate, or other), and topic of article (philosophical or political, technology, program evaluation, program description, examinations, or career decisions). Interrater agreement was estimated by means of the kappa statistic. A chi2 test for independence was used to assess whether the relative distribution of articles was similar for the two periods. RESULTS: More articles per year were published in 1987-1997 (n = 12.6, P < .01) compared with 1966-1986 (n = 9.2). Articles pertinent to radiologic resident education predominated (50.7% vs 29.9% in the prior study, P < .01). In both periods, most articles were expository (37.7% vs 49.5%), and the most common topic was program description (34% vs 35%). Editorials decreased from 35.5% to 18.1%. Experimental studies accounted for 12.3%, increased from 8.7%. The fastest-growing topic of study was technology (30.4% vs 17.5%, P < .01). CONCLUSION: The increased number of articles addressing radiologic education is encouraging. Although the percentage of experimental studies increased slightly in this period, there is still little empirical research in radiologic education.

Value of case-of-the-week presentations on the radiology component of the Comprehensive Clinical Assessment examination.

RATIONALE AND OBJECTIVES: The Comprehensive Clinical Assessment (CCA) examination at the University of Michigan Medical School is a series of test stations through which the mastery of clinical skills is evaluated. The purpose of this study was to determine whether student performance on the radiology station improved in years when radiology faculty presented case-of-the-week unknowns to the 3rd-year students. MATERIALS AND METHODS: The authors compared four separate classes of medical students in examination years 1993, 1994, 1995, and 1996 by using the total CCA examination score, the radiology station score, and radiology station pass/fail rates. Radiology case-of-the-week presentations were given by the radiology faculty only in academic years 1993-1994 and 1994-1995 (examination years 1994 and 1995). RESULTS: The means and standard deviations of the radiology station scores for the examination years when case-of-the-week presentations were not given, 1993 and 1996, were 78.92 +/- 13.62 and 79.76 +/- 13.62, respectively. In the years case-of-the-week presentations were given, 1994 and 1995, the radiology station scores averaged 90.83 +/- 8.58 and 89.97 +/- 9.66, respectively (P < .001, global alpha = .05). Total CCA percentage correct scores were similar for all years studied. In 1993 and 1996, 7.6% and 5.3% of students, respectively, failed the radiology station. In 1994 and 1995, 0.4% and 0% of students, respectively, failed (P < .0001). CONCLUSION: Case-of-the-week presentations by radiology faculty increased 3rd-year students' basic radiologic knowledge as evidenced by increased scores on the radiology station of the CCA examination.

Performance on the radiology component of a critical clinical skills examination.

RATIONALE AND OBJECTIVES: Clinical competence certification is now required in some specialties in medicine. A Comprehensive Clinical Assessment (CCA) was created to test mastery of critical skills by students at the end of the 3rd year of medical school. METHODS: The CCA is a series of stations that test skills the faculty consider important for all medical students (eg, breast examination, electrocardiogram reading, chest pain assessment, ophthalmology photographs). The radiology station was designed to evaluate imaging skills believed to be taught and learned in the core 3rd-year rotations. RESULTS: External measures (National Board Examinations, grade point average, and overall score) of clinical performance of the 608 medical students who completed the CCA examination between 1991 and 1993 were found to be correlated with the radiology station scores. CONCLUSION: The radiology station in the CCA examination is a reproducible measure of clinical performance.

Digital mammography: observer performance study of the effects of pixel size on the characterization of malignant and benign microcalcifications.

RATIONALE AND OBJECTIVES: The authors performed this study to evaluate the effects of pixel size on the characterization of mammographic microcalcifications by radiologists. MATERIALS AND METHODS: Two-view mammograms of 112 microcalcification clusters were digitized with a laser scanner at a pixel size of 35 microm. Images with pixel sizes of 70, 105, and 140 microm were derived from the 35-microm-pixel size images by averaging neighboring pixels. The malignancy or benignity of the microcalcifications had been determined with findings at biopsy or 2-year follow-up. Region-of-interest images containing the microcalcifications were printed with a laser imager. Seven radiologists participated in a receiver operating characteristic (ROC) study to estimate the likelihood of malignancy. The classification accuracy was quantified with the area under the ROC curve (Az). The statistical significance of the differences in the Az values for different pixel sizes was estimated with the Dorfman-Berbaum-Metz method and the Student paired t test. The variance components were analyzed with a bootstrap method. RESULTS: The higher-resolution images did not result in better classification; the average Az with a pixel size of 35 microm was lower than that with pixel sizes of 70 and 105 microm. The differences in Az between different pixel sizes did not achieve statistical significance. CONCLUSION: Pixel sizes in the range studied do not have a strong effect on radiologists' accuracy in the characterization of microcalcifications. The low specificity of the image features of microcalcifications and the large interobserver and intraobserver variabilities may have prevented small advantages in image resolution from being observed.

Enterocolitis associated with Hirschsprung's disease: a clinical-radiological characterization based on 168 patients.

The enterocolitis associated with Hirschsprung's disease (HD) has not been clearly characterized. This study was undertaken to analyze the clinical and radiological findings of Hirschsprung's enterocolitis (HEC) in 168 patients treated from July 1974 through October 1992. HEC occurred in 57 patients (33.9%), either preoperatively (13; 7.7%) or postoperatively (36; 21.4%). In eight patients (4.8%), it occurred pre- and postoperatively. The number of bouts of HEC per patient ranged from one to six (mean, 2.2). The major presenting features were abdominal distension (83%), explosive diarrhea (69%), vomiting (51%), fever (34%), lethargy (27%), rectal bleeding (5%), and colonic perforation (2.5%). There were no deaths directly related to HEC. The analysis of 150 plain x-rays of the abdomen, taken at the onset of HEC or in between bouts, showed that colonic dilatation was the most sensitive radiological finding (90% sensitivity), but it had poor specificity (24%). However, an intestinal cutoff sign (gaseous intestinal distension with abrupt cutoff at the level of the pelvic brim) was both sensitive (74%) and specific (86%) for HEC. Barium enema was of limited value in the diagnosis of HEC bouts because most of the radiographic findings persisted for prolonged periods after cessation of such bouts. The authors conclude that (1) HEC can be characterized as abdominal distension and explosive diarrhea associated with the intestinal cutoff sign and (2) the occurrence of explosive diarrhea in any patient with HD is suggestive of HEC, even in the absence of systemic symptoms, and should be treated to avoid the morbidity and potential mortality of HEC.