Why Physician Virtue Is Critical to the Survival of Radiology.

Physician virtue, a set of disposition and personality traits based on the caring virtues, is vital to the continued eminence of radiology as a medical profession in the dawn of the age of artificial intelligence. This Viewpoint outlines what physician virtue is, why it can be challenging to access in radiology, and what radiologists can do to try to nurture it within themselves.

Severity of traumatic adrenal injury does not meaningfully affect clinical outcomes.

PURPOSE: There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury. METHODS: After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded. RESULTS: A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p < 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10 days vs. 16 days, p = 0.03). CONCLUSION: The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

Imaging Manifestations of Chest Trauma.

Trauma is the leading cause of death among individuals under 40 years of age, and pulmonary trauma is common in high-impact injuries. Unlike most other organs, the lung is elastic and distensible, with a physiologic capacity to withstand significant changes in contour and volume. The most common types of lung parenchymal injury are contusions, lacerations, and hematomas, each having characteristic imaging appearances. A less common type of lung injury is herniation. Chest radiography is often the first-line imaging modality performed in the assessment of the acutely injured patient, although there are inherent limitations in the use of this modality in trauma. CT images are more accurate for the assessment of the nature and extent of pulmonary injury than the single-view anteroposterior chest radiograph that is typically obtained in the trauma bay. However, the primary limitations of CT concern the need to transport the patient to the CT scanner and a longer processing time. The American Association for the Surgery of Trauma has established the most widely used grading scale to describe lung injury, which serves to communicate severity, guide management, and provide useful prognostic factors in a systematic fashion. The authors provide an in-depth exploration of the most common types of pulmonary parenchymal, pleural, and airway injuries. Injury grading, patient management, and potential complications of pulmonary injury are also discussed. ©RSNA, 2021.

Imaging review of sickle cell disease for the emergency radiologist.

Sickle cell disease (SCD), one of the most common inherited genetic syndromes in the USA, is characterized by recurring episodes of acute illness and progressive multisystem organ injury. Individuals with SCD frequently present to the emergency department for a spectrum of complications, such as vaso-occlusive crises, infection, cholecystitis, and stroke. Imaging correlates for most of these presentations exist, positioning the emergency radiologist to play a pivotal role in facilitating patient care. Using a systems-based approach, we describe the acute and chronic imaging manifestations of SCD that an emergency radiologist can expect to encounter in most practice settings, highlighting the unique pathophysiology of this disorder that typically underlies the imaging findings.

The effect of COVID-19 on emergency department imaging: what can we learn?

PURPOSE: To investigate the effect of the COVID-19 pandemic on emergency department (ED) imaging. METHODS: This retrospective study included all ED visits at a four-hospital academic health system in two matched 5-week periods. Demographic information, COVID-19 status, and disposition were reviewed. Type of imaging, acquisition time, and radiology reports were analyzed. Significance level was set at p < 0.05. RESULTS: A 43.2% decrease in ED visits and 12% reduction in overall ED imaging occurred during the pandemic period. Mean age was unchanged, but a shift in gender and racial characteristics was observed (p < 0.001). In the pandemic period, COVID-19 ED patients were older (61.8 ± 16.9 years, p < 0.001) and more likely to be Black (64.2%; p < 0.001) than non-COVID-19 patients. Imaging per ED encounter increased to 2.4 ± 2.8 exams from 1.7 ± 1.1 (p < 0.001). Radiography increased (57.2% vs. 52.4%) as a fraction of total ED imaging, while computed tomography (23.4% vs. 27.2%) and ultrasound (8.5% vs. 9.6%) decreased (pre-pandemic vs. pandemic). COVID-19 ED patients underwent CT and US at a lower rate (11.5% and 5.4%) than non-COVID-19 patients (25.4% and 9.1%). The proportion of imaging study reports concluding "no disease" or "no acute disease" decreased from 56.7 to 40.6% (p < 0.001). CONCLUSION: The COVID-19 pandemic led to a significant reduction in ED visits, a shift in patient demographics, and a significant decrease in imaging volume. Additional impact included a significant increase in the proportion of positive imaging studies.

The American Association for the Surgery of Trauma Organ Injury Scale 2018 update for computed tomography-based grading of renal trauma: a primer for the emergency radiologist.

The most widely used trauma injury grading system is the Organ Injury Scale (OIS) by the American Association for the Surgery of Trauma (AAST). The AAST OIS for renal trauma was revised in 2018 to reflect necessary updates based on decades of experience with computed tomography (CT)-based injury diagnosis and, specifically, to better incorporate vascular injuries, which were not comprehensively addressed in the original OIS. In this review article, we describe CT findings of the AAST OIS for the kidney according to the 2018 revision, with an emphasis on real-world application, and highlight important differences from the prior grading scheme. Routine use of this grading system allows for a standardized classification of the range of renal injuries to aid in management, adding value in the imaging care of trauma patients.

The state of emergency radiology fellowships in North America and the development of a standardized curriculum.

BACKGROUND AND OBJECTIVES: The number of emergency radiology (ER) training programs in North America is small compared to the projected growth in demand for ER-trained radiologists. To date, there is no consensus-based training curriculum that sets a standard for all ER fellowship training programs. This study seeks to (1) identify the programmatic measures currently used in North American ER fellowship programs and (2) gather the perspectives of existing ER fellowship program directors (PD) and their recommendations for minimum and ideal curricular standards. METHODS: We distributed an 18-question survey to the PDs of every North American ER fellowship program (N = 15). Surveys were completed during the 2016-2017 academic year. We performed a cross-sectional analysis to gain an understanding of existing training curricula, expected areas of competency by the end-of-training, and PD opinions of what a standard ER training curriculum should contain. RESULTS: The data revealed heterogeneity in programmatic structure across the continent, as well as some areas of agreement. PD suggestions for a standard ER training curriculum showed consistency in many areas, including competency and proficiency expectations and clinical exposures, with some variability. These data were used to inform the creation of the first curricular standard for ER fellowship training. CONCLUSION: This study yielded the creation of a standard fellowship training resource for the field of ER. This deliverable serves as a curricular guideline for existing ER fellowships, as well as a model for new ER fellowship programs.

US of Right Upper Quadrant Pain in the Emergency Department: Diagnosing beyond Gallbladder and Biliary Disease.

Acute cholecystitis is the most common diagnosable cause for right upper quadrant abdominal (RUQ) pain in patients who present to the emergency department (ED). However, over one-third of patients initially thought to have acute cholecystitis actually have RUQ pain attributable to other causes. Ultrasonography (US) is the primary imaging modality of choice for initial imaging assessment and serves as a fast, cost-effective, and dynamic modality to provide a definitive diagnosis or a considerably narrowed list of differential possibilities. Multiple organ systems are included at standard RUQ US, and a variety of ultrasonographically diagnosable disease processes can be identified, including conditions of hepatic, pancreatic, adrenal, renal, gastrointestinal, vascular, and thoracic origin, all of which may result in RUQ pain. In certain cases, subsequent computed tomography, magnetic resonance (MR) imaging, MR cholangiopancreatography, or cholescintigraphy may be considered, depending on the clinical situation and US findings. Familiarity with the spectrum of disease processes outside of the gallbladder and biliary tree that may manifest with RUQ pain and recognition at US of these alternative conditions is pivotal for early diagnosis and appropriate management. Diagnosis at the time of initial US can reduce unnecessary imaging and its consequences, including excess cost, radiation exposure, nephrotoxic contrast medium use, and time to diagnosis, thereby translating into improved patient care and outcome. This article (a) reviews the causes of RUQ pain identifiable at US using an organ-system approach, (b) illustrates the US appearance of select conditions from each organ system with multimodality imaging correlates, and (c) discusses the relevant pathophysiology and treatment of these entities to aid in efficient direction of management. Online supplemental material is available for this article. ©RSNA, 2018.

Diagnostic radiology resident perspectives on fellowship training and career interest in emergency radiology.

PURPOSE: (1) Evaluate radiology resident perception of emergency radiology (ER). (2) Identify potential barriers to pursuing fellowship training or a career in ER among radiology residents. MATERIALS AND METHODS: A 9-question digital survey was designed using Qualtrics Experience Management software (Qualtrics Inc., Provo, UT) and distributed to all US radiology residents via a multi-pronged distribution approach. RESULTS: Four hundred fifty-one residents responded out of an estimated national total of 4432 residents (10.2%). Gender proportion was nationally representative (female = 24.5%; p = 0.57), with a slight R1 predominance (p = 0.034). Of the residents, 88.8% were aware that an ER subspecialty exists, 82.0% were aware that ER fellowships exist, but only 51.7% were aware that the American Society of Emergency Radiology (ASER) exists. Nearly a quarter reported no ER division or ER resident rotation. Residents in a program without an ER division or rotation were nearly twice as likely to be unaware of the existence of ER subspecialty, ER fellowships, and ASER compared to others (p = 0.017). The presence of an ER division and rotation significantly increases the knowledge of ASER (65.5% vs. 40.7%, p < 0.001) and increases residents' ratings of their ER training (p < 0.001). The following factors were ranked as the most important for fellowship choice: (1) personal interest, (2) intellectually stimulating, and (3) work hours. When asked if ER had an appealing work schedule, the mean response was 56 out of 100 (0 = disagree, 100 = agree). CONCLUSION: US radiology residents with the greatest exposure to ER during residency are more familiar with ER training, ER career opportunities, and ASER and had a more favorable perception of the field. Subspecialty leaders should focus on ER's inherent intellectual appeal and reframe its nontraditional schedule as positive (flexible).

Pearls and pitfalls of hepatobiliary and splenic trauma: what every trauma radiologist needs to know.

With the universal acceptance of contrast-enhanced computed tomography (CT) as the imaging modality of first resort in the assessment of blunt abdominal injury, the trauma radiologist must be able to accurately and rapidly identify the range of CT manifestations of the traumatized abdomen. In this article, we lay out the fundamental principles in CT interpretation of blunt trauma to the hepatobiliary system and spleen, including vascular injury, with a focus on technical and interpretive pearls and pitfalls. This review will help radiologists and trainees become more familiar with key aspects of abdominal CT trauma protocol selection, CT-based solid organ injury grading, and the various appearances and mimics of hepatobiliary and splenic injury.

Highlights from the scientific and educational abstracts presented at the ASER 2015 annual scientific meeting and postgraduate course.

The American Society of Emergency Radiology (ASER) 2015 Annual Scientific Meeting and Postgraduate Course offered dedicated learning sessions, oral presentations, and digital exhibits on a broad spectrum of topics in emergency radiology, including traumatic and non-traumatic emergencies, quality, communication, education, technological innovations, and the evolving identity of the emergency radiology subspecialty. This article highlights the scientific and educational abstracts presented at the meeting.

Multireader evaluation of radiologist performance for COVID-19 detection on emergency department chest radiographs.

BACKGROUND: Chest radiographs (CXR) are frequently used as a screening tool for patients with suspected COVID-19 infection pending reverse transcriptase polymerase chain reaction (RT-PCR) results, despite recommendations against this. We evaluated radiologist performance for COVID-19 diagnosis on CXR at the time of patient presentation in the Emergency Department (ED). MATERIALS AND METHODS: We extracted RT-PCR results, clinical history, and CXRs of all patients from a single institution between March and June 2020. 984 RT-PCR positive and 1043 RT-PCR negative radiographs were reviewed by 10 emergency radiologists from 4 academic centers. 100 cases were read by all radiologists and 1927 cases by 2 radiologists. Each radiologist chose the single best label per case: Normal, COVID-19, Other - Infectious, Other - Noninfectious, Non-diagnostic, and Endotracheal Tube. Cases labeled with endotracheal tube (246) or non-diagnostic (54) were excluded. Remaining cases were analyzed for label distribution, clinical history, and inter-reader agreement. RESULTS: 1727 radiographs (732 RT-PCR positive, 995 RT-PCR negative) were included from 1594 patients (51.2% male, 48.8% female, age 59 ± 19 years). For 89 cases read by all readers, there was poor agreement for RT-PCR positive (Fleiss Score 0.36) and negative (Fleiss Score 0.46) exams. Agreement between two readers on 1638 cases was 54.2% (373/688) for RT-PCR positive cases and 71.4% (679/950) for negative cases. Agreement was highest for RT-PCR negative cases labeled as Normal (50.4%, n = 479). Reader performance did not improve with clinical history or time between CXR and RT-PCR result. CONCLUSION: At the time of presentation to the emergency department, emergency radiologist performance is non-specific for diagnosing COVID-19.

Doctorhood in Radiology: What Makes a Radiologist a Physician?

Because image interpretation occurs out of public view, the lay public does not always know what a radiologist is, or that a radiologist is even a physician. Despite the reality that many radiologists have little to no patient contact, all have considerable impact on patient care. As viewed through the lens of patient impact and in the context of the social contract that physicians enter, radiologists lay equal claim to the title "doctor" as any other physician. With titles come responsibilities: as physicians, radiologists are obligated through the social contract to provide humanistic and virtuous care, irrespective of time spent in close proximity with patients. This paper touches on ways in which radiologists can honor the social contract, providing care through a commitment to empathy, compassion, generosity, honesty and collaboration with nonradiologist colleagues. This invitation for introspection assumes special meaning for a profession that is undergoing an identity change at the behest of AI, serving as a reminder that radiologists ought to pay as much heed to maintaining virtuous physician character as they do to the fine points of image interpretation.

Using Point-of-Care Patient Photographs With Musculoskeletal Radiography to Identify Errors of Laterality in Emergency Department Imaging.

PURPOSE: To evaluate the utility of point-of-care patient photographs accompanying musculoskeletal (MSK) radiography to identify errors in laterality. MATERIALS AND METHODS: In this Institutional Review Board-approved study, 347 consecutive MSK radiograph-photograph combinations and corresponding radiography provider orders between October 1, 2018 and January 31, 2019, were retrospectively reviewed. Photographs were obtained simultaneously with the radiographs using the PatCam System (Camerad Technologies, Decatur, GA). In each case, laterality was recorded for all photographs, radiograph side markers, and radiography orders, and any laterality discrepancy among these variables was recorded. The side indicated on the provider order was taken as the gold standard. RESULTS: Three hundred and forty-seven consecutive MSK radiograph-photograph combinations from 253 unique patients consisted of 129 upper extremity and 218 lower extremity radiographs. Two discrepancies (0.58%) in laterality were identified. The first discrepant case consisted of a left foot radiograph, which was labeled as "R" on the radiograph and left on the order. In this case, the patient photograph confirmed with certainty that the incorrect side marker was placed. The second discrepant case was a hip radiograph, in which 1 of 3 images had discrepant L/R labeling; the patient was covered with a sheet, both hips were included in the photograph, but a monitoring device on the patient's left side in the photograph also included on the radiographs determined which film was incorrectly labeled. CONCLUSIONS: Patient photographs obtained concurrently with MSK radiographs can provide a valuable quality tool in identifying errors of laterality. In our study, over 1 in 200 patients was identified as having such an error.

ACR Appropriateness Criteria® Epigastric Pain.

Epigastric pain can have multiple etiologies including myocardial infarction, pancreatitis, acute aortic syndromes, gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, and hiatal hernia. This document focuses on the scenarios in which epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis, which raise suspicion for gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, or hiatal hernia. Although endoscopy may be the test of choice for diagnosing these entities, patients may present with nonspecific or overlapping symptoms, necessitating the use of imaging prior to or instead of endoscopy. The utility of fluoroscopic imaging, CT, MRI, and FDG-PET for these indications are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Review of Multimodality Imaging of Renal Trauma.

Blunt trauma accounts for more than 95% of traumatic renal injury and results from shear forces from rapid acceleration or deceleration and/or collision against the spine or ribs. The use of multiphasic contrast-enhanced computed tomography (CT) has proven pivotal in the evaluation and management of traumatic kidney injury, and CT imaging features provide the basis for nonsurgical staging. This article describes the epidemiology and mechanisms of blunt and penetrating traumatic renal injury and reviews the range of findings from various imaging modalities, with a particular emphasis on contrast-enhanced CT.

Aligning the Implicit Curriculum with the Explicit Curriculum in Radiology.

Physician education occurs through two mechanisms that operate in tandem: the explicit and the implicit curriculum. The explicit, or formal, curriculum is the official version that is usually taken as the one-and-only curriculum and which is detailed in official documentation; however, an implicit curriculum exists, comprised of subtle messaging about professional norms, values, and beliefs that are tacitly communicated through both positive and negative role modeling. Both contribute to the overall education of the medical student and physician-in-training. Despite its well-documented influence in medical education, much of the teachings of the implicit curriculum occurs in the shadows, unspoken and unarticulated, and outside the awareness of both teacher and student. As panel members of the The Implicit Curriculum in Radiology Task Force of the Association of University Radiologists-Radiology Research Alliance (AUR-RRA), we present a review of the implicit curriculum, exploring its origin and impact on medical education, and on the overall professional development of medical students, post-graduate medical trainees and practicing physicians. Strategies for recognizing and contending with the implicit curriculum in radiology training are discussed, with a special emphasis on opportunities to leverage its potential through positive role modeling.

The Introduction and Development of the H-index for Imaging Utilizers: A Novel Metric for Quantifying Utilization of Emergency Department Imaging.

OBJECTIVE: The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging. METHODS: Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h. RESULTS: Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%. CONCLUSIONS: The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources.