The Impact of Emerging Technologies on Residency Selection by Medical Students in 2017 and 2021, With a Focus on Diagnostic Radiology.

RATIONALE AND OBJECTIVES: We sought to determine the perceived impact of artificial intelligence (AI) and other emerging technologies (ET) on various specialties by medical students in both 2017 and 2021 and how this might affect their residency selections. MATERIALS AND METHODS: We conducted a brief, anonymous survey of all medical students at a single institution in 2017 and 2021. Survey questions evaluated (1) incentives motivating residency selection and career path, (2) degree of interest in each specialty, (3) perceived effect that ET will have on job prospects for each specialty, and (4) those specialties that students would not consider because of concerns regarding ET. RESULTS: A total of 72% (384/532) and 54% (321/598) of medical students participated in the survey in 2017 and 2021, respectively, and results were largely stable. Students perceived ET would reduce job prospects for pathology, diagnostic radiology, and anesthesiology, and enhance prospects for all other specialties (p < 0.01) except dermatology. For both surveys, 23% of students would NOT consider diagnostic radiology because ET would make it obsolete, higher than all other specialties (p < 0.01). Regarding the one student class that was surveyed twice, 50% felt ET would reduce job prospects for radiology in 2017, increasing to 71% in 2021 (p < 0.01), and similar percentages-20% in 2017 and 23% in 2021-said they explicitly would not consider radiology because of concerns levied by ET. CONCLUSIONS: Current perceptions of ET likely affect residency selection for a large proportion of medical students and may impact the future of various specialties, particularly diagnostic radiology.

Ultrasound for Lower Extremity Deep Venous Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in Ultrasound Consensus Conference.

Venous ultrasound is the standard imaging test for patients suspected of having acute deep venous thrombosis (DVT). There is variability and disagreement among authoritative groups regarding the necessary components of the test. Some protocols include scanning the entire lower extremity, whereas others recommend scans limited to the thigh and knee supplemented with serial testing. Some protocols use gray-scale ultrasound alone, whereas others include Doppler interrogation. Point-of-care ultrasound is recommended in some settings, and there is heterogeneity of these protocols as well. Heterogeneity of recommendations can lead to errors including incorrect application of guidelines, confusion among requesting physicians, and incorrect follow-up. In October 2016, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to evaluate the current evidence to develop recommendations regarding ultrasound protocols for DVT and the terminology used to communicate results to clinicians. Recommendations were made after open discussion and by unanimous consensus.The panel recommends a comprehensive duplex ultrasound protocol from thigh to ankle with Doppler at selected sites rather than a limited or complete compression-only examination. This protocol is currently performed in many facilities and is achievable with standard ultrasound equipment and personnel. The use of these recommendations will increase the diagnosis of calf DVT and provide better data to explain the presenting symptoms. The panel recommends a single point-of-care protocol that minimizes underdiagnoses of proximal DVT.The panel recommends the term chronic postthrombotic change to describe the residual material that persists after the acute presentation of DVT to avoid potential overtreatment of prior thrombus.Adoption of a single standardized comprehensive duplex ultrasound and a single point-of-care examination will enhance patient safety and clinicians' confidence.

ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee.

Thyroid nodules are a frequent finding on neck sonography. Most nodules are benign; therefore, many nodules are biopsied to identify the small number that are malignant or require surgery for a definitive diagnosis. Since 2009, many professional societies and investigators have proposed ultrasound-based risk stratification systems to identify nodules that warrant biopsy or sonographic follow-up. Because some of these systems were founded on the BI-RADS® classification that is widely used in breast imaging, their authors chose to apply the acronym TI-RADS, for Thyroid Imaging, Reporting and Data System. In 2012, the ACR convened committees to (1) provide recommendations for reporting incidental thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound reporting, and (3) propose a TI-RADS on the basis of the lexicon. The committees published the results of the first two efforts in 2015. In this article, the authors present the ACR TI-RADS Committee's recommendations, which provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance. The authors also describe the committee's future directions.

Teaching and Working With Millennial Trainees: Impact on Radiological Education and Work Performance.

Many feel that the generational differences encountered with Millennial trainees are novel; the reality is that prior generations have always bemoaned generational differences. This is not a new problem; some of the same things may even have been said about us during our own training! There are a variety of myths and misconceptions about the Millennial generation (also known as Generation Y). In this article we review some of the differences frequently encountered as we educate and work alongside our Millennial colleagues, dispelling some of the myths and misconceptions. With increased understanding of this talented group of individuals, we hope to be more effective teachers and have more successful professional relationships.

Optimizing modality selection for image-guided procedures: an analysis of the challenges to ultrasound guidance.

INTRODUCTION: Selection of the most appropriate modality for image guidance is essential for procedural success. We identified specific factors contributing to failure of ultrasound-guided procedures that were subsequently performed using CT guidance. MATERIALS AND METHODS: This single-center, retrospective study included 164 patients who underwent a CT-guided biopsy, aspiration/drainage, or ablation after initially having the same procedure attempted unsuccessfully with ultrasound guidance. Review of the procedure images, reports, biopsy results, and clinical follow-up was performed and the reasons for inability to perform the procedure with ultrasound guidance were recorded. Patient cross-sectional area and depth to target were calculated. Differences in area and depth were compared using general linear modeling. Depth as a predictor of an unfavorable body habitus designation was modeled using logistic regression. RESULTS: US guidance was successful in the vast majority of cases (97%). Of the 164 procedures, there were 92 (56%) biopsies, 63 (38%) aspirations/drainages, and 9 (5%) ablations. The most common reason for procedure failure was poor acoustic window (83/164, 51%). Other reasons included target lesion being poorly discerned from adjacent tissue (61/164, 37%), adjacent bowel gas (34/164, 21%), body habitus (27/164, 16%), and gas-containing collection (22/164, 13%). Within the biopsy subgroup, patients for whom body habitus was a limiting factor were found to have on average a larger cross-sectional area and lesion depth relative to patients whose body habitus was not a complicating factor (p < 0.0001 and p = 0.0009). CONCLUSION: Poor acoustic window was the most common reason for procedural failure with ultrasound guidance. In addition, as lesion depth increased, the odds that body habitus would limit the procedure also increased. If preliminary imaging suggests a limited sonographic window, particularly for deeper lesions, proceeding directly to CT guidance should be considered.

Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee.

Ultrasound is the most commonly used imaging technique for the evaluation of thyroid nodules. Sonographic findings are often not specific, and definitive diagnosis is usually made through fine-needle aspiration biopsy or even surgery. In reviewing the literature, terms used to describe nodules are often poorly defined and inconsistently applied. Several authors have recently described a standardized risk stratification system called the Thyroid Imaging, Reporting and Data System (TIRADS), modeled on the BI-RADS system for breast imaging. However, most of these TIRADS classifications have come from individual institutions, and none has been widely adopted in the United States. Under the auspices of the ACR, a committee was organized to develop TIRADS. The eventual goal is to provide practitioners with evidence-based recommendations for the management of thyroid nodules on the basis of a set of well-defined sonographic features or terms that can be applied to every lesion. Terms were chosen on the basis of demonstration of consistency with regard to performance in the diagnosis of thyroid cancer or, conversely, classifying a nodule as benign and avoiding follow-up. The initial portion of this project was aimed at standardizing the diagnostic approach to thyroid nodules with regard to terminology through the development of a lexicon. This white paper describes the consensus process and the resultant lexicon.

Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee.

The incidental thyroid nodule (ITN) is one of the most common incidental findings on imaging studies that include the neck. An ITN is defined as a nodule not previously detected or suspected clinically, but identified by an imaging study. The workup of ITNs has led to increased costs from additional procedures, and in some cases, to increased risk to the patient because physicians are naturally concerned about the risk of malignancy and a delayed cancer diagnosis. However, the majority of ITNs are benign, and small, incidental thyroid malignancies typically have indolent behavior. The ACR formed the Incidental Thyroid Findings Committee to derive a practical approach to managing ITNs on CT, MRI, nuclear medicine, and ultrasound studies. This white paper describes consensus recommendations representing this committee's review of the literature and their practice experience.

A pilot study estimating liver fibrosis with ultrasound shear-wave elastography: does the cause of liver disease or location of measurement affect performance?

OBJECTIVE: The purpose of this study was to evaluate the diagnostic accuracy of real-time shear-wave elastography for assessment of liver fibrosis in an unselected patient population, comparing shear-wave elastography measurements obtained at and remote from the site of random liver biopsy. SUBJECTS AND METHODS: In a prospective study of 50 patients (21 with and 29 without hepatitis C) referred for clinically indicated random liver biopsy for diffuse liver disease, shear-wave elastography measurements were taken from four locations before biopsy: one at the left lobe, two at the right lobe, and one at the biopsy location. The mean, minimum, maximum, and SD of shear-wave elastography were compared with pathologic grading. Steatosis and serum markers were analyzed using multiple logistic regression. Optimized shear-wave elastography thresholds were calculated using AUC analysis. RESULTS: The AUC (95% CI) at the biopsy site, ipsilateral lobe, and contralateral lobe were 0.82 (0.63-1.0), 0.84 (0.67-1.0), and 0.59 (0.19-0.99) in hepatitis C patients; 0.89 (0.75-1.0), 0.88 (0.73-1.0), and 0.93 (0.80-1.0) in nonhepatitis C patients; and 0.85 (0.74-0.96), 0.89 (0.79-0.99), and 0.80 (0.67-0.93) in all patients, respectively. Optimized biopsy site shear-wave elastography values for detecting Metavir score F2 or greater were 1.87 m/s (75% sensitivity and specificity), 2.00 m/s (80% sensitivity and specificity), and 1.89 m/s (76% sensitivity and specificity) in hepatitis C, nonhepatitis C, and all patients, respectively. Steatosis and serum markers were not significant. CONCLUSION: Real-time shear-wave elastography accurately predicted significant fibrosis (stage ≥ 2) in an unselected patient population with diffuse disease, including patients with and without hepatitis C. Shear-wave elastography best predicts pathologic grading when taken at the biopsy site or ipsilateral lobe in hepatitis C patients. Percentage steatosis was not predictive of shear-wave elastography results.

Resident experience increases diagnostic rate of thyroid fine-needle aspiration biopsies.

RATIONALE AND OBJECTIVES: The aim of this study was to determine whether the diagnostic yield of thyroid fine-needle aspirations (FNAs) changes over the course of residency training. MATERIALS AND METHODS: We identified 5418 ultrasound-guided thyroid nodule FNAs performed in our radiology department from 2004 through 2012. For each FNA, we recorded if the FNA was performed by a resident and if so the name of the resident and supervising attending radiologist. For each resident, we determined the level of training based on their graduation year from our residency program and the date of the FNA as well as prior surgical training and if they completed subsequent interventional radiology fellowship. Pathology reports were reviewed, and FNAs were classified as diagnostic or nondiagnostic (ND). Generalized mixed models were used to assess ND rate with postgraduate years, including residents with and without prior surgical training or if they subsequently completed an interventional radiology fellowship. RESULTS: Of the 5418 thyroid FNAs, 3164 (58.4%) were performed by a radiology resident under the direct supervision of an attending physician. There was a significant decrease in ND rate as postgraduate years increased (P < .05). A significant decrease in ND rate was found as postgraduate years increased for residents without prior surgical training (P = .0007) or subsequent training in interventional radiology (P = .0014); however, no significant decrease was found for residents with surgical training (P = .37) or completing an interventional radiology fellowship (P = .08). In addition, no significant difference was found for ND rate between postgraduate year 4 (PGY4) and PGY5 (P > .05). CONCLUSIONS: ND thyroid FNA rates progressively decrease with training level, suggesting that early and continued participation in procedures throughout residency improves outcomes. This is particularly true for residents without prior surgical training or subsequent interventional radiology fellowship.

Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy?

PURPOSE: To identify demographic and ultrasonographic (US) features associated with malignancy after initially nondiagnostic results of fine-needle aspiration (FNA) to help clarify the role of repeat FNA, surgical excision, or serial US in these nodules. MATERIALS AND METHODS: This study was HIPAA compliant and institutional review board approved; informed consent was waived. Thyroid nodules (n = 5349) that underwent US-guided FNA in 2004-2012 were identified; 393 were single nodules with nondiagnostic FNA results but adequate cytologic, surgical, or US follow-up. Demographic information and diameters and volume at US at first biopsy were modeled with malignancy as outcome through medical record review. Exact logistic regression was used to model malignancy outcomes, demographic comparisons with age were made (Student t test, Satterthwaite test), and proportion confidence intervals (CIs) were estimated (Clopper-Pearson method). RESULTS: Of 393 nodules with initially nondiagnostic results, nine malignancies (2.3%) were subsequently diagnosed with repeat FNA (n = 2, 0.5%) or surgical pathologic examination (n = 7, 1.8%), 330 (84.0%) were benign, and 54 (13.7%) were stable or decreased in size at serial US (mean follow-up, 3.0 years; median, 2.5 years; range, 1.0-7.8 years). Patients with malignancies were significantly older (mean age, 62.7 years; median, 64 years; range, 47-77 years) than those without (mean age, 55.4 years; median, 57 years; range, 12-94 years; P = .0392). Odds of malignancy were 4.2 times higher for men versus women (P = .045) and increased significantly for each 1-cm increase in anteroposterior, minimum, and mean nodule diameter (1.78, 2.10, and 1.96, respectively). In 393 nodules, no malignancies were detected in cystic or spongiform nodules (both, n = 11, 2.8%; 95% CI: 1.4%, 5.0%), nodules with eggshell calcifications (n = 9, 2.3%; 95% CI: 1.1%, 4.3%), or indeterminate echogenic foci (n = 39, 9.9%; 95% CI: 7.2%, 13.3%). CONCLUSION: Very few malignancies were diagnosed with repeat FNA following nondiagnostic FNA results (two of 336, 0.6%); therefore, clinical and US follow-up may be more appropriate than repeat FNA following nondiagnostic biopsy results.

Retirement issues for radiologists, part 2: Consensus statement on retirement and preretirement issues by the Commission on Human Resources of the ACR.

There are many retirement and preretirement issues facing individual radiology groups and practices. The discussion of the numerous options available for radiologists contemplating retirement sometimes becomes contentious within a practice and may pit younger radiologists against the more senior members of the group. The potential exists for the process to degenerate into personality clashes. The purpose of this article is to offer some objective guidance on retirement issues.

Retirement issues for radiologists and the radiology practice, part 1: a report of the ACR Commission on Human Resources, Subcommittee on Retirement.

Retirement and issues associated with the initiation of retirement have undergone extensive change in the past decade. Multiple factors, including economic conditions, have resulted in a delay in the initiation of retirement. Delayed retirement of senior radiologists is a factor contributing to a diminished job market for entering radiology graduates. These senior radiologists have extensive experience in operational issues and understanding complex relationships with other health professionals, hospitals, and often medical schools. In addition, although they may not be as facile with MRI or PET/CT, senior radiologists have a tremendous command of traditional imaging, which is lacking in recently trained radiologists. The authors examine many of the issues related to delayed retirement and propose some possible solutions.

Injuries from ingesting wire bristles dislodged from grill-cleaning brushes--Providence, Rhode Island, 2009-2012.

Foreign object ingestion is a common reason for visiting an emergency department; however, wire grill-cleaning brush bristles are an uncommon foreign object. This report describes a series of twelve cases identified in a single hospital system from July 2009 through June 2012. Patients included six males and six females; ages ranged from 11 to 75 (mean: 47 years). The patients all reported recent outdoor residential food grilling and use of commercially available wire grill-cleaning brushes. The severity of injury ranged from puncture of the soft tissues of the neck, causing severe pain on swallowing, to perforation of the gastrointestinal tract requiring emergent surgery. Before cooking, persons should examine the grill surface carefully for the presence of wire bristles that might have dislodged from the grill brush and could embed in cooked food. Alternative residential grill-cleaning methods or products might be considered.

Nonshadowing echogenic foci in thyroid nodules: are certain appearances enough to avoid thyroid biopsy?

OBJECTIVES: The purpose of this study was to further classify nonshadowing echogenic foci and examine the association with malignancy. METHODS: This study received Institutional Review Board approval and was Health Insurance Portability and Accountability Act compliant. A total of 371 consecutive thyroid nodules were evaluated in 189 patients (177 female and 12 male; mean age, 59 years; range, 21-92 years). Eighty-six nodules (23%) measured 5 mm or larger and contained nonshadowing echogenic foci with a mean nodule diameter of 16 mm (5-66 mm). Blinded review of these nodules 12 months later was performed. Echogenic foci were classified as follows: showing a comet tail artifact (type 1), linear and brightly echogenic (type 2), round and indeterminate (type 3), and microcalcifications (type 4). All available thyroid sonograms and pathologic data were then reviewed. RESULTS: Nineteen nodules (22%) showed a classic comet tail artifact, with malignancy in 0 of 19. Six (32%) had negative pathologic results, and 9 (47%) had stable imaging follow-up (mean, 37 months). Twenty-nine nodules (34%) showed linear and brightly echogenic foci, with malignancy in 0 of 29. Fifteen (52%) had negative pathologic results, and 11 (38%) had stable imaging follow-up (mean, 34 months). Twenty-four nodules (28%) showed round and indeterminate echogenic foci, with 1 of 24 (4%) containing papillary carcinoma. Thirteen (54%) had negative pathologic results, and 8 (33%) had stable imaging follow-up (mean, 24 months). Fourteen nodules (16%) contained microcalcifications, with 4 of 14 (29%) containing papillary thyroid cancer. Nine (64%) had negative pathologic results, and 1 (7%) had stable imaging follow-up (63 months). CONCLUSIONS: Nonshadowing brightly echogenic linear foci with or without a comet tail artifact may be a benign finding. Confirmatory studies are needed for this result to be applied clinically.

CT-guided percutaneous lung biopsy: comparison of conventional CT fluoroscopy to CT fluoroscopy with electromagnetic navigation system in 60 consecutive patients.

PURPOSE: To determine if use of an electromagnetic navigation system (EMN) decreases radiation dose and procedure time of CT fluoroscopy guided lung biopsy in lesions smaller than 2.5 cm. MATERIALS/METHODS: 86 consecutive patients with small lung masses (<2.5 cm) were approached. 60 consented and were randomized to undergo biopsy with CT fluoroscopy (CTF) (34 patients) or EMN (26 patients). Technical failure required conversion to CTF in 8/26 EMN patients; 18 patients completed biopsy with EMN. Numerous biopsy parameters were compared as described below. RESULTS: Average fluoroscopy time using CTF was 28.2s compared to 35.0 s for EMN (p=0.1). Average radiation dose was 117 mGy using CTF and 123 mGy for EMN (p=0.7). Average number of needle repositions was 3.7 for CTF and 4.4 for EMN (p=0.4). Average procedure time was 15 min for CTF and 20 min for EMN (p=0.01). There were 7 pneumothoracesin the CTF group and 6 pneumothoraces in the EMN group (p=0.7). One pneumothorax in the CTF group and 3 pneumothoraces in the EMN group required chest tube placement (p=0.1). One pneumothorax patient in each group required hospital admission. Diagnostic specimens were obtained in 31/34 patients in the CTF group and 22/26 patients in the EMN group (p=0.4). CONCLUSIONS: EMN was not statistically different than CTF for fluoroscopy time, radiation dose, number of needle repositions, incidence of pneumothorax, need for chest tube, or diagnostic yield. Procedure time was increased with EMN.

Renal cortical thickness measured at ultrasound: is it better than renal length as an indicator of renal function in chronic kidney disease?

OBJECTIVE: The purpose of our study was to determine whether there is a relationship between renal cortical thickness or length measured on ultrasound and the degree of renal impairment in chronic kidney disease (CKD). MATERIALS AND METHODS: From October to December 2007, 25 patients (13 men and 12 women, mean age 73 years) were identified who had CKD but were not on dialysis. The patients were from a single institution and had undergone renal ultrasound and at least three serum creatinines within 90 days. The lowest creatinine was used for estimated glomerular filtration rate (eGFR) calculation using both the Cockcroft-Gault (CG) and the Modification of Diet in Renal Disease Study (MDRD) equations. Ultrasounds were consensus reviewed by three radiologists (2 attendings and a resident) blinded to specific renal function. Cortical thickness was measured in the sagittal plane over a medullary pyramid, perpendicular to the capsule. Length was measured pole-to-pole. Linear regression was used for statistical analysis. RESULTS: Mean cortical thickness was 5.9 mm (range, 3.2-11.0 mm). Mean length was 10 cm (7.2-12.4 cm). Mean minimum serum creatinine was 2.1 mg/dL (1.1-6.1 mg/dL). Mean eGFR using CG was 34.8 mL/min (10.6-99.4 mL/min) and 36 mL/min (8-66 mL/min) using MDRD. There was a statistically significant relationship between eGFR and cortical thickness using both CG (p < 0.0001) and MDRD (p = 0.005). There was a statistically significant relationship between CG and length (p = 0.003) but not between MDRD and length (p = 0.08). CONCLUSION: Cortical thickness measured on ultrasound appears to be more closely related to eGFR than renal length. Reporting cortical thickness in patients with CKD who are not on dialysis should be considered.

Hashimoto thyroiditis: Part 1, sonographic analysis of the nodular form of Hashimoto thyroiditis.

OBJECTIVE: The purpose of this article is to analyze the sonographic appearance of nodular Hashimoto thyroiditis. SUBJECTS AND METHODS: As part of an ongoing multiinstitutional study, patients who underwent ultrasound examination and fine-needle aspiration of one or more thyroid nodules were analyzed for multiple predetermined sonographic features. Patients completed a questionnaire, including information about thyroid function and thyroid medication. Patients (n = 61) with fine-needle aspiration cytologic results consistent with nodular Hashimoto thyroiditis (n = 64) were included in the study. RESULTS: The mean (+/- SD) diameter of nodular Hashimoto thyroiditis was 15 +/- 7.33 mm. Nodular Hashimoto thyroiditis occurred as a solitary nodule in 36% (23/64) of cases and in the setting of five or more nodules in 23% (15/64) of cases. Fifty-five percent (35/64) of the cases of nodular Hashimoto thyroiditis occurred within a sonographic background of diffuse Hashimoto thyroiditis, and 45% (29/64) of cases occurred within normal thyroid parenchyma. The sonographic appearance was extremely variable. It was most commonly solid (69% [42/61] of cases) and hypoechoic (47% [27/58] of cases). Twenty percent (13/64) of nodules had calcifications (seven with nonspecific bright reflectors, four with macrocalcifications, and three eggshell), and 5% (3/64) of nodules had colloid. Twenty-seven percent (17/64) of nodules had a hypoechoic halo. The margins were well defined in 60% (36/60) and ill defined in 40% (24/60) of nodules. On Doppler analysis, 35% (22/62) of nodules were hypervascular, 42% (26/62) were isovascular or hypovascular, and 23% (14/62) were avascular. CONCLUSION: The sonographic features and vascularity of nodular Hashimoto thyroiditis were extremely variable.