The hidden curriculum in radiology residency programs: a path to isolation or integration?

PURPOSE: In this qualitative case study involving five academic Radiology centres across Canada, the authors seek to identify the hidden curriculum. METHODS: A qualitative case study methodology was used for its potential to explore and provide rich descriptions and allow for the in-depth analysis of multiple data sources that include official institutional documents, surveys, observations and interviews (including undergraduate students, postgraduate, radiologists, imaging scientists, residents, faculty and administrators). This study relied on 48 interviews and involved primary data analysis by the core research team, and a secondary analysis by external examiners. RESULTS: The results revealed that in four of the five major centres studied, a hidden curriculum of isolation prevailed, reinforcing an image of the radiologist as an independent operator within an organization dependent upon collaboration for optimal performance. The fifth site exhibited a hidden curriculum of collaboration and support, although the messages received were conflicting when addressing issues around teaching. CONCLUSIONS: The authors conclude by noting two possibilities for medical imaging departments to consider that of isolation or that of integration. They examine the implications of each and propose a way forward that situates Radiology as the crossroads of medicine. As such, the need for a new, generative metaphor reasserts the importance of recognizing the role and function of scholarship in teaching and learning contexts across Canada.

Feasibility of 3D ultrasound to evaluate upper extremity nerves.

PURPOSE: This study investigates the performance of a 3 D Ultrasound (US) system in imaging elbow and wrist nerves. MATERIALS AND METHODS: Twenty healthy volunteers with asymptomatic median, ulnar and radial nerves were prospectively investigated. Bilateral 3DUS scans of the elbows and wrists were acquired by using a commercially available US scanner (18 MHz, AplioXG, Toshiba) and stored as a 3 D volume by a dedicated software (CURE, Robarts Research Institute). Retrospectively, qualitative (image quality, atypical nerve location, findings potentially associated with compression neuropathy) and quantitative (cross-sectional area measurements) evaluations were performed. RESULTS: In all 200 nerves 3DUS was feasible (100%). Image quality was insufficient in 13.5% (25 ulnar nerve elbow, 2 radial nerve) and sonomorphology was not assessable in those nerves. Measurement of cross sectional areas was feasible in all nerves (100%). Median cross-sectional area (range) were: median nerve elbow 7 mm2 (6-9), radial nerve 3 mm2 (1-4), ulnar nerve elbow 8 mm2 (5-11), median nerve wrist 8 mm2 (5-10), and ulnar nerve wrist 4 mm2 (2-6). No significant changes in nerve cross-sectional area along each nerve was found. Ulnar nerve subluxation was found in 2 nerves (6.7%). No anconeus epitrochlearis muscle or osteophytes were found. CONCLUSION: 3DUS is a feasible method for assessing nerves of the upper extremity and has been shown to provide a good overview of the median, ulnar and radial nerve at the elbow and wrist, but is limited for evaluation of the ulnar nerve in the cubital tunnel. This technique enables reliable measurements at different locations along the nerve.

US-guided therapy of calcific tendinopathy: clinical and radiological outcome assessment in shoulder and non-shoulder tendons.

PURPOSE: To analyze the effectiveness and complication rate of ultrasound (US)-guided perforation and lavage using a two-needle technique with 16 - 18 G needles in the treatment of patients with calcific tendinopathy in the shoulder, elbow, hip, and knee by radiological and clinical follow-up. MATERIALS AND METHODS: A retrospective chart review was performed and 40 patients (13 male, 27 female; mean age, 53.5 years; range 24 -74 years) were identified as having received US-guided perforation and lavage due to symptomatic calcific tendinopathy of the rotator cuff tendons, triceps, extensor and flexor tendons at the elbow, rectus femoris tendon and patellar tendons. The radiographic outcome was assessed by comparison of the size and quality of the calcification before and 6 weeks after the procedure. On US images, the quality of the acoustic shadow was assessed, together with other alterations of the tendon and surrounding tissue. Patients were interviewed by telephone to assess the clinical outcome regarding pre-treatment and post-treatment pain and tendon function. RESULTS: 34 shoulder tendons and 6 non-shoulder tendons were identified. The mean calcium reduction was 39.9 mm(2) (range, 0 - 215; p < 0.001), while 80 % of patient showed a resolution of more than 60 % resulting in good clinical improvement. A very low complication rate was found (1 partial tear). CONCLUSION: The US-guided perforation and lavage technique is an effective and safe treatment for rotator cuff calcifications as well as for other body tendons. Although the two-needle technique and large needles were used in this study, a very low complication rate was detected.

Real-time sonoelastography: findings in patients with symptomatic achilles tendons and comparison to healthy volunteers.

PURPOSE: Real-time sonoelastography (SE), a newly introduced ultrasound technique, has already shown conclusive results in breast, prostate, and thyroid tumor diagnostics. This study investigated the performance of SE for the differentiation of Achilles tendon alterations of tendinopathy compared to clinical examination and conventional ultrasound (US). MATERIALS AND METHODS: Achilles tendons in 25 consecutive patients with chronic Achilles tendinopathy and 25 healthy volunteers were examined clinically by US and by SE. RESULTS: In the healthy volunteers, SE showed the tendon to be hard (93 %), while distinct softening was found in 57 % of the patients. SE showed more frequent involvement of the distal (64 %) and middle third (80 %) than the proximal third (28 %) of the Achilles tendon. Using SE a mean sensitivity of 94 %, specificity of 99 %, and accuracy of 97 % were found when clinical examination was used as the reference standard. The correlation to US was 0.89. Mild softening was found in 7 % of the healthy volunteers and in 11 % of the patients. CONCLUSION: Our results emphasize that only distinct softening of Achilles tendons is comparable to clinical examination and US findings. However, mild softening might be explained by very early changes in tissue elasticity in the case of Achilles tendinopathy, which should be assessed in follow-up studies.

CT imaging of wet specimens from a pathology museum: How to build a "virtual museum" for radiopathological correlation teaching.

X-rays and CT have been used to examine specimens such as human remains, mummies and formalin-fixed specimens. However, CT has not been used to study formalin-fixed wet specimens within their containers. The purpose of our study is firstly to demonstrate the role of CT as a non-destructive imaging method for the study of wet pathological specimens and secondly to use the CT data as a method for teaching pathological and radiological correlation. CT scanning of 31 musculoskeletal specimens from a pathology museum was carried out. Images were reconstructed using both soft-tissue and bone algorithms. Further processing of the data produced coronal and sagittal reformats of each specimen. The container and storage solution were manually removed using Volume Viewer Voxtool software to produce a 3D reconstruction of each specimen. Photographs of each specimen (container and close-up) were displayed alongside selected coronal, sagittal, 3D reconstructions and cine sequences in a specially designed computer program. CT is a non-destructive imaging modality for building didactic materials from wet specimens in a Pathology Museum, for teaching radiological and pathological correlation.

4 T MRI of chondrocalcinosis in combination with three-dimensional CT, radiography, and arthroscopy: a report of three cases.

OBJECTIVE: To describe 4 T MRI techniques in imaging chondrocalcinosis within the knee and examine the results together with those demonstrated using three-dimensional (3D) computed tomography, conventional radiography, and arthroscopy. DESIGN AND PATIENTS: From a larger clinical imaging study of early osteoarthritis, knee arthroscopy patients were imaged using high-field MRI and high-resolution 3D CT prior to their surgery. Retrospective review of the imaging data diagnosed three patients with chondrocalcinosis. Fat-suppressed 3D spoiled gradient (3D SPGR) and two-dimensional fat-suppressed fast spin echo (FSE) imaging was performed at 4 T. The MR images, multi-planar reformatted CT (MPR-CT) and maximum intensity projection CT (MIP-CT) images, and radiographs were examined by a musculoskeletal radiologist for the presence and location of chondrocalcinosis. The findings from arthroscopy were also included. RESULTS: MRI showed 16 sites of punctate hypointense regions from 18 articular surfaces and five of six menisci with similar signal characteristics. Both meniscal chondrocalcinosis and meniscal tears were clearly visible using the 3D SPGR sequence. Only three sites were demonstrated to have calcification using MPR-CT and MIP-CT revealed an additional three. In articular cartilage surfaces showing surface disruption, arthroscopy demonstrated 11 sites with crystal deposition. Arthroscopy also revealed five menisci with calcification present. CONCLUSION: Our preliminary findings suggest that imaging chondrocalcinosis using spoiled gradient 4 T MRI is superior and complementary to the other imaging modalities in the detection of crystal deposition in both articular cartilage and menisci.

Imaging features of ischial bursitis with an emphasis on ultrasonography.

OBJECTIVE: The aim of this study was to evaluate the imaging features of ischial bursitis with an emphasis on ultrasonography (US). DESIGN AND PATIENTS: Our study included 31 patients with a painful mass or tenderness in their buttock who underwent US (n=27), CT (n=1), or MR imaging (n=4). A needle aspiration (n=6) or a bursal excision (n=5) was performed in those patients who had no clinical improvement in spite of the conservative treatment. Evaluation included lesion location, size, wall of the bursae, and intrinsic characteristics on US, CT and MR imaging. RESULTS: Ischial bursitis was superficial to the ischial tuberosity in all patients (n=31). The lesion ranged from 1.5 cm to 7 cm (average 3.8 cm) in diameter. The bursal wall was identifiable in 25 cases (81%). Internal septa and mural nodules were seen in 12 (39%) and 17 cases (55%), respectively. Sonography showed that fluid within the bursa was hypoechoic (59%), hyperechoic (26%), or of mixed echogenicity (15%). The bursae were compressible by the transducer. Power Doppler examination (n=7) showed hypervascularity of the bursal wall. All lesions imaged with contrast-enhanced CT and MR imaging had an enhancing thin wall and mural nodule. CONCLUSIONS: Ischial bursitis, superficial to the ischial tuberosity, can be clearly demonstrated on sonography and appears as a thin-walled cystic lesion, with or without internal septa and mural nodules.

Ultrasound of the shoulder joint: non "rotator cuff" lesions.

Most of the papers in the literature are on rotator cuff lesions. This paper will deal with a somewhat forgotten part of the shoulder, the joint and the nontendinous structures around the joint. Since 1985, we have performed ultrasound examinations of the shoulder. We have collected many cases and some of them will be performed. The shoulder joint can be partly examined by ultrasound. We can get some information about joint effusions, humeral head cartilage, some part of the labrum, loose bodies, ganglions and fractures around the joint. The acromio-clavicular joint is also part of the examination, leading to diagnosis of sprains, osteoarthritis and dislocations. Non rotator cuff examination of the shoulder must be a routine part of the ultrasound examination of the shoulder.

Introduction of problem-based learning in a traditional medical curriculum in Singapore--students' and tutors' perspectives.

OBJECTIVES: The Faculty of Medicine at the National University of Singapore was founded in 1905 and has trained many generations of medical practitioners. Teaching has been based on a traditional British-style curriculum with 2 years of training in the basic clinical sciences and 3 years in the clinical disciplines. Starting in the academic year 1999-2000, a more integrated curriculum was introduced. In conjunction with this, approximately one-fifth of the curriculum time was dedicated to problem-based learning (PBL). This will be the first time that PBL is being implemented in the medical school and both staff and students will be new at it. Thus, the objective of this study was to gather information on the reactions of both staff and students after the actual implementation. MATERIALS AND METHODS: A questionnaire was designed to assess the following: (1) What are tutors' and students' opinions on the relative benefits on students' learning process and participation of PBL versus traditional lectures? (2) What is the level of satisfaction with various aspects of their PBL experience? (3) What were the difficulties that were encountered? RESULTS: Several positive and negative aspects of the tutors' and students' experiences were revealed. Most reported fairly high levels of satisfaction with their PBL experience. CONCLUSIONS: Overall, the experiences have been positive and both groups are willing to "struggle" with this new way of learning.

Physeal injury in a lightning strike survivor.

Electrical injuries resulting in physeal injury in children are an uncommon but well-recognized clinical entity. Almost all these injuries are sustained from man-made electrical sources. To date, there have been no published cases of growth arrest after lightning strike. The authors report the case of a 12-year-old girl who survived a lightning strike 2 years ago and who presented with asymmetric growth arrest in both legs. The authors discuss the pathophysiology of lightning strike and consider the evidence for direct electrical injury versus ischemic insult to the physis as explanations for the cause of the growth arrest observed in this patient.

Normal and acutely torn posterior cruciate ligament of the knee at US evaluation: preliminary experience.

PURPOSE: To determine the ultrasonographic (US) findings of normal and acutely torn posterior cruciate ligament (PCL) of the knee and evaluate the usefulness of US in the injured PCL. MATERIALS AND METHODS: US images were obtained in 30 knees in 15 asymptomatic volunteers as a control group and in 35 patients clinically suspected of having an acute PCL injury. Only the distal half of the PCL was evaluated. Of the 35 patients, 28 had their PCL status confirmed: 13 had a normal PCL at magnetic resonance (MR) imaging plus clinical examination, and 15 had a torn PCL at either MR imaging and surgery or MR imaging and clinical follow-up. RESULTS: Normal PCLs were homogeneously hypoechoic, with a well-defined posterior border. Torn PCLs were heterogeneously hypoechoic (12 [80%] of 15 patients), with an indistinct posterior margin (11 [73%] of 15 patients). Torn PCLs were significantly thicker (range, 12.0-20.0 mm; mean, 15.6 mm +/- 2.5 [SD]; P <.01), as compared with normal PCLs in 13 patients (range, 3.8-5.8 mm; mean, 4.6 mm +/- 1.0; P <.01) and in the volunteers (range, 3.7-6.2 mm; mean, 4.5 mm +/- 1.2; P <.01). CONCLUSION: An acutely torn PCL thickens (>10 mm), loses its sharply defined posterior border, and has a heterogeneously hypoechoic appearance. US may be useful as a screening examination for patients suspected of having PCL injury and for deciding whether to perform more expensive MR imaging or surgical intervention.

Role of ultrasound in musculoskeletal infections.

Ultrasound is able to play a key role in the management of musculoskeletal soft tissue infections. It is an easily accessible imaging modality that can be used immediately after plain radiographs have been obtained. Quick diagnosis is essential in the clinical setting of musculoskeletal infection because delay can lead to significant morbidity. In addition to its diagnostic capabilities, US offers a safe, real-time, and convenient technique to perform immediately a guided-needle aspiration of any suspicious fluid collection. US provides the most efficient way to document quickly an infection of the musculoskeletal soft tissues and to identify the offending micro-organism.

Imaging of fungal, viral, and parasitic musculoskeletal and spinal diseases.

There are many nonbacterial infections that have musculoskeletal manifestations and radiologic findings. These infections produce a limited range of tissue responses, depending on the organism, the tissue compartment affected, and the immune competence of the host. Diagnosis is dependent on obtaining an appropriate travel or geographic history, the clinical and laboratory features, and on occasion the specific radiologic findings.

Musculoskeletal infections: US manifestations.

One of the most important prognostic factors in patients with musculoskeletal infections is the delay in establishing therapy. Early diagnosis of septic arthritis requires analysis of joint fluid. Ultrasonography (US) is a rapid, portable, sensitive technique for confirming the presence of joint effusions. The study can be easily repeated for follow-up of lesions. US allows real-time guidance of fluid aspiration and can reduce the risk of contaminating other anatomic compartments, especially in the hands, wrists, and feet. Radiography provides complementary information and should be performed in conjunction with US. US is the imaging modality of choice for diagnosis of superficial abscesses. Dynamic compression with the US probe and color Doppler imaging can facilitate detection of superficial abscesses. US may help in the early diagnosis of osteomyelitis by demonstrating subperiosteal or juxtacortical fluid collections and by providing guidance for aspiration of these collections. Evaluation of osseous involvement requires additional imaging; a US examination with normal results does not allow exclusion of bone infection. US is not degraded by metallic artifact and may be useful in cases of osteomyelitis complicating metallic fixation in an extremity. After initial radiography, US can play an important role in the management of musculoskeletal infections.

Joint sonography.

Sonographic evaluation of joint and periarticular pathology clearly has applications in numerous clinical scenarios, not only for diagnosis but in some situations for US-guided biopsy, aspiration, and injections. It is a rapid, inexpensive technique that with adequate equipment, training, and expertise makes it compelling for use as a first-line imaging modality for the assessment of periarticular masses, localized pain, possible infection, joint swelling, as well as posttraumatic articular and periarticular lesions.

Comprehensive radiographic evaluation of diffuse idiopathic skeletal hyperostosis: development and interrater reliability of a scoring system.

OBJECTIVE: To develop a scoring system for radiographic findings in diffuse idiopathic skeletal hyperostosis (DISH) and to test interrater reliability. MATERIALS AND METHODS: Fifty-five DISH patients and 35 spondylosis patients underwent two views (anteroposterior and lateral) of the cervical, thoracic, and lumbar spine, lateral views of both ankles, knees, and elbows, and anteroposterior views of the pelvis and shoulders. Two raters reviewed and scored the x-rays. Interrater reliability was assessed with the alpha statistic (alpha) for categorical variables and with the intraclass correlation coefficient (ICC) for continuous variables. RESULTS: The agreement was similar for the three spinal segments (alpha = 0.44 to 0.71). The lower extremity agreement ranged from 0.28 to 0.76, with higher agreement at the knee (alpha > or = 0.46) and the ankle (alpha > or = 0.56) than at the pelvis (ICC < or = 0.58). The agreement at the shoulders and elbows ranged from 0.50 to 0.75. The agreement between the readers was higher with summary measurements than with single (site-by-site) measurements: for each spinal segment, the ICC was 0.83 or greater; for the lower extremity, the ICC = 0.79; and for the upper extremity, the ICC = 0.68. CONCLUSION: We have described a comprehensive scoring system to assess the spinal and peripheral involvement of DISH.

Ultrasound-guided interventional procedures in the musculoskeletal system.

Ultrasound is a low-cost, nonionizing, readily available diagnostic technique for the evaluation of tendons, muscles, soft tissue masses, cysts, and other fluid collections. Ultrasound is also a valuable tool for guiding a variety of musculoskeletal interventions. Procedures that can be performed under ultrasound guidance include aspiration of fluid for analysis, injection for medication, decompression of cysts, drainage of abscess and hematoma, biopsy, treatment of calcified tendinitis, and foreign body retrieval.

A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status.

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but little-studied disorder in the elderly that is infrequently recognized by physicians. Its prevalence in adults over 40 years of age is estimated at 3.8% for men and 2.6% for women. The present case-control study evaluated the history of pain and stiffness, radicular pain and enthesitis, physical findings on the musculoskeletal examination, and level of physical and psychologic disability in 130 persons: 56 patients with DISH, 43 control patients with spondylosis of the lumbar spine, and 31 healthy control patients. DISH patients were more likely to report a past history of upper extremity pain, medial epicondylitis of the elbow, enthesitis of the patella or heel, or dysphagia than spondylosis patients. They had more extremity and spinal stiffness and pain than healthy controls. DISH patients weighed more at a young age and their body mass index was greater at the time of the clinical evaluation than either spondylosis or healthy control patients. On musculoskeletal examination, DISH patients had a greater reduction in neck rotation and thoracic movements than either spondylosis patients or healthy controls, and had a greater reduction in lumbar movement than healthy controls. DISH patients had similar levels of spinal disability and physical disability overall, as measured by standardized indices, as spondylosis patients. No differences were found among the 3 groups of patients for the laboratory tests evaluated. DISH is clearly a distinct disorder with signs and symptoms that distinguish it from other causes of spinal complaint and from healthy individuals. It has the potential to cause major disability. Future studies need to address the natural history of DISH, pursue pathogenic mechanisms, and evaluate treatment modalities.