Approaches and Limitations of Machine Learning for Synthetic Ultrasound Generation: A Scoping Review.

This scoping review examines the emerging field of synthetic ultrasound generation using machine learning (ML) models in radiology. Nineteen studies were analyzed, revealing three primary methodological strategies: unconditional generation, conditional generation, and domain translation. Synthetic ultrasound is mainly used to augment training datasets and as training material for radiologists. Blind expert assessment and Fréchet Inception Distance are common evaluation methods. Current limitations include the need for large training datasets, manual annotations for controllable generation, and insufficient research on incorporating new domain knowledge. While generative ultrasound models show promise, further work is required for clinical implementation.

Knowledge and Perceptions of Competency-Based Medical Education in Diagnostic Radiology Post-Graduate Medical Education: Identifying Priorities and Developing a Framework for Professional Development Activities.

Introduction: We evaluated knowledge and perceptions of an established Competency-Based Medical Education (CBME) model developed by the Royal College of Physicians and Surgeons of Canada, Competence by Design (CBD), and identified evidence-informed priorities for professional development activities (PDAs). Materials and Methods: Teaching faculty and residents at a single, large diagnostic radiology post-graduate medical education (PGME) program were eligible to participate in this cross-sectional, survey-based study. Knowledge of CBD was evaluated through multiple choice questions (MCQs), which assessed participants' understanding of major principles and terms associated with CBD. Participants' perceptions of the anticipated impact of CBD on resident education and patient care were evaluated and priorities for PDAs were identified, which informed a framework for CBD PDAs. Results: Fifty faculty and residents participated. The faculty and resident response rates were 11.6% (n = 29/249) and 55.3% (n = 21/38), respectively. The mean ± standard deviation overall score on MCQs was 39.0% ± 20.4%. The majority of participants perceived the impact of CBD on resident education to be equivocal and to not impact patient care. Knowledge of CBD was not statistically significantly associated with participants' perceptions of the impact of CBD on either resident education or patient care (P > .05). Delivery of high-quality feedback was the greatest priority identified for PDAs. Discussion: Our results and proposed CBD PDAs framework may help to guide diagnostic radiology PGME programs in designing evidence-informed PDAs, which may meaningfully contribute to the successful implementation of CBD in diagnostic radiology PGME. As diagnostic radiology PGME programs throughout the world increasingly implement CBME models, evidence-informed PDAs will become of increasing importance.

Preparedness of Residents and Medical Students for the Transition to Competence by Design in Diagnostic Radiology Post-Graduate Medical Education.

Introduction: This needs assessment evaluated residents' and medical students' knowledge of Competence by Design (CBD), perceived benefits of and challenges or barriers to the transition to CBD for residents, and perceived overall preparedness for the transition to CBD in diagnostic radiology. Materials and Methods: All diagnostic radiology residents and medical students in Canada were eligible to participate in this national cross-sectional, questionnaire-based needs assessment. Knowledge of CBD was evaluated through participants' self-reported rating of their knowledge of CBD on a 5-point Likert scale. Perceived benefits of and challenges or barriers to the transition to CBD for residents were rank ordered. Participants' overall self-reported preparedness for the transition to CBD was assessed on a 5-point Likert scale. Data were summarized by descriptive statistics and bivariate analyses were conducted as appropriate. Results: Ninety-four residents (n = 77) and medical students (n = 17) participated in this needs assessment. Participants' mean ± standard deviation self-reported rating of their overall knowledge of CBD was 2.86 ± .94. Provision of meaningful feedback to learners and learners' ability to identify their own educational needs were among the highest ranked perceived benefits of the transition to CBD, while demands on time and increased frequency of evaluation were among the highest ranked perceived challenges or barriers to the transition to CBD. Few participants reported being either "prepared" (4.7%) or "somewhat prepared" (14.0%) for the transition to CBD. Conclusion: Preparedness for the transition to CBD in diagnostic radiology may be improved. Targeted interventions to augment the preparedness of residents and medical students should be considered.

Rotator Cuff Injury and Repair.

Rotator cuff pathology is a commonly encountered clinical and radiologic entity that can manifest as tendinopathy or tearing. Magnetic resonance imaging (MRI) and ultrasonography offer similar sensitivity and specificity for the evaluation of the native rotator cuff, and the chosen modality may vary, depending on local practice and accessibility. MR arthrography is frequently used in the postoperative setting as a problem-solving tool. Key findings to include in the preoperative MRI report include the size and location of the tear, thickness of the tendon involved (partial versus full thickness), and overall tendon quality. The report should also address features associated with poor surgical outcomes, such as fatty atrophy, a decreased acromiohumeral interval, and evidence of rotator cuff arthropathy. Musculoskeletal radiologists should be familiar with the various surgical techniques and expected postoperative imaging appearance of rotator cuff repairs. Imaging also plays a role in identifying recurrent tearing, graft failure, hardware loosening, infection, and other complications.

Leadership Development Programs for Radiology Residents: A Literature Review.

PURPOSE: Leadership development has become increasingly important in medical education, including postgraduate training in the specialty of radiology. Since leadership skills may be acquired, there is a need to establish leadership education in radiology residency training. However, there is a paucity of literature examining the design, delivery, and evaluation of such programs. The purpose of this study is to collate and characterize leadership training programs across postgraduate radiology residencies found in the literature. METHODS: A scoping review was conducted. Relevant articles were identified through a search of Ovid MEDLINE, Ovid EMBASE, Cochrane, PubMed, Scopus, and ERIC databases from inception until June 22, 2020. English-language studies characterizing leadership training programs offered during postgraduate radiology residency were included. A search of the grey literature was completed via a web-based search for target programs within North America. RESULTS: The literature search yielded 1168 citations, with 6 studies meeting inclusion criteria. Four studies were prospective case series and two were retrospective. There was heterogeneity regarding program structure, content, teaching methodology, and evaluation design. All programs were located in the United States. Outcome metrics and success of the programs was variably reported, with a mix of online and in person feedback used. The grey literature search revealed 3 American-based programs specifically catered to radiology residents, and none within Canada. CONCLUSION: The review highlighted a paucity of published literature describing leadership development efforts within radiology residency programs. The heterogeneity of programs highlighted the need for guidance from regulatory bodies regarding delivery of leadership curricula.

Lessons Learned From the Effects of COVID-19 on the Training and Education Workflow of Radiology Residents-A Time for Reflection: Perspectives of Residency Program Directors and Residents in Canada.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has led to widespread changes in all health care settings including academic radiology departments. The purpose of this survey-based study was to investigate the impact of COVID-19 on radiology resident training and education workflow in Canada in terms of the nature, scale, and heterogeneity of the changes, preparedness and adaptation, and perceptions of the present and future of radiology training. METHODS: A 30-question web-based survey was sent to 17 radiology residency program directors across Canada. A separate 32-question survey was sent to 460 residents currently enrolled in a radiology residency in Canada. These surveys were open for 3 weeks. RESULTS: We received responses from 16 program directors and 80 residents (response rates 94.1% and 17.4%, respectively). Most respondents agreed that objectives were being met for knowledge and interpretation but less so for case volumes and technical skills. Less time was allotted for on-site activities (eg, readouts) with more time for off-site activities (eg, videoconferencing). Daytime rotations were at least partly cancelled. Most respondents felt these changes were met with enthusiasm by both faculty and residents. However, there were perceived challenges including lack of training on virtual platforms for delivery of teaching and decreased staff-resident interaction, with short- and long-term anxiety reported. CONCLUSIONS: The coronavirus disease 2019 has dramatically changed radiology resident training in Canada, with increased virtual learning at the expense of cancelled rotations and the resultant reduction in case volumes and staff-resident interaction. Although adopted with enthusiasm, these changes present substantial challenges and anxiety regarding the future of radiology resident education.

Vertebral Fractures: Which Radiological Criteria Are Better Associated With the Clinical Course of Osteoporosis?

STUDY PURPOSE: Morphometric methods categorize potential osteoporotic vertebral fractures (OVF) on the basis of loss of vertebral height. A particular example is the widely used semiquantitative morphometric tool proposed by Genant (GSQ). A newer morphologic algorithm-based qualitative (mABQ) tool focuses on vertebral end-plate damage in recognizing OVF. We used data from both sexes in the Canadian Multicentre Osteoporosis Study (CaMos) to compare the 2 methods in identifying OVF at baseline and during 10 years of follow-up. MATERIALS AND METHODS: We obtained lateral thoracic and lumbar spinal radiographs (T4-L4) 3 times, at 5-year intervals, in 828 participants of the population-based CaMos. Logistic regressions were used to study the association of 10-year changes in bone mineral density (BMD) with incident fractures. RESULTS: At baseline, 161 participants had grade 1 and 32 had grade 2 GSQ OVF; over the next 10 years, only 9 of these participants had sustained incident GSQ OVF. Contrastingly, 21 participants at baseline had grade 1 and 48 grade 2 mABQ events; over the next 10 years, 79 subjects experienced incident grade 1 or grade 2 mABQ events. Thus, incident grades 1 and 2 morphologic fractures were 8 times more common than morphometric deformities alone. Each 10-year decrease of 0.01 g/cm2 in total hip BMD was associated with a 4.1% (95% CI: 0.7-7.3) higher odds of having an incident vertebral fracture. CONCLUSIONS: This analysis further suggests that morphometric deformities and morphologic fractures constitute distinct entities; morphologic fractures conform more closely to the expected epidemiology of OVF.

Gender Disparity Among Leaders of Canadian Academic Radiology Departments.

OBJECTIVE. Underrepresentation of women in the top hierarchy of academic medicine exists despite women comprising more than half of the medical school graduates and residency positions. The purpose of this study is to analyze and quantify the relationship of gender, research productivity, and career advancement in Canadian academic radiology departments. MATERIALS AND METHODS. Seventeen academic radiology departments with affiliated residency programs in Canada were searched for publicly available data on faculty to generate a database for gender and academic profiles of the radiologists. Bibliometric data were collected using Scopus archives. The associations of gender, academic ranks, and leadership positions were assessed, and a p value of ≤ 0.05 was defined as significant. Significant variables were analyzed using a multivariate linear regression model. RESULTS. Of 1266 faculty members, gender information and academic rank were available for 932 faculty members: 597 (64.05%) were men and 335 (35.95%) were women (χ2 = 21.82; p < 0.0001). Of a total of 563 assistant professors, 331 (58.79%) were men and 232 (41.21%) were women; of 258 associate professors, 177 (68.60%) were men and 81 (31.40%) were women; and of 111 professors, 89 (80.18%) were men and 22 (19.82%) were women. The gender gap widens at higher academic ranks, displaying a threefold drop in the ratio of women holding the rank of full professor (6.57%) compared with 14.91% male professors; 29.55% of women radiologists have first-in-command leadership positions compared with 70.45% of men. A comparable or higher h-index is noted for women Canadian radiologists after adjusting for number of citations, number of publications, and years of active research. CONCLUSION. Canadian academic radiology departments have fewer women radiologists in senior faculty and leadership positions. Our study results show that Canadian female radiologists at the professor level have more publications than their male counterparts.

Diagnostic Imaging Modalities to Assess Treatment Response of Bone Metastasis in Patients Receiving Palliative Radiotherapy: A Scoping Review of the Literature.

PURPOSE: Several studies have used objective radiologic data to assess the effect of palliative radiotherapy on tumor burden. The purpose of this literature review was to survey the various metrics that have been used to quantify bone tumor response to palliative radiotherapy by radiographical means and to determine whether any of these metrics were associated with clinical palliative outcomes. METHODS: In accordance with PRISMA extension for Scoping Reviews guidelines, a literature search Ovid Medline and OldMedline from 1946 to February 6, 2019, Embase Classic/Embase from 1947 to 2019 week 5, and Cochrane Central Register of Controlled Trials February 2019 to extract articles related to quantified radiologic evaluation of bone metastases following palliative radiotherapy. Imaging modality, quantification metric, and association between imaging modality and clinical response were recorded. RESULTS: Fourteen articles selected for full-text review utilized computed tomography (10 studies), fluorodeoxyglucose-positron emission tomography (3 studies), magnetic resonance imaging (1 study), diffusion-weighted magnetic resonance imaging (3 studies), and X-ray (1 study) imaging modalities. Variables assessed included tumor volume regression, bone density, metabolic activity, and signal intensity. Studies differed both in the type of imaging modality used and metric derived to quantify the radiologic findings. Fifty percent of the included studies aimed to identify a relationship between a quantified radiologic metric and clinical palliative response. Of these studies, 86% reported a correlation. CONCLUSION: Quantified radiologic metrics can provide an objective measure of response to palliative radiotherapy and may be useful in predicting clinical palliative response. More studies are needed to validate these metrics and develop a standardized protocol for radiologic evaluation that can be implemented into a clinical workflow.

How Much Sciatic Nerve Does Hip Flexion Require?

Measured nerve conduction velocity in the fibular nerve increases across the knee during hip flexion. This is due to stretching of sciatic and fibular nerves. We modeled the additional nerve length required for the sciatic nerve to course around the flexed hip, based upon distance between the hip and the sciatic nerve on magnetic resonance imaging (MRI). The median distance from the femoral head to the sciatic nerve was 41 mm. The model predicted that 64 mm of sciatic nerve is required for hip flexion. This impacts our understanding of lower limb nerve conduction studies and clinical straight leg raising tests.

Online self-study of chest X-rays shows no difference between blocked and mixed practice.

CONTEXT: Chest radiograph interpretation is a complex skill and learners may benefit from deliberate instructional design modalities, such as mixed practice. Proposed benefits of mixed over blocked practice include the elimination of cueing and the highlighting of contrasting features. However, current evidence for the superiority of mixed practice is conflicting. OBJECTIVES: This study compares mixed versus blocked practice, after the initial teaching of concepts, among medical students using online self-study chest X-ray (CXR) modules. METHODS: Two online CXR modules were developed that cover identical content but differ in the organisation of practice images. Blocked modules provided practice CXRs after each category, whereas mixed modules randomly ordered practice radiographs after all categories had been taught. Medical students in Years 1-3 were randomised to either module and were tested on 20 new CXRs immediately after completion and at 2 weeks. The primary outcome was immediate diagnostic accuracy. Secondary outcomes included diagnostic accuracy at 2 weeks, time per module and reported module difficulty. RESULTS: A total of 58 medical students participated (32 in the blocked and 26 in the mixed module). Level of training and previous CXR experience were similar across the groups. Totals of 1160 and 1120 answers were evaluated for immediate and 2 week post-test scores, respectively. There were no significant differences in mean diagnostic accuracy between the blocked (mean score: 11.7/20) and mixed (mean score: 11.0/20) practice groups on immediate testing (t = 0.83, d.f. = 56, p = 0.41) or at 2 weeks (mean score: 11.2/20 versus 10.9/20; t = 0.518, d.f. = 54, p = 0.61). Post-test scores showed no correlation with training level (R = 0.23, p = 0.09) or completion time (R = -0.09, p = 0.5). Reported module difficulty was similar between the mixed (3.22/5) and blocked (3.19/5) groups. On multivariable linear regression controlling for completion time, training level and CXR experience, between-group differences remained non-significant. CONCLUSIONS: Performance after mixed practice was similar to that after blocked practice. Results may reflect similarities between modules in teaching, which emphasised contrast learning, greater effect of initial teaching rather than practice, or absence of tutor-led instruction. Alternatively, results may reflect the higher cognitive load in mixed practice imposed by contrasting multiple diagnoses.

Factors Influencing Radiology Residents' Fellowship Training and Practice Preferences in Canada.

PURPOSE: The study aimed to examine the postresidency plans of Canadian radiology residents and factors influencing their fellowship choices and practice preferences, including interest in teaching and research. METHODS: Institutional ethics approval was obtained at McMaster University. Electronic surveys were sent to second to fifth-year residents at all 16 radiology residency programs across Canada. Each survey assessed factors influencing fellowship choices and practice preferences. RESULTS: A total of 103 (31%) Canadian radiology residents responded to the online survey. Over 89% from English-speaking programs intended to pursue fellowship training compared to 55% of residents from French-speaking programs. The most important factors influencing residents' decision to pursue fellowship training were enhanced employability (46%) and personal interest (47%). Top fellowship choices were musculoskeletal imaging (19%), body imaging (17%), vascular or interventional (14%), neuroradiology (8%), and women's imaging (7%). Respondents received the majority of their fellowship information from peers (68%), staff radiologists (61%), and university websites (58%). Approximately 59% planned on practicing at academic institutions and stated that lifestyle (43%), job prospects (29%), and teaching opportunities (27%) were the most important factors influencing their decisions. A total of 89% were interested in teaching but only 46% were interested in incorporating research into their future practice. CONCLUSIONS: The majority of radiology residents plan on pursuing fellowship training and often receive their fellowship information from informal sources such as peers and staff radiologists. Fellowship directors can incorporate recruitment strategies such as mentorship programs and improving program websites. There is a need to increase resident participation in research to advance the future of radiology.

Bilateral atypical femoral fractures: how much symmetry is there on imaging?

OBJECTIVE: To evaluate bilateral atypical femoral fractures (AFFs) and to compare imaging features of paired fractures. MATERIALS AND METHODS: Bilateral femoral imaging studies of 124 patients on bisphosphonate therapy with at least one AFF were retrospectively reviewed. Time between AFF diagnoses was determined. The following imaging features were evaluated for each AFF: fracture location, femoral angle, length of cortical thickening, medial spike location, fracture orientation, and comminution. Associations between imaging findings on pairs of bilateral AFFs were assessed with Spearman's correlation (rs) and the Kappa statistic (κ). RESULTS: Bilateral AFFs were present in 78/124 (62.9%) cases (3 men, 75 women; mean age 67.3 years). Average time between contralateral AFF diagnoses was 10.3 months. Contralateral AFFs were diagnosed within 12 months of the index fracture in 60/78 (76.9%) cases and within 3 years in 69/78 (88.5%) cases. There was a strong correlation between bilateral AFF locations (rs = 0.65), with 58/76 (76.3%) occurring within a distance of <5 cm and 41/76 (53.9%) within a distance of ≤2.5 cm. Bilateral AFF pairs had moderately correlated femoral angles (rs = 0.42), and weakly correlated lengths of cortical thickening (rs = 0.28). There was substantial agreement for medial spike location (κ = 0.68) and fracture orientation (κ = 0.64), and moderate agreement for lack of comminution (κ = 0.42). All findings were independent of time between AFF diagnoses. CONCLUSIONS: Patients with unilateral atypical femoral fractures are likely to be diagnosed with a contralateral AFF within the first year of presentation. Bilateral AFFs commonly have similar imaging features, including location along the femur.

Multisource feedback and self-assessment of the communicator, collaborator, and professional CanMEDS roles for diagnostic radiology residents.

PURPOSE: To develop a tool for the external and self-evaluation of residents in the Communicator, Collaborator, and Professional CanMEDS roles. METHODS: An academic teaching institution affiliated with 4 major urban hospitals conducted a survey that involved 46 residents and 216 hospital staff members. Residents selected at least 13 external evaluators from different categories (including physicians, nurses or technologists, peers or fellows, and support staff members) from their last 6 months of rotations. The external evaluators and residents answered 4 questions that pertained to each of the 3 CanMEDS roles being assessed. The survey results were analysed for feasibility, variance within and between rater groups, and the relationships between multisource and self-evaluation scores, and between multisource feedback and in-training evaluation report scores. RESULTS: The multisource feedback survey had an overall response rate of 73% with 683 evaluations sent out to 216 unique evaluators. The ratings from different groups of evaluators were only weakly correlated. Residents were most likely to receive their best rating from a collaborating physician and their worst rating from a site secretary or a program assistant. Generally, self-assessment scores were significantly lower than multisource feedback scores. Although there was a strong correlation within the multisource feedback data and within the in-training evaluation report data, there was a weak correlation among the data sets. CONCLUSIONS: Multisource feedback provides useful feedback and scores that relate to critical CanMEDS roles that are not necessarily reflected in a resident's in-training evaluation report. The self-assessment feature of multisource feedback permits a resident to compare the accuracy of his or her assessments to improve their life-long learning skills.

Osteoporotic Fractures: Diagnosis, Evaluation, and Significance From the International Working Group on DXA Best Practices.

Osteoporotic fractures, also known as fragility fractures, are reflective of compromised bone strength and are associated with significant morbidity and mortality. Such fractures may be clinically silent, and others may present clinically with pain and deformity at the time of the injury. Unfortunately, and even at the time of detection, most individuals sustaining fragility fractures are not identified as having underlying metabolic bone disease and are not evaluated or treated to reduce the incidence of future fractures. A multidisciplinary international working group with representation from international societies dedicated to advancing the care of patients with metabolic bone disease has developed best practice recommendations for the diagnosis and evaluation of individuals with fragility fractures. A comprehensive narrative review was conducted to identify key articles on fragility fractures and their impact on the incidence of further fractures, morbidity, and mortality. This document represents consensus among the supporting societies and harmonizes best practice recommendations consistent with advances in research. A fragility fracture in an adult is an important predictor of future fractures and requires further evaluation and treatment of the underlying osteoporosis. It is important to recognize that most fragility fractures occur in patients with bone mineral density T scores higher than -2.5, and these fractures confirm the presence of skeletal fragility even in the presence of a well-maintained bone mineral density. Fragility fractures require further evaluation with exclusion of contributing factors for osteoporosis and assessment of clinical risk factors for fracture followed by appropriate pharmacological intervention designed to reduce the risk of future fracture. Because most low-trauma vertebral fractures do not present with pain, dedicated vertebral imaging and review of past imaging is useful in identifying fractures in patients at high risk for vertebral fractures. Given the importance of fractures in confirming skeletal fragility and predicting future events, it is recommended that an established classification system be used for fracture identification and reporting.

High-resolution ultrasound in the evaluation of the adult hip.

This paper reviews ultrasound of the hip, which is a commonly requested examination for symptomatic hip issues. This includes both intra-articular and extra-articular causes of hip pain. Ultrasound is easily accessible, lacks radiation exposure, and allows for evaluation of the contralateral hip as well as assessment of dynamic maneuvers. Ultrasound can be used to guide interventional procedures. Ultrasound of the hip can be challenging due to the deep location of structures and complex anatomy. Typically, high-frequency transducers are used to examine the hip, however the choice of ultrasound transducer depends on the patient's body habitus, with lower frequency transducers required to penetrate deep structures in obese patients. It is important to have an approach to ultrasound of the hip which includes assessment of the anterior, lateral, posterior, and medial aspects of the hip. The technique and relevant anatomy of each of these compartments are discussed as well as the use of Doppler examination of the hip. Several dynamic maneuvers can be performed to help determine the cause of hip pathology in various locations, and these are described and illustrated. Ultrasound is useful for guided procedures about the hip, and these indications will be reviewed.