Academic clinical fellows in radiology: how can we improve success?

AIM: To survey past and current radiology academic clinical fellows (ACFs) for feedback on their experiences, academic achievements, challenges faced in balancing academic and clinical responsibilities, and opinion on how to optimise the fellowship programme. MATERIALS & METHODS: A 26-question online survey approved by the Royal College of Radiologists (RCR) Academic Committee was distributed over a 7-month period (June 2021 to January 2022) to current and past radiology ACFs via the National Institute for Health and Care Research (NIHR) integrated academic training imaging leads, radiology training programme directors, and social media. RESULTS: Thirty-five survey responses were received from past or present ACFs. Of the respondents, 42.8% (15/35) entered ACF training from another research post, and most continued their academic interests after ACF training (59.3%, 16/27 that had completed the post). The majority (22/35, 63%) had or were in the process of obtaining a postgraduate research degree. The most common academic outputs were scientific publications and national/international conference presentations. Most (23/35, 66%) would recommend the ACF post to colleagues, although some found it challenging balancing on-call and examination commitments during training. CONCLUSIONS: Entry into the radiology ACF programme is often after a prior academic post. Many ACFs appear to enjoy their fellowship experience and continue academic interests after training, some achieving higher research degrees. Challenges in balancing clinical workload require some flexibility from local clinical and academic supervisors. Suggestions for alternative structuring of the ACF pathway and how to optimise entry into these competitive posts are also outlined.

Subchondral bone changes after joint distraction treatment for end stage knee osteoarthritis.

OBJECTIVE: Increased subchondral cortical bone plate thickness and trabecular bone density are characteristic of knee osteoarthritis (OA). Knee joint distraction (KJD) is a joint-preserving knee OA treatment where the joint is temporarily unloaded. It has previously shown clinical improvement and cartilage regeneration, indicating reversal of OA-related changes. The purpose of this research was to explore 3D subchondral bone changes after KJD treatment using CT imaging. DESIGN: Twenty patients were treated with KJD and included to undergo knee CT imaging before, one, and two years after treatment. Tibia and femur segmentation and registration to canonical surfaces were performed semi-automatically. Cortical bone thickness and trabecular bone density were determined using an automated algorithm. Statistical parametric mapping (SPM) with two-tailed F-tests was used to analyze whole-joint changes. RESULTS: Data was available of 16 patients. Subchondral cortical bone plate thickness and trabecular bone density were higher in the weight-bearing region of the most affected compartment (MAC; mostly medial). Especially the MAC showed a decrease in thickness and density in the first year after treatment, which was sustained towards the second year. CONCLUSIONS: KJD treatment results in bone changes that include thinning of the subchondral cortical bone plate and decrease of subchondral trabecular bone density in the first two years after treatment, potentially indicating a partial normalization of subchondral bone.

Quantitative 3D imaging parameters improve prediction of hip osteoarthritis outcome.

Osteoarthritis is an increasingly important health problem for which the main treatment remains joint replacement. Therapy developments have been hampered by a lack of biomarkers that can reliably predict disease, while 2D radiographs interpreted by human observers are still the gold standard for clinical trial imaging assessment. We propose a 3D approach using computed tomography-a fast, readily available clinical technique-that can be applied in the assessment of osteoarthritis using a new quantitative 3D analysis technique called joint space mapping (JSM). We demonstrate the application of JSM at the hip in 263 healthy older adults from the AGES-Reykjavík cohort, examining relationships between 3D joint space width, 3D joint shape, and future joint replacement. Using JSM, statistical shape modelling, and statistical parametric mapping, we show an 18% improvement in prediction of joint replacement using 3D metrics combined with radiographic Kellgren & Lawrence grade (AUC 0.86) over the existing 2D FDA-approved gold standard of minimum 2D joint space width (AUC 0.73). We also show that assessment of joint asymmetry can reveal significant differences between individuals destined for joint replacement versus controls at regions of the joint that are not captured by radiographs. This technique is immediately implementable with standard imaging technologies.

A new quantitative 3D approach to imaging of structural joint disease.

Imaging of joints with 2D radiography has not been able to detect therapeutic success in research trials while 3D imaging, used regularly in the clinic, has not been approved for this purpose. We present a new 3D approach to this challenge called joint space mapping (JSM) that measures joint space width in 3D from standard clinical computed tomography (CT) data, demonstrating its analysis steps, technical validation, and reproducibility. Using high resolution peripheral quantitative CT as gold standard, we show a marginal over-estimation in accuracy of +0.13 mm and precision of ±0.32 mm. Inter-operator reproducibility bias was near-zero at -0.03 mm with limits of agreement ±0.29 mm and a root mean square coefficient of variation 7.5%. In a technical advance, we present results from across the hip joint in 3D with optimum validation and reproducibility metrics shown at inner joint regions. We also show JSM versatility using different imaging data sets and discuss potential applications. This 3D mapping approach provides information with greater sensitivity than reported for current radiographic methods that could result in improved patient stratification and treatment monitoring.

A new CT grading system for hip osteoarthritis.

OBJECTIVES: We have developed a new grading system for hip osteoarthritis using clinical computed tomography (CT). This technique was compared with Kellgren and Lawrence (K&L) grading and minimum joint space width (JSW) measurement in digitally reconstructed radiographs (DRRs) from the same CT data. In this paper we evaluate and compare the accuracy and reliability of these measures in the assessment of radiological disease. DESIGN: CT imaging of hips from 30 female volunteers aged 66 ± 17 years were used in two reproducibility studies, one testing the reliability of the new system, the other testing K&L grading and minimum JSW measurement in DRRs. RESULTS: Intra- and inter-observer reliability was substantial for CT grading according to weighted kappa (0.74 and 0.75 respectively), while intra- and inter-observer reliability was at worst moderate (0.57) and substantial (0.63) respectively for DRR K&L grading. Bland-Altman analysis showed a systematic difference in minimum JSW measurement of 0.82 mm between reviewers, with a least detectable difference of 1.06 mm. The area under the curve from ROC analysis was 0.91 for our CT composite score. CONCLUSIONS: CT grading of hip osteoarthritis (categorised as none, developing and established) has substantial reliability. Sensitivity was increased when CT features of osteoarthritis were assigned a composite score (0 = none to 7 = severest) that also performed well as a diagnostic test, but at the cost of reliability. Having established feasibility and reliability for this new CT system, sensitivity testing and validation against clinical measures of hip osteoarthritis will now be performed.

Severity mapping of the proximal femur: a new method for assessing hip osteoarthritis with computed tomography.

OBJECTIVE: Plain radiography has been the mainstay of imaging assessment in osteoarthritis for over 50 years, but it does have limitations. Here we present the methodology and results of a new technique for identifying, grading, and mapping the severity and spatial distribution of osteoarthritic disease features at the hip in 3D with clinical computed tomography (CT). DESIGN: CT imaging of 456 hips from 230 adult female volunteers (mean age 66 ± 17 years) was reviewed using 3D multiplanar reformatting to identify bone-related radiological features of osteoarthritis, namely osteophytes, subchondral cysts and joint space narrowing. Scoresheets dividing up the femoral head, head-neck region and the joint space were used to register the location and severity of each feature (scored from 0 to 3). Novel 3D cumulative feature severity maps were then created to display where the most severe disease features from each individual were anatomically located across the cohort. RESULTS: Feature severity maps showed a propensity for osteophytes at the inferoposterior and superolateral femoral head-neck junction. Subchondral cysts were a less common and less localised phenomenon. Joint space narrowing <1.5 mm was recorded in at least one sector of 83% of hips, but most frequently in the posterolateral joint space. CONCLUSIONS: This is the first description of hip osteoarthritis using unenhanced clinical CT in which we describe the co-localisation of posterior osteophytes and joint space narrowing for the first time. We believe this technique can perform several important roles in future osteoarthritis research, including phenotyping and sensitive disease assessment in 3D.

FIESTA: an MR arthrography celebration of shoulder joint anatomy, variants, and their mimics.

Magnetic resonance (MR) arthrography is currently the gold standard radiological investigation for shoulder joint instability. Not only does this investigation allow for identification of important disease processes, but the reduced slice thickness and increased in-plane resolution allowed by the latest imaging sequences also gives excellent demonstration of shoulder joint internal anatomy. This article describes the technique of MR arthrography of the shoulder practiced at our institution, briefly outlining features of the FIESTA (fast imaging employing steady state acquisition) MR sequence employed, including its advantages and limitations. A pictorial review of shoulder MR arthrography performed with this technique is presented, concentrating on normal shoulder joint internal anatomy and anatomical variants that may mimic pathology.

Digital subtraction angiography of the superior mesenteric artery: identifying arterial branches.

This "problem in diagnostic imaging" provides an overview of the technique of digital subtraction angiography. The possibility of artefacts arising from movement subsequent to the taking of the masking image is discussed. It is also important that contrast medium is allowed to backflow into the parent vessel (in this case the aorta) to ensure that there has been filling of the proximal branches of the vessel of interest (in this case the superior mesenteric artery). An accessory middle colic artery is demonstrated. Detection of such variant vessels is important not only to surgeons but also to specialist radiologists carrying out therapeutic embolization.

A survey of medical students on the impact of a new digital imaging library in the dissection room.

Radiology has a recognised role in undergraduate anatomy education. The recent digitalisation of radiology has created new learning opportunities involving techniques such as image labelling, 3D reconstruction, and multiplanar reformatting. An opportunity was identified at the University of Nottingham to create a digital library of normal radiology images as a learner-driven adjunct in anatomy dissection sessions. We describe the process of creating a de novo digital library by sourcing images for presentation at computer workstations. Students' attitudes towards this new resource were assessed using a questionnaire which used a 5 point Likert scale and also offered free text responses. One hundred and forty-one out of 260 students (54%) completed the questionnaire. The most notable findings were: a positive response to the relevance of imaging to the session topics (median score 4), strong agreement that images should be available on the university website (median score 5), and disagreement that enough workstations were available (median score 2). About 24% of respondents suggested independently that images needed more labeling to help with orientation and identification. This first phase of supplying a comprehensive imaging library can be regarded as a success. Increasing availability and incorporating dynamic labeling are well recognized as important design concepts for electronic learning resources and these will be improved in the second phase of delivery as a direct result of student feedback. Hopefully other centers can benefit from this experience and will consider such a venture to be worthwhile.