Concordance Assessment of Pathology Results with Imaging Findings after Image-Guided Biopsy.

PURPOSE: To assess the impact of radiology review for discordance between pathology results from computed tomography (CT)-guided biopsies versus imaging findings performed before a biopsy. MATERIALS AND METHODS: In this retrospective review, which is compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board, 926 consecutive CT-guided biopsies performed between January 2015 and December 2017 were included. In total, 453 patients were presented in radiology review meetings (prospective group), and the results were classified as concordant or discordant. Results from the remaining 473 patients not presented at the radiology review meetings were retrospectively classified. Times to reintervention and to definitive diagnosis were obtained for discordant cases; of these, 49 (11%) of the 453 patients were in the prospective group and 55 (12%) of the 473 patients in the retrospective group. RESULTS: Pathology results from CT-guided biopsies were discordant with imaging in 11% (104/926) of the cases, with 57% (59/104) of these cases proving to be malignant. In discordant cases, reintervention with biopsy and surgery yielded a shorter time to definitive diagnosis (28 and 14 days, respectively) than an imaging follow-up (78 days) (P < .001). The median time to diagnosis was 41 days in the prospective group and 56 days in the retrospective group (P = .46). When radiologists evaluated the concordance between pathology and imaging findings and recommended a repeat biopsy for the discordant cases, more biopsies were performed (50% [11/22] vs 13% [4/31]; P = .005). CONCLUSIONS: Eleven percent of CT-guided biopsies yielded pathology results that were discordant with imaging findings, with 57% of these proving to be malignant on further workup.

Analyzing the Administrative Burden of Competency Based Medical Education.

PURPOSE: Postgraduate residency programs in Canada are transitioning to a competency-based medical education (CBME) system. Within this system, resident performance is documented through frequent assessments that provide continual feedback and guidance for resident progression. An area of concern is the perception by faculty of added administrative burden imposed by the frequent evaluations. This study investigated the time spent in the documentation and submission of required assessment forms through analysis of quantitative data from the Queen's University Diagnostic Radiology program. METHODS AND MATERIALS: Data regarding time taken to complete Entrustable Professional Activities (EPA) assessments was collected from 24 full-time and part-time radiologists over a period of 18 months. This data was analyzed using SPSS to determine mean time of completion by individuals, departments, and by experience with the assessment process. RESULTS: The average time taken to complete an EPA assessment form was 3 minutes and 6 seconds. Assuming 3 completed EPA assessment forms per week for each resident (n = 12) and equal distribution among all staff, this averaged out to an additional 18 minutes of administrative burden per staff member over a 4 week block. CONCLUSIONS: This study investigated the perception by faculty of additional administrative burden for assessment in the CBME framework. The data provided quantitative evidence of administrative burden for the documentation and submission of assessments. The data indicated that the added administrative burden may be reasonable given mandate for CBME implementation and the advantages of adoption for postgraduate medical education.

Creating a Competency-Based Medical Education Curriculum for Canadian Diagnostic Radiology Residency (Queen's Fundamental Innovations in Residency Education)-Part 1: Transition to Discipline and Foundation of Discipline Stages.

PURPOSE: The Royal College of Physicians and Surgeons of Canada (RCPSC) has mandated the transition of postgraduate medical training in Canada to a competency-based medical education (CBME) model divided into 4 stages of training. As part of the Queen's University Fundamental Innovations in Residency Education proposal, Queen's University in Canada is the first institution to transition all of its residency programs simultaneously to this model, including Diagnostic Radiology. The objective of this report is to describe the Queen's Diagnostic Radiology Residency Program's implementation of a CBME curriculum. METHODS: At Queen's University, the novel curriculum was developed using the RCPSC's competency continuum and the CanMEDS framework to create radiology-specific entrustable professional activities (EPAs) and milestones. In addition, new committees and assessment strategies were established. As of July 2015, 3 cohorts of residents (n = 9) have been enrolled in this new curriculum. RESULTS: EPAs, milestones, and methods of evaluation for the Transition to Discipline and Foundations of Discipline stages, as well as the opportunities and challenges associated with the implementation of a competency-based curriculum in a Diagnostic Radiology Residency Program, are described. Challenges include the increased frequency of resident assessments, establishing stage-specific learner expectations, and the creation of volumetric guidelines for case reporting and procedures. CONCLUSIONS: Development of a novel CBME curriculum requires significant resources and dedicated administrative time within an academic Radiology department. This article highlights challenges and provides guidance for this process.

Extrahepatic Fat-Containing Lesions of the Abdomen and Pelvis: An Organ-Based Approach to Differential Diagnoses.

The presence of intralesional fat provides an invaluable tool for narrowing the differential diagnosis for both benign and malignant neoplasms of the abdomen and pelvis. The ability to characterize intralesional fat is further expanded by the ability of magnetic resonance imaging to detect small quantities (intravoxel) of fat. While the presence of intralesional fat can help to provide a relatively narrow set of diagnostic possibilities, depending on the type of fat (macroscopic vs intravoxel) that is present and the organ of origin, radiologists must be aware of uncommon mimickers of pathology, both benign and malignant.

Fat-Containing Lesions of the Liver: A Review of Differential Diagnoses.

The presence of intralesional fat provides an invaluable tool for narrowing the differential diagnosis for both benign and malignant neoplasms of the abdomen and pelvis. The ability to characterize intralesional fat is further expanded by the ability of magnetic resonance imaging to detect small quantities (intravoxel) of fat. The differential diagnosis of fat-containing lesions arising in the liver is broader than that of many other solid organs. However, this differential can be further refined depending on the type of fat (macroscopic vs intravoxel) and with the use of ancillary imaging findings. Radiologists must be aware of benign and malignant mimickers of common lesions.

MRI Evaluation of the Urothelial Tract: Pitfalls and Solutions.

OBJECTIVE: MR urography (MRU) can be an alternative to CT urography (CTU) for imaging of the kidneys, urinary bladder, and collecting systems. MRU can be a challenging examination to perform and interpret, which may result in technical and interpretive errors being made. This article highlights the pitfalls associated with MRU and discusses how to recognize and avoid them. CONCLUSION: When performed properly, MRU may provide imaging quality generally comparable to that of CTU, and it enables comprehensive evaluation of the entire urinary tract.

Suburothelial and extrinsic lesions of the urinary bladder: radiologic and pathologic features with emphasis on MR imaging.

OBJECTIVE: The purpose of this article is to present a contemporary review of the imaging appearance of diseases which affect the deeper layers of the urinary bladder, including both suburothelial and extrinsic pathologies, using radiologic-pathologic correlation. CONCLUSION: Compared to the more common urothelial lesions, at cystoscopy, suburothelial and extrinsic diseases of the urinary bladder wall often have a non-specific appearance or may be occult. Cross-sectional imaging, in particular MRI, plays an integral role in diagnosis. Mesenchymal tumors have distinct imaging features on MRI. Leiomyomas are characteristically low signal intensity on T2-weighted (T2W) imaging and progressively enhance. Lipomas and lipomatous hypertrophy are diagnosed by the presence of macroscopic fat. Neurofibromas, hemangiomas, and paragangliomas are hyperintense on T2W sequences and hypervascular. Reactive lesions occur in the setting of chronic inflammation and include: nephrogenic adenoma, cystitis cystica, and cystitis glandularis. Imaging findings are commonly non-specific; however, a mass with internal cystic spaces in association with pelvic lipomatosis is suggestive of cystitis glandularis. Urachal anomalies may be complicated by infection or malignancy. Urachal mucinous adenocarcinoma has a poor prognosis and may present as a T2-hyperintense suburothelial/extrinsic mass centered in the bladder dome. Other diseases may extrinsically involve the urinary bladder by hematogenous and peritoneal spread, including infection, endometriosis, and malignancy. A familiarity with suburothelial and extrinsic pathologies of the urinary bladder is critical for the radiologist, who may be the first to suggest these diagnoses.

Radiologist preferences for faculty development initiatives to improve resident feedback in the era of competency-based medical education.

INTRODUCTION: Since 2022, all Canadian post-graduate medical programs have transitioned to a Competence by Design (CBD) model within a Competency-Based Medical Education (CBME) framework. The CBME model emphasized more frequent, formative assessment of residents to evaluate their progress towards predefined competencies in comparison to traditional medical education models. Faculty members therefore have increased responsibility for providing assessments to residents on a more regular basis, which has associated challenges. Our study explores faculty assessment behaviours within the CBD framework and assesses their openness to opportunities aimed at improving the quality of written feedback. Specifically, we explore faculty's receptiveness to routine metric performance reports that offer comprehensive feedback on their assessment patterns. METHODS: Online surveys were distributed to all 28 radiology faculty at Queen's University. Data were collected on demographics, feedback practices, motivations for improving the teacher-learner feedback exchange, and openness to metric performance reports and quality improvement measures. Following descriptive statistics, unpaired t-tests and one-way analysis of variance were conducted to compare groups based on experience and subspecialty. RESULTS: The response rate was 89% (25/28 faculty). 56% of faculty were likely to complete evaluations after working with a resident. Regarding the degree to which faculty felt written feedback is important, 62% found it at least moderately important. A majority (67%) believed that performance reports could influence their evaluation approach, with volume of written feedback being the most likely to change. Faculty expressed interest in feedback-focused development opportunities (67%), favouring Grand Rounds and workshops. CONCLUSION: Assessment of preceptor perceptions reveals that faculty recognize the importance of offering high-quality written feedback to learners. Faculty openness to quality improvement interventions for curricular reform relies on having sufficient time, knowledge, and skills for effective assessments. This suggests that integrating routine performance metrics into faculty assessments could serve as a catalyst for enhancing future feedback quality.

Peering Into the Future: A First Look at the CBME Transition to Practice Stage in Diagnostic Radiology.

RATIONALE AND OBJECTIVES: Queen's University (Kingston, ON, Canada) adopted a competency-based medical education (CBME) curriculum for Diagnostic Radiology residency training in an accelerated manner in 2017, with the curriculum comprised of four stages of training. This article focuses on the final stage (Transition to Practice), during which assessment methods of the new national curriculum (implemented in July 2022) were piloted. This study aims to highlight the challenges and opportunities associated with the implementation of CBME in Diagnostic Radiology training and specific considerations for programs undergoing this curricular transition. MATERIALS AND METHODS: Ethics approval was provided by the affiliated hospital Research Ethics Board. All relevant electronic assessments pertaining to all trainees who had completed the Transition to Practice stage (n = 3) were collated, deidentified, analyzed, and presented in tabulated format. RESULTS: A total of 39 evaluations completed by 13 assessors were assessed, with an average time of 3 minutes and 6 seconds to complete an assessment form. Also, 95% of evaluations were rated as entrustments. However, no residents met the minimum number of required entrustments for all five stage-specific Entrustable Professional Activities. These 39 evaluations included 219 milestone rating scores, with 86% rated as "achieved." Following review by the residency program Competence Committee, all three residents were promoted from the Transition to Practice stage. CONCLUSION: Challenges in CBME implementation include the number and quality of resident assessments. Strategies for success may include providing clear guidelines and training for both faculty and residents, early identification and intervention, and adopting a holistic evaluation strategy. CBME has the potential to enhance medical education quality by emphasizing learner progress toward competency and providing personalized feedback and support.

Deep gray matter maturation in very preterm neonates: regional variations and pathology-related age-dependent changes in magnetization transfer ratio.

PURPOSE: To elucidate the relationship between gestational age, pathologic findings, and magnetic resonance (MR) imaging measures of tissue maturation-myelination in deep gray matter areas in very preterm neonates imaged at birth. MATERIALS AND METHODS: The study was approved by the research ethics board. Written informed consent was given by the infants' parents. Forty-two preterm neonates (19 boys; median gestational age, 28.7 weeks) with normal-appearing gray matter structures at presentation underwent MR imaging within 2 weeks of birth that included T1- and T2-weighted, magnetization transfer, and T1 relaxometry sequences. Neonates were separated into the following groups: those with normal findings (n = 23), those with white matter injury (WMI) (n = 9), those with grade I germinal matrix hemorrhage (GMH) (n = 3), and those with grade II GMH and WMI (n = 7). Analysis of covariance was used to determine regional effects of age and pathologic findings on magnetization transfer ratio (MTR) and to assess the relationship between MTR and T1. RESULTS: MTR increased linearly with age (P ≤ .0265), with a similar rate of change of 0.32% per week (95% confidence interval [CI]: 0.16, 0.49) in the basal ganglia (BG) and thalami. A lower trend (0.11% per week; 95% CI: -0.05, 0.28) was seen in the pons. Higher MTRs were seen in the thalami and pons than in the BG (P < .05), indicating earlier maturation. Accordingly, higher T1 values were observed in the BG relative to the thalami (P < .0001). Higher MTRs in the BG were observed in the group of neonates with normal findings at presentation than in the group with WMI (P = .02). CONCLUSION: MTR measurements can be used to monitor early myelination in the developing brain and to help detect changes in tissue that are not shown on T1- and T2-weighted MR images.

Quantitative and qualitative liver CT: imaging feature association with histopathologically confirmed hepatic cirrhosis.

PURPOSE: To assess the diagnostic performance of quantitative and qualitative imaging features of hepatic cirrhosis on CT. METHODS: A single-center retrospective cohort study was performed on all patients who had undergone non-targeted liver biopsy < 3 months following abdominal CT imaging between 2007 and 2020. Histopathology was required as a reference standard for hepatic cirrhosis diagnosis. Two readers independently assessed all CT quantitative and qualitative features, blinded to the clinical history and the reference standard. The diagnostic performance of each imaging feature was assessed using multivariate regression and logistic regression in a recursive feature elimination framework. RESULTS: 98 consecutive patients met inclusion criteria including 26 with histopathologically confirmed hepatic cirrhosis, and 72 without cirrhosis. Liver surface nodularity (p < 0.0001), lobar redistribution (p < 0.0001), and expanded gallbladder fossa (p < 0.0016) were qualitative CT features associated with liver cirrhosis consistent between both reviewers. Liver surface nodularity demonstrated highest sensitivity (73-77%) and specificity (79-82%). Falciform space width was the only quantitative feature associated with cirrhosis, for a single reviewer (p < 0.04). Using a recursive feature elimination framework, liver surface nodularity and falciform space width were the strongest performing features for identifying cirrhosis. No feature combinations strengthened diagnostic performance. CONCLUSION: Many quantitative and qualitative CT imaging signs of hepatic cirrhosis have either poor accuracy or poor inter-observer agreement. Qualitative imaging features of hepatic cirrhosis on CT performed better than quantitative metrics, with liver surface nodularity the most optimal feature for diagnosing hepatic cirrhosis.

An adaptation-focused evaluation of Canada's first competency-based medical education implementation in radiology.

OBJECTIVES: Systematic program evaluation of the Queen's University diagnostic radiology residency program following transition to a competency-based medical education (CBME) curriculum. METHODS: Rapid Evaluation methodology and the Core Components Framework were utilized to measure CBME implementation. A combination of interviews and focus groups were held with program leaders (n = 6), faculty (n = 10), both CBME stream and traditional stream residents (n = 6), and program staff (n = 2). Interviews and focus groups were transcribed and analyzed abductively. Study team met with program leaders to review common themes and plan potential adaptations. RESULTS: Strengths of CBME implementation included more frequent and timely feedback as well as the role of the Academic Advisor. However, frontline faculty felt insufficiently supported with regards to the theory and practical implementation of the new curriculum and found assessment tools unintuitive. The circumstances surrounding the curricular implementation also resulted in some negative sentiment. Additional faculty and resident education workshops were identified as areas for improvement as well as changes to assessment tools for increased clarity. Residents overall viewed the changes favorably, with traditional stream residents indicating that they also had a desire for increased feedback. CONCLUSIONS: Rapid Evaluation is an effective method for program assessment following curricular change in diagnostic radiology. A departmental champion driving enthusiasm for change from within may be valuable. Adequate resident and faculty education is key to maximize change and smooth the transition. Advances in knowledge: This study provides insights for other radiology training programs transitioning to a CBME framework and provides a structure for programmatic assessment.

Optimized T1- and T2-weighted volumetric brain imaging as a diagnostic tool in very preterm neonates.

BACKGROUND: T1- and T2-W MR sequences used for obtaining diagnostic information and morphometric measurements in the neonatal brain are frequently acquired using different imaging protocols. Optimizing one protocol for obtaining both kinds of information is valuable. OBJECTIVE: To determine whether high-resolution T1- and T2-W volumetric sequences optimized for preterm brain imaging could provide both diagnostic and morphometric value. MATERIALS AND METHODS: Thirty preterm neonates born between 24 and 32 weeks' gestational age were scanned during the first 2 weeks after birth. T1- and T2-W high-resolution sequences were optimized in terms of signal-to-noise ratio, contrast-to-noise ratio and scan time and compared to conventional spin-echo-based sequences. RESULTS: No differences were found between conventional and high-resolution T1-W sequences for diagnostic confidence, image quality and motion artifacts. A preference for conventional over high-resolution T2-W sequences for image quality was observed. High-resolution T1 images provided better delineation of thalamic myelination and the superior temporal sulcus. No differences were found for detection of myelination and sulcation using conventional and high-resolution T2-W images. CONCLUSION: High-resolution T1- and T2-W volumetric sequences can be used in clinical MRI in the very preterm brain to provide both diagnostic and morphometric information.