Asymptomatic Skeletal Cystic Angiomatosis May Be Managed Conservatively With Close Observation.

Cystic angiomatosis (CA) is a rare disease characterized by the proliferation of vascular and lymphatic channels lined by a single layer of endothelial cells. CA may present with isolated skeletal or visceral disease. There is no consensus for the standard of care in these patients, and diverse regimens for CA have been reported, including observation, surgery, radiation, and a variety of medical therapies. We present a case of multifocal, isolated skeletal CA, treated with close observation alone and review the literature. We suggest that these cases may be safely followed without intervention and may be stable for prolonged periods of time.

Awareness of implicit bias mitigates discrimination in radiology resident selection.

OBJECTIVES: Implicit bias is common and is thought to drive discriminatory behaviour. Having previously demonstrated discrimination against specific applicant demographics by academic radiology departments in a simulated resident selection process, the authors sought to better understand the relationship between implicit bias and discrimination, as well as the potential and mechanisms for their mitigation. METHODS: A total of 51 faculty reviewers at three academic radiology departments, who had participated in a 2017 audit study in which they were shown to treat applicants differently based on race or ethnicity and physical appearance, were invited to complete testing for implicit racial and weight bias using the Implicit Association Test in 2019. Respondents were also surveyed regarding awareness of their own personal racial and weight biases, as well as any prior participation in formal diversity training. Comparisons were made between implicit bias scores and applicant ratings, as well as between diversity training and self-awareness of bias. RESULTS: A total of 31 out of 51 faculty reviewers (61%) completed and submitted results of race and weight Implicit Association Tests. A total of 74% (23/31) reported implicit anti-obese bias, concordant with discrimination demonstrated in the resident selection simulation, in which obese applicants were rated 0.40 standard deviations (SDs) lower than non-obese applicants (P < .001). A total of 71% (22/31) reported implicit anti-Black bias, discordant with application ratings, which were 0.47 SDs higher for Black than for White applicants (P < .001). A total of 84% (26/31) of participants reported feeling self-aware of potential racial bias at the time of application review, significantly higher than the 23% (7/31) reporting self-awareness of potential anti-obese bias (P < .001). Participation in formal diversity training was not associated with implicit anti-Black or anti-fat bias, nor with self-reported awareness of potential racial or weight-based bias (all P > .2). CONCLUSIONS: These findings suggest that implicit bias, as measured by the Implicit Association Test, does not inevitably lead to discrimination, and that personal awareness of implicit biases may allow their mitigation.

Isolated Central Nervous System Chloroma as a Presenting Sign of Relapsed Pediatric Acute Lymphoblastic Leukemia.

Central nervous system (CNS) chloromas are an exceedingly rare presentation of CNS relapse in acute lymphoblastic leukemia (ALL). We report a relapsed ALL patient who presented with 2 separate chloromas and cerebrospinal fluid lymphoblastocytosis, and outline a treatment plan of systemic chemotherapy and CNS-directed radiation therapy. A review of the literature indicates that multiagent chemotherapy combined with CNS radiotherapy is effective, with hematopoietic stem cell transplantation used in half of reported cases. We conclude that intensive systemic multiagent chemotherapy with CNS-directed radiation therapy can be successfully used to treat relapsed pediatric ALL with CNS lymphoblastic chloroma.

Pediatric providers and radiology examinations: knowledge and comfort levels regarding ionizing radiation and potential complications of imaging.

BACKGROUND: Pediatric providers should understand the basic risks of the diagnostic imaging tests they order and comfortably discuss those risks with parents. Appreciating providers' level of understanding is important to guide discussions and enhance relationships between radiologists and pediatric referrers. OBJECTIVE: To assess pediatric provider knowledge of diagnostic imaging modalities that use ionizing radiation and to understand provider concerns about risks of imaging. MATERIALS AND METHODS: A 6-question survey was sent via email to 390 pediatric providers (faculty, trainees and midlevel providers) from a single academic institution. A knowledge-based question asked providers to identify which radiology modalities use ionizing radiation. Subjective questions asked providers about discussions with parents, consultations with radiologists, and complications of imaging studies. RESULTS: One hundred sixty-nine pediatric providers (43.3% response rate) completed the survey. Greater than 90% of responding providers correctly identified computed tomography (CT), fluoroscopy and radiography as modalities that use ionizing radiation, and ultrasound and magnetic resonance imaging (MRI) as modalities that do not. Fewer (66.9% correct, P<0.001) knew that nuclear medicine utilizes ionizing radiation. A majority of providers (82.2%) believed that discussions with radiologists regarding ionizing radiation were helpful, but 39.6% said they rarely had time to do so. Providers were more concerned with complications of sedation and cost than they were with radiation-induced cancer, renal failure or anaphylaxis. CONCLUSION: Providers at our academic referral center have a high level of basic knowledge regarding modalities that use ionizing radiation, but they are less aware of ionizing radiation use in nuclear medicine studies. They find discussions with radiologists helpful and are concerned about complications of sedation and cost.

Congenital duodenal obstruction: causes and imaging approach.

Bilious emesis is a common cause for evaluation in pediatric radiology departments. There are several causes of congenital duodenal obstruction, most of which require elective surgical correction, but the potential of malrotation with midgut volvulus demands prompt imaging evaluation. We review the various causes of congenital duodenal obstruction with an emphasis on the approach to imaging evaluation and diagnosis.

Medical student perspectives on radiology subspecialties prior to core clerkship.

RATIONALE AND OBJECTIVES: Radiology remains underrepresented in U.S. medical school clinical curricula, and preconceived opinions about the field may impact whether students pursue elective exposure. A core radiology clerkship at one academic institution presents an opportunity to evaluate students' early preferences for different radiology subspecialties, thus informing curricular design and inspiring student recruitment. MATERIALS AND METHODS: At a single allopathic medical school, a required, four-week, clinical-year radiology clerkship that occurs in the second year includes immersive one-week experiences in two subspecialties. Prior to their clerkship, students rank their immersion preferences by distributing 100 points across eight fields, the values of which were analyzed as a proxy for interest. A secondary survey was distributed to active first- and second-year medical students to further investigate the factors drawing them to radiology. RESULTS: Immersive experiences in musculoskeletal, body, and breast imaging were most preferred, earning ≥20 points from 41.6 %, 34.3 %, and 31.9 % of students, respectively. Women were significantly more likely than men to express interest in breast imaging (35.8 % vs. 24.8 %, p = 0.037) and pediatric radiology (28.8 % vs. 12.8 %, p = 0.001). Men were significantly more likely than women to prefer body imaging (41.9 % vs. 30.2 %, p = 0.034), neuroradiology (29.1 % vs. 19.5 %, p = 0.048), and nuclear medicine (11.1 % vs. 5.1 %, p = 0.044). CONCLUSION: Early in their clinical education, medical students prefer certain subspecialties, especially musculoskeletal, body, and breast imaging. Women expressed significantly stronger interest in breast imaging and pediatric radiology, while men indicated significantly stronger interest in body imaging, neuroradiology, and nuclear medicine.

Women in leadership matters: Achieving diversity in radiology residency recruitment.

RATIONALE AND OBJECTIVES: To assess whether academic radiology departments and residency programs with efforts toward supporting and augmenting Diversity, Equity, and Inclusion (DEI) are associated with a higher proportion of residents from diverse backgrounds. MATERIALS AND METHODS: Program Directors within the Radiology Residency Education Research Alliance were surveyed to gather information about program characteristics, incorporation of diversity in resident recruitment, the sponsoring department's commitment to efforts at expanding diversity, and a summary of their current and past residents, staff and faculty members (academic years 2020 and 2023) with respect to a list of diversity characteristics. RESULTS: Survey response rate was 51 %. Sixty-three percent (15/24) of participating programs have departmental committees dedicated to DEI work; 46 % (11/24) of programs' departments have a Vice Chair for DEI. Sixty percent (15/24) of programs use their social media accounts to advertise their DEI programming efforts. Ninety-six percent (23/24) of programs participating in the survey use diversity factors to select candidates for their program. Women Leadership was associated with above-median diversity of residents and faculty. CONCLUSION: This study of radiology residency programs encourages a more prominent role for women in leadership positions within academic radiology departments to drive diversity and inclusion efforts.

Subventricular zone stem cell niche injury is associated with intestinal perforation in preterm infants and predicts future motor impairment.

Brain injury is highly associated with preterm birth. Complications of prematurity, including spontaneous or necrotizing enterocolitis (NEC)-associated intestinal perforations, are linked to lifelong neurologic impairment, yet the mechanisms are poorly understood. Early diagnosis of preterm brain injuries remains a significant challenge. Here, we identified subventricular zone echogenicity (SVE) on cranial ultrasound in preterm infants following intestinal perforations. The development of SVE was significantly associated with motor impairment at 2 years. SVE was replicated in a neonatal mouse model of intestinal perforation. Examination of the murine echogenic subventricular zone (SVZ) revealed NLRP3-inflammasome assembly in multiciliated FoxJ1+ ependymal cells and a loss of the ependymal border in this postnatal stem cell niche. These data suggest a mechanism of preterm brain injury localized to the SVZ that has not been adequately considered. Ultrasound detection of SVE may serve as an early biomarker for neurodevelopmental impairment after inflammatory disease in preterm infants.

Comparison of conventional and simulated reduced-tube current MDCT for evaluation of suspected appendicitis in the pediatric population.

OBJECTIVE: The purpose of this study was to compare CT with conventional and simulated reduced-tube current in the evaluation for acute appendicitis in children. MATERIALS AND METHODS: Validated noise-addition (tube current-reduction) software was used to create 50% and 75% tube current reductions in 60 CT examinations performed for suspected appendicitis, resulting in 180 image sets. Three blinded pediatric radiologists scored the randomized studies for the following factors: presence of the normal appendix or appendicitis (5-point scale; 1=definitely absent and 5=definitely present), presence of alternate diagnoses, and overall image quality (1=nondiagnostic and 5=excellent). Truth was defined by the interpretation of the conventional examination. RESULTS: For conventional examinations, the total number of reviews (60 cases×3 readers=180) in which the normal appendix was identified was 120 of 180 (66.7%), compared with 108 of 180 (60%) in the 50% (p=0.19) and 91 of 180 (50.6%) in the 75% (p=0.002) tube current-reduction groups. Appendicitis was identified in a total of 39 of 180 (21.7%), 38 of 180 (21.1%), and 37 of 180 (20.6%) examinations, respectively (p>0.05). This translates to sensitivities of 97% and 95% for the 50% and 75% tube current-reduction groups, respectively. Alternate diagnoses were detected in 14%, 16%, and 13% of scans, respectively. Compared with conventional-tube current examinations, reader confidence and assessment of image quality were significantly decreased for both tube current-reduction groups. CONCLUSION: Simulated tube current-reduction technology provides for systematic evaluation of diagnostic thresholds. Application of this technology in the setting of suspected appendicitis shows that tube current can be reduced by at least 50% without significantly affecting diagnostic quality, despite a decrease in reader confidence and assessment of image quality.

A pattern-based approach to bowel obstruction in the newborn.

Intestinal obstruction is common in newborns, and the radiologist plays a critical role in the care of these children. Diagnosing and managing the potentially obstructed newborn can be challenging, especially given the myriad underlying pathologies that range from benign to acutely life-threatening. A familiarity with the most common diagnoses is essential, but equally important to the radiologist is a systematic approach to management of the child in this setting. We propose an approach based on the recognition of eight radiographic patterns, five upper gastrointestinal examination (UGI) patterns and four contrast enema patterns. Recognition of these patterns directs further imaging when necessary and allows triage of children who can be managed medically, those requiring elective or urgent surgery and those requiring emergent surgery.

Unintended Consequence: Diversity as a Casualty of Eliminating United States Medical Licensing Examination Step 1 Scores.

PURPOSE: The purpose of this study was to use a discrete-choice experiment to model the trade-offs evaluators make between academic attributes and demographics when the United States Medical Licensing Examination (USMLE) Step 1 switches to pass/fail. METHODS: A discrete-choice experiment was administered to faculty members from a geographically diverse mix of 14 academic and community radiology departments in the United States from August through November 2020. Reviewers reviewed 10 applicant pairs with numeric Step 1 scores (part 1) and 10 applicant pairs with a pass Step 1 result (part 2). Applicant attributes included medical school rank, gender, race/ethnicity, USMLE Step 1 score, USMLE Step 2 score, class rank, clerkship honors, and publications. Conditional logistic regression modeled the influence of attribute levels. RESULTS: Two hundred twelve evaluators completed the study (response rate 59%). The most influential attribute was Step 1 score in part 1 and medical school rank in part 2. The relative importance of race/ethnicity and gender decreased by 25% and 29%, respectively, when Step 1 switches to pass/fail. Evaluators weigh race/ethnicity the strongest when applicants have the same Step 1 score (preference weights of 0.85 for African American, 1.42 for Hispanic, and 0 for White and Asian applicants). Race/ethnicity is relatively more important when Step 1 scores are higher (preference weights of 1.58 for African American, 0.90 for Hispanic, and 0 for White and Asian applicants). CONCLUSIONS: The loss of numeric Step 1 scores reduced the residency evaluator preference for diversity. Reviewers prioritize underrepresented-in-medicine applicants when Step 1 scores are higher and comparable with White and Asian applicants.

An Elite Privilege: Top-Ranked Medical Schools Provide Fewer Comparative Performance Data on Their Students.

PURPOSE: The objective of this study was to determine differences in the reporting of performance data on medical student performance evaluations (MSPEs) by medical school ranking. METHODS: MSPEs from all US allopathic and osteopathic medical schools received by a single diagnostic radiology residency program during the 2021-2022 application cycle were retrospectively reviewed. Preclinical class and core clerkship grades were categorized as pass/fail or multitiered. Comparative summative assessments provided in the MSPEs were recorded. Medical schools were grouped by their US News & World Report rankings, and the proportion of reported performance metrics for each group was compared. RESULTS: Information from 95% of US allopathic medical schools (148 of 155) and 73% of osteopathic medical schools (27 of 37) was collected, on the basis of 1,046 applications received. For preclinical classes, multitiered grading was reported by no schools ranked in the top 10, 17% of schools ranked 11th to 50th, 52% of schools ranked 51st to 100th, and 59% of unranked schools (P < .001). For core clinical clerkships, multitiered grades were reported by 70% of the top 10 ranked schools, 90% of schools ranked 11th to 50th, 94% of those ranked 51st to 100th, and 94% of unranked schools (P = .0463). Comparative summative assessments were reported by none of the top 10 ranked schools, 56% of schools ranked 11th to 50th, 80% of those ranked 51th to 100th, and 81% of unranked schools (P < .001). CONCLUSIONS: Higher ranked medical schools are less likely to provide comparative assessment data on their MSPEs, which may disadvantage students from lower ranked medical schools.

The Impact of the Dobbs Decision on Diagnostic Radiology Applicants, Residents, and Program Directors.

In the Dobbs decision the United States Supreme Court overturned Roe v. Wade, returning the issue of abortion to the states. To date, there is little published data on the impact this might have on where future residents choose to pursue graduate medical education. We investigated the potential effects of the resultant varied political landscape of abortion care access laws with respect to influence on the selection of prospective diagnostic radiology training programs by medical students, comparing application rates for the 2022 recruitment cycle to the prior 4 years across a geographically diverse group of 22 academic and community sites across the United States. We provide strategies for program directors to consider in dealing with topics related to this continually evolving issue as it pertains to resident recruitment and retention.

Hidden Curriculum and the Demographic Stoicism That Keeps Women and Minorities Away From Radiology: A Mixed-Methods Study of Medical Students.

OBJECTIVE: To understand how women and historically underrepresented minority medical students perceive radiology as a potential career choice. METHODS: Medical students representing a broad spectrum of radiology exposure from a single institution were invited to participate in a mixed-methods study. Participants completed a 16-item survey about demographics and perceptions of radiology. Ten focus groups were administered to probe decision making regarding career selection. The themes influencing women and historically underrepresented minority students are presented. RESULTS: Forty-nine medical students, including 29 (59%) women and 17 (35%) underrepresented minorities, participated. Most participants (28 of 48, 58%) reported men outnumbered women in radiology. Female participants reported a lack of mentorship and role models as major concerns. Outreach efforts focused on the family-friendly nature of radiology were viewed as patronizing. Demographic improvements in the field were viewed as very slow. Forty-six percent (22 of 48) of participants indicated that radiology had a less underrepresented racial or ethnic workforce than other medical specialties. Minority participants especially noted a lack of radiology presence in mainstream media, so students have few preconceived biases. A failure to organically connect with the mostly White male radiologists because of a lack of shared background was a major barrier. Finally, participants described a hidden curriculum that pushes minority medical students away from specialty fields like radiology and toward primary care fields to address underserved communities and health care disparities. DISCUSSION: Women and historically underrepresented minority medical students perceive major barriers to choosing a career in radiology. Radiology departments must develop sophisticated multilevel approaches to improve diversity.

The Influence of Extracurricular Activities on Radiology Resident Selection Decisions.

PURPOSE: Extracurricular activities (EAs) listed on radiology residency applications can signal traits and characteristics desired in holistic reviews. The authors conducted an objective analysis to determine the influence of EAs on resident selection decisions. METHODS: A discrete-choice experiment was designed to model radiology resident selection and determine the relative weights of EAs among academic and demographic application factors. Faculty members involved in resident selection at 30 US radiology programs chose between hypothetical pairs of applicant profiles between October 2021 and February 2022. Each applicant profile included one of 22 EAs chosen for study. A conditional logistic regression model assessed the relative weights of the attributes and odds ratios (ORs) were calculated. RESULTS: Two hundred forty-four participants completed the exercise. Community-service EAs were ranked most highly by participants. LGBTQ Pride Alliance (OR, 1.56; 95% confidence interval [CI], 1.14-2.15; P = .006) and Young Republicans (OR, 0.60; 95% CI, 0.43-0.82; P = .001) significantly influenced decisions. The highest ranked EAs were significantly preferred over the lowest ranked EAs (OR, 1.916; 95% CI, 1.671-2.197; P < .001). Participants preferred EAs that reflected active over passive engagement (OR, 1.154; 95% CI, 1.022-1.304; P = .021) and progressive over conservative ideology (OR, 1.280; 95% CI, 1.133-1.447; P < .001). Participants who ranked progressive EAs more highly preferred applicants with progressive EAs (P < .05 for all). CONCLUSIONS: The influence of EAs on resident selection decisions is significant and likely to gain importance in resident selection as medical student performance metrics are further eliminated. Applicants and selection committees should consider this influence and the bias that EAs can bring to resident selection decisions.

Patient and Radiologist Demographics Influence Perceptions of Screening Mammography Reports.

PURPOSE: The aim of this study was to test whether patient and radiologist demographics influence perceptions of screening mammography reports and the interpreting radiologist. METHODS: Patients presenting for breast imaging were surveyed. Demographics were collected, and each participant was shown five mock screening mammography reports with BI-RADS category 2 findings, each with a recommendation for 1-year screening. Each report included a picture of the interpreting radiologist, who was Black or White and male or female. Participants answered seven questions, on a Likert-type scale, about understanding, satisfaction, and trust in the report and radiologist. Generalized estimating equation ordinal logistic regression compared responses on the basis of participant and radiologist demographics. RESULTS: A total of 178 women participated, with a mean age of 55.1 ± 10.2 years. Most participants self-identified as White (71%) or Black (20%) and non-Hispanic (98%), with broad educational representation (28% with bachelor's degrees and 28% with master's degrees). After controlling for demographics, Black participants reported greater agreement regarding trust in the report's finding (P = .037) if the radiologist was also Black. Black participants were less likely to be satisfied in the report quality (P = .043). Additionally, participants without any college education reported lower agreement that they were satisfied with the report quality (P = .020) and felt the radiologist cares about his or her patients (P = .037). There were no significant associations for radiologist sex or participant age. CONCLUSIONS: Participant perceptions of screening mammography reports and the interpreting radiologist can be influenced by participant and provider race as well as participant education. These findings could have implications for mammography adherence, breast radiologist recruitment, and developing patient-centric reports.

Radiology Stereotypes, Application Barriers, and Hospital Integration: A Mixed-methods Study of Medical Student Perceptions of Radiology.

RATIONALE AND OBJECTIVES: Limited exposure to radiology by medical students can perpetuate negative stereotypes and hamper recruitment efforts. The purpose of this study is to understand medical students' perceptions of radiology and how they change based on medical education and exposure. MATERIALS AND METHODS: A single-institution mixed-methods study included four groups of medical students with different levels of radiology exposure. All participants completed a 16-item survey regarding demographics, opinions of radiology, and perception of radiology stereotypes. Ten focus groups were administered to probe perceptions of radiology. Focus groups were coded to identify specific themes in conjunction with the survey results. RESULTS: Forty-nine participants were included. Forty-two percent of participants had positive opinions of radiology. Multiple radiology stereotypes were identified, and false stereotypes were diminished with increased radiology exposure. Opinions of the impact of artificial intelligence on radiology closely aligned with positive or negative views of the field overall. Multiple barriers to applying for a radiology residency position were identified including board scores and lack of mentorship. COVID-19 did not affect perceptions of radiology. There was broad agreement that students do not enter medical school with many preconceived notions of radiology, but that subsequent exposure was generally positive. Exposure both solidified and eliminated various stereotypes. Finally, there was general agreement that radiology is integral to the health system with broad exposure on all services. CONCLUSION: Medical student perceptions of radiology are notably influenced by exposure and radiology programs should take active steps to engage in medical student education.

Can the use of deception be justified in medical education research? A point/counterpoint and case study.

Deception is a common feature of behavioral research design, although not commonly employed in the medical literature. It can promote scientific validity but is ethically controversial because it compromises subject autonomy and incurs additional costs.  In this Point/Counterpoint monograph, we review the nature of deception in research and present arguments for and against its ethical use as a research methodology in behavioral studies.  We describe the necessary guidelines, safeguards, and oversight, when deceptive methodology is considered, and report our experiences and lessons learned from conducting a multi-institutional audit study that relied upon deception of academic radiology faculty.