Harnessing Technology: Using an iPad to Enhance Radiology Medical Student Education.

RATIONALE AND OBJECTIVES: Our goal was to determine whether use of the iPad would increase the students' radiologic knowledge, aid in their interpretation of imaging exams, and increase learner satisfaction. MATERIAL AND METHODS: iPads were pre-populated with ten image data sets, which included plain film, ultrasound, and CT of the head, chest, abdomen, and pelvis. The students, working in small groups, were charged with identifying the salient imaging findings, formulating a differential diagnosis, and choosing the most appropriate imaging modality, if further work-up was necessary. After the student group problem-solved for an hour, a faculty facilitator joined the group and reviewed the cases with them in an interactive fashion. Pre- and post- intervention tests were administered, and statistical analysis was performed. RESULTS: Student satisfaction surveys were administered to 125 students in the first 2 years of the study. These scores rated their assessment of the iPad exercise and ranged from 4.6 to 4.9 out of 5. The knowledge evaluation group included 219 students, 110 in the study group and 109 in the control group, in the latter 3 years of the study. The average improvement from the initial to the second test was 1.04 points among the control group and 2.32 among the study group, which was statistically significant (p = 0.0001). CONCLUSION: We demonstrate increased learner satisfaction, as well as improved knowledge acquisition and interpretive skills of third year medical students engaged in hands-on learning using iPads.

Virtual evaluation of selected cervical lymph nodes with three-dimensional ultrasound in thyroid cancer patients after thyroidectomy.

BACKGROUND: We evaluated the usefulness of three-dimensional (3D) ultrasound of cervical lymph nodes (LN), when two-dimensional (2D) ultrasound evaluation is not sufficient to clearly evaluate lymph node characteristics, in thyroid cancer patients being followed after thyroidectomy. METHODS: Two readers retrospectively analyzed 2D and 3D images of 147 LNs; LNs were categorized as normal, reactive, suspicious, or indeterminate, and confidence level was rated. Results were compared to cytological/clinical data. Inter-reader agreement was calculated. RESULTS: Addition of 3D ultrasound significantly increased specificity (0.787 with 2D ultrasound vs 0.905 with 2D + 3D ultrasound for reader 1, P = .009; 0.701 with 2D ultrasound vs 0.898 with 2D + 3D ultrasound for reader 2, P = .01). Addition of 3D ultrasound significantly increased confidence level of readers (P < .001). Inter-reader agreement in LN categorization was almost perfect with 2D + 3D ultrasound. CONCLUSION: 3D ultrasound of cervical LNs enables better demonstration of imaging features that are important in differentiating benign and malignant LNs. These improvements can potentially obviate the need for FNA in post thyroidectomy cancer patients.

Applications of 3-Dimensional Ultrasonography in the Neck, Excluding the Thyroid.

Ultrasonography (US) of the neck is an accepted, useful imaging modality for many applications beyond its usefulness in thyroid disease. Two-dimensional US has been effectively used for evaluation of many types of neck conditions, and now, 3-dimensional US can be added to the imaging armamentaria. Three-dimensional US is useful in the evaluation of cervical lymph nodes, recurrent/residual thyroid neoplasia, parathyroid glands, parotid and submandibular glands, as well as thyroglossal duct cysts and other assorted palpable and visible abnormalities because of its unique capabilities, including multiplanar reconstruction, accessibility of the coronal view, volume calculation, and regularly spaced incremental slice evaluation.

Sensitivity of 3-Dimensional Sonography in Preoperative Evaluation of Parathyroid Glands in Patients With Primary Hyperparathyroidism.

OBJECTIVES: Preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism facilitates targeted surgery. We assessed the sensitivity of 3-dimensional (3D) sonography for preoperative localization of abnormal parathyroid glands. METHODS: We conducted a retrospective review of patients who underwent parathyroidectomy for primary hyperparathyroidism at a single site at our institution. We compared preoperative 2-dimensional (2D) sonography, 3D sonography, and sestamibi scans with final gland localization at surgery. Two readers reviewed the sonograms to assess inter-reader variability. RESULTS: From January 2010 through April 2015, 52 patients underwent parathyroidectomy after preoperative 2D sonography, 3D sonography, and sestamibi scans. Three-dimensional sonography had sensitivity of 88-92% compared with 69-71% for 2D sonography for gland localization. In patients in whom sonography and sestamibi scans localized abnormalities to the same side, the sensitivities were 100% (43 of 43) for 3D sonography and 96% (48 of 50) for 2D sonography. Three-dimensional sonography had significantly higher sensitivity for localization of glands smaller than 500 mg compared with 2D sonography (88% versus 58%; P = .012). There was better inter-reader agreement between the radiologists when using 3D sonography (κ = 0.65) compared with 2D sonography (κ = 0.41). CONCLUSIONS: We found a significantly higher sensitivity and better inter-reader agreement for 3D sonography compared with 2D sonography for preoperative identification of abnormal parathyroid glands, especially among smaller glands.

New Dimensions in Renal Transplant Sonography: Applications of 3-Dimensional Ultrasound.

BACKGROUND: The aim of this study is to demonstrate the usefulness of adding 3-dimensional (3D) ultrasound in evaluation of renal transplant vasculature compared to 2-dimensional (2D) Duplex ultrasound. METHODS: One hundred thirteen consecutive renal transplant 2D and 3D ultrasound examinations were performed and retrospectively reviewed by 2 board-certified radiologists and a radiology resident individually; each reviewed 2D and then 3D images, including color and spectral Doppler. They recorded ability to visualize the surgical anastomosis and rated visualization on a subjective scale. Interobserver agreement was evaluated. Variant anastomosis anatomy was recorded. Tortuosity or stenosis was evaluated if localized Doppler velocity elevation was present. RESULTS: The reviewers directly visualized the anastomosis more often with 3D ultrasound ((Equation is included in full-text article.)=97.5%) compared with 2D ((Equation is included in full-text article.)=54.5%) [difference in means (DM) = 43% (95% confidence interval (CI) = 36%-50%) (P < 0.001)]. The reviewers visualized the anastomosis more clearly with 3D ultrasound (P < 0.001) [difference in medians = 0.5, 1.0, and 1.0, (95% CI = 0.5-1.0, 0.5-1.0, and 1.0-1.5)]. Detection of variant anatomy improved with 3D ultrasound by 2 reviewers [DM = 7.1% and 8.9% (95% CI = 1%-13% and 4%-14%, respectively) (P < 0.05)]. There was high interobserver agreement [(Equation is included in full-text article.)= 95.3%, (95% CI = 91.9%-98.7%) regarding anastomosis visualization among reviewers with wide-ranging experience. CONCLUSIONS: Direct visualization of the entire anastomosis was improved with 3D ultrasound. Three-dimensional evaluation improved detection of anatomic variants and identified tortuosity as the likely cause of borderline localized elevation in Doppler velocity. The data added by 3D ultrasound may obviate confirmatory testing with magnetic resonance angiography or computed tomographic angiography after equivocal 2D ultrasound results.

Three-Dimensional Sonography of Biliary Tract Disorders.

In this pictorial essay, we review the 3-dimensional sonographic appearance of the normal gallbladder and biliary tree, as well as the appearance of congenital and acquired biliary tract disorders. Using examples, we demonstrate the advantage of 3-dimensional scanning compared with 2-dimensional sonography and, even in certain cases, magnetic resonance cholangiopancreatography.

Integrating the ACR Appropriateness Criteria Into the Radiology Clerkship: Comparison of Didactic Format and Group-Based Learning.

PURPOSE: The aim of this study was to determine whether group-based or didactic teaching is more effective to teach ACR Appropriateness Criteria to medical students. METHODS: An identical pretest, posttest, and delayed multiple-choice test was used to evaluate the efficacy of the two teaching methods. Descriptive statistics comparing test scores were obtained. RESULTS: On the posttest, the didactic group gained 12.5 points (P < .0001), and the group-based learning students gained 16.3 points (P < .0001). On the delayed test, the didactic group gained 14.4 points (P < .0001), and the group-based learning students gained 11.8 points (P < .001). The gains in scores on both tests were statistically significant for both groups. However, the differences in scores were not statistically significant comparing the two educational methods. CONCLUSIONS: Compared with didactic lectures, group-based learning is more enjoyable, time efficient, and equally efficacious. The choice of educational method can be individualized for each institution on the basis of group size, time constraints, and faculty availability.

Three-Dimensional Sonography of Axillary Lymph Nodes in Patients With Breast Cancer.

Sonography is useful in the evaluation of axillary lymph nodes in patients with breast cancer. In this pictorial essay, we review the range of grayscale and Doppler appearances of abnormal axillary lymph nodes on 2-dimensional and 3-dimensional imaging.

Outside the inside: a review of soft-tissue abnormalities seen on thoracoabdominal computed tomography.

In this review, we illustrate the computed tomographic features of thoracoabdominal soft-tissue abnormalities, which may be easily overlooked and often can provide important information regarding systemic processes. Examples include necrotizing fasciitis, heterotopic ossification, fat necrosis, benign and malignant neoplasms, endometriosis, and collagen vascular disease as well as systemic and congenital pathology.

Three-dimensional sonography in the evaluation of primary hyperparathyroidism.

Three-dimensional sonography is useful in the preoperative evaluation of patients with primary hyperparathyroidism. In this pictorial essay, we review the characteristic spectrum of grayscale and Doppler appearances of parathyroid glands on 2-dimensional sonography and demonstrate the additional benefits of 3-dimensional scanning.

Aesthetic surgery of the buttocks: imaging appearance.

Familiarity with the imaging appearance and potential complications of buttocks aesthetic surgery is important for radiologists. In this review, we illustrate the spectrum of imaging features after buttocks implants, liposuction, fat injections and silicone injections. Complications such as fat necrosis, abscess, and silicone migration are also presented.

Multimodality imaging of normal hepatic transplant vasculature and graft vascular complications.

Orthotopic liver transplantation is an important treatment option for patients with end-stage liver disease. Advances in surgical technique, along with improvements in organ preservation and immunosuppression have improved patient outcomes. Post-operative complications, however, can limit this success. Ultrasound is the primary imaging modality for evaluation of hepatic transplants, providing real-time information about vascular flow in the graft. Graft vascular complications are not uncommon, and their prompt recognition is crucial to allow for timely graft salvage. A multimodality approach including CT angiography, MRI, or conventional angiography may be necessary in cases of complex transplant vascular anatomy or when sonography and Doppler are inconclusive to diagnose the etiologies of these complications. The purpose of this article is to familiarize radiologists with the normal post-transplant vascular anatomy and the imaging appearances of the major vascular complications that may occur within the hepatic artery, portal vein, and venous outflow tract, with an emphasis on ultrasound.

Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.

BACKGROUND: Errors related to high-alert medications, such as chemotherapeutic agents, have resulted in serious adverse events. A fast-paced application of Lean Sigma methodology was used to safeguard the chemotherapy preparation process against errors and increase compliance with United States Pharmacopeia 797 (USP 797) regulations. WORKSHOP STRUCTURE AND PROCESS: On Days 1 and 2 of a Lean Sigma workshop, frontline staff studied the chemotherapy preparation process. During Days 2 and 3, interventions were developed and implementation was started. FINDINGS AND INTERVENTIONS: The workshop participants were satisfied with the speed at which improvements were put to place using the structured workshop format. The multiple opportunities for error identified related to the chemotherapy preparation process, workspace layout, distractions, increased movement around ventilated hood areas, and variation in medication processing and labeling procedures. Mistake-proofing interventions were then introduced via workspace redesign, process redesign, and development of standard operating procedures for pharmacy staff. Interventions were easy to implement and sustainable. Reported medication errors reaching patients and requiring monitoring decreased, whereas the number of reported near misses increased, suggesting improvement in identifying errors before reaching the patients. DISCUSSION: Application of Lean Sigma solutions enabled the development of a series of relatively inexpensive and easy to implement mistake-proofing interventions that reduce the likelihood of chemotherapy preparation errors and increase compliance with USP 797 regulations. The findings and interventions are generalizable and can inform mistake-proofing interventions in all types of pharmacies.

Transforming care at the bedside: an ambulatory model for improving the patient experience.

Transforming Care at the Bedside is a nationwide effort to design a model for improving care to hospitalized patients. With the projected growth of ambulatory services, it is increasingly important to focus on potential methods to increase patient satisfaction and care delivery improvement in the outpatient setting, as well. The authors describe the University of Pittsburgh Medical Center Hillman Cancer Center's adaptation of the Transforming Care at the Bedside care delivery improvement model to its ambulatory services arena and its promising results.

Assessing and monitoring override medications in automated dispensing devices.

BACKGROUND: Medication override is not without risk because the absence of pharmacist review may increase the potential for a medication error. The University of Pittsburgh Medical Center's Department of Pharmacy and Therapeutics assessed the safety of the automated dispensing device (ADD) override process to reduce the number of override medications stored in the ADD. METHODS: A representative expert panel developed criteria for override access and revised the override medication list; an override monitoring tool was used to perform random audits and determine nursing compliance; and changes in override practices for use of opioids, a high-alert medication class, were measured. RESULTS: The expert panel reduced the number of medications and dosage forms on the override list by 42%, from 119 different medications (in 244 different dosage forms) in 2001 to 92 different medications (in 163 different dosage forms) by December 2003. By May 2004 the opioid override rates were significantly decreased; although slight increases in rates occurred by December 2004, possibly reflecting the lack of formal override monitoring by nursing and pharmacy, the rates were still significantly lower than the baseline in October 2003. CONCLUSION: Pharmacists, in collaboration with the medical and nursing staffs, developed a sustainable process for preventing unauthorized and inappropriate override medication dispensing from ADDs.

Adolescent depression and externalizing problems: testing two models of comorbidity in an inpatient sample.

Differentiating between additive (quantitative) and interactive (qualitative) effects of comorbidity has important treatment implications. This study illustrates the heuristic superiority of a multifactorial approach over simple group comparisons in testing quantitative versus qualitative models of comorbidity. Analysis of variance was used to compare 266 adolescent inpatients identified as depressed, externalizing, both, or neither on self-report measures of personality, school problems, and substance abuse. The results support quantitative rather than qualitative models of comorbidity. Depressed status related most strongly to group differences in interpersonal and self-critical concerns. Externalizing status related most strongly to group differences in school problems and drug use. Main effects for the two statuses together explained especially elevated levels of reactance and alcohol abuse among the comorbid adolescents.

The role of separation-individuation experiences and personality in predicting externalizing and internalizing dimensions of functional impairment in a rural preadolescent and adolescent sample.

Studied 4th- through 8th-grade students in a rural school district (N = 382, 201 girls; M age = 12.48) who, at the end of the academic year, completed self-report measures assessing functional impairment, self-concept, reactance, and autonomy experiences in relation to parents. Confirmatory factor analysis supported a distinction between 2 aspects of autonomy: mutuality (perceptions of parents as encouraging of autonomy) and conflictual dependence (negative representations of "self-in-relation-to-parent" and related feelings of anger and shame). Path analysis findings mostly were consistent with a mediated model predicting personality from autonomy experiences and functional impairment from personality. However, conflictual dependence rather than negative self-feelings directly predicted girls' emotional difficulties. Comparisons of total effects suggested that conflictual dependence may have stronger and more consistent implications for adolescent psychopathology than mutuality. In general, significant relations between conflictual dependence and psychopathology remained significant even after controlling for a measure of negative affectivity (NA).