Medical Student Ultrasound Education: The Radiology Chair Weighs In.

ABSTRACT: To assess the radiology department chairs' opinions concerning current status and plans for teaching ultrasound to medical students, the American College Taskforce on Radiology Ultrasound Education, commissioned by the American College of Radiology, distributed a survey to 142 radiology chairs and a medical school dean subgroup.The response rate was 30% (42/142), and 76% indicated ultrasound was currently part of the medical student curriculum. In preclinical years, radiology involvement was only 6.4%. During clinical years, radiology led ultrasound education with 51.7% in general and 82.9% in elective rotations. Regarding actual content, top 4 results were evenly distributed between learning hands-on scanning (81.1%), diagnostic use of ultrasound (75.7%), anatomy/pathology (75.7%), and ultrasound guidance for procedures (54.0%). Educational leaders in preclinical courses were emergency medicine (72.7%) followed by radiology (45.4%) physicians. During clinical years, leaders were radiology (52.6%) and emergency medicine (47.4%) physicians. Most chairs stated that knowledge of diagnostic ultrasound should be mandatory (76.2%), stressing the importance of teaching the diagnostic capabilities and uses of ultrasound as the primary goal (78.8%). Perceived barriers to implementation were evenly distributed between lack of space in the curriculum (55.6%), lack of faculty (48.2%), lack of resources (44.4%), and lack of institutional support (40.7%). The American College Taskforce on Radiology Ultrasound Education survey shows that radiology's role in ultrasound undergraduate education occurs almost exclusively during clinical years, and the chairs voice a desire to improve upon this role. Barriers include both intradepartmental (faculty and resources) and institutional (curricular) factors.

Biliary and pancreatic complications of molecular targeted therapies in cancer imaging.

The purpose of this review is to familiarize radiologists with the different imaging manifestations of biliary and pancreatic toxicity of molecular targeted therapies. The advent of molecular targeted therapies for cancer treatment has prompted radiologists to be familiar with these new molecules, their patterns of response, and their class-specific toxicities. While liver and bowel toxicities have been extensively reported in literature, less is known about the pathogenesis and imaging of toxicity involving the pancreatobiliary system. Biliary and pancreatic toxicity of molecular targeted therapies present with variable manifestations and varying degrees of severity, from asymptomatic liver function tests elevation to acute pancreatitis or cholecystitis. Management of these conditions depends on the clinical scenario and the severity of the findings. In this article, we will (1) present the various classes of molecular targeted therapies most commonly associated with biliary and pancreatic toxicity; (2) illustrate imaging findings of drug-associated biliary and pancreatic injuries and their possible differential diagnosis; and (3) provide a guide for management of these conditions.

National ultrasound curriculum for medical students.

Ultrasound (US) is an extremely useful diagnostic imaging modality because of its real-time capability, noninvasiveness, portability, and relatively low cost. It carries none of the potential risks of ionizing radiation exposure or intravenous contrast administration. For these reasons, numerous medical specialties now rely on US not only for diagnosis and guidance for procedures, but also as an extension of the physical examination. In addition, many medical school educators recognize the usefulness of this technique as an aid to teaching anatomy, physiology, pathology, and physical diagnosis. Radiologists are especially interested in teaching medical students the appropriate use of US in clinical practice. Educators who recognize the power of this tool have sought to incorporate it into the medical school curriculum. The basic question that educators should ask themselves is: "What should a student graduating from medical school know about US?" To aid them in answering this question, US specialists from the Society of Radiologists in Ultrasound and the Alliance of Medical School Educators in Radiology have collaborated in the design of a US curriculum for medical students. The implementation of such a curriculum will vary from institution to institution, depending on the resources of the medical school and space in the overall curriculum. Two different examples of how US can be incorporated vertically or horizontally into a curriculum are described, along with an explanation as to how this curriculum satisfies the Accreditation Council for Graduate Medical Education competencies, modified for the education of our future physicians.

Redesign and implementation of the radiology clerkship: from traditional to longitudinal and integrative.

PURPOSE: The authors discuss the evolution and application of 3 radiology teaching methods-a fundamentals-of-imaging course, a combined clinical-radiology case conference, and a radiology objective structured clinical examination-to medical education at the Brigham and Women's Hospital site of Harvard Medical School. METHODS: The evolution of the medical student radiology teaching program from content needs assessment to blueprint creation, through implementation, is outlined. RESULTS: The 3 components of the teaching program are described. The changes in format in response to feedback and challenges faced in deploying this new curriculum are detailed. Results from student surveys and the radiology objective structured clinical examination scores from recent years are also presented. CONCLUSIONS: As radiology assumes an increasingly central role in patient care and diagnosis, the need for effective integration of radiology teaching into medical education becomes more critical. The concepts presented here have been deemed to be successful by students and faculty members and may be applicable to other institutions.

Lithium nephropathy: unique sonographic findings.

This case series describes a unique sonographic appearance consisting of numerous microcysts and punctate echogenic foci seen on renal sonograms of 10 adult patients receiving chronic lithium therapy. Clinically, chronic renal insufficiency was present in 6 and nephrogenic diabetes insipidus in 2. Sonography showed numerous microcysts and punctate echogenic foci. Computed tomography in 5 patients confirmed microcysts and microcalcifications, which were fewer in number than on sonography. Magnetic resonance imaging in 2 patients confirmed microcysts in each case. Renal biopsy in 1 patient showed chronic interstitial nephritis, microcysts, and tubular dilatation. The diagnosis of lithium nephropathy should be considered when sonography shows these findings.

Imaging presentation of venous thrombosis in patients with cancer.

OBJECTIVE: The purpose of this article is to review the imaging of venous thrombosis in patients with cancer. CONCLUSION: Multiple imaging techniques have the capacity to display thrombosis accurately. The optimal choice is dictated by the location and duration of symptoms and by the availability of imaging techniques. Peripheral and superficial thrombi are best managed with ultrasound, whereas central thrombi require CT or MRI. If CT and MRI are contraindicated, flow studies are appropriate. FDG PET/CT appropriately shows venous thrombosis and might play a prominent role in the future.

Defibrotide for the treatment of severe hepatic veno-occlusive disease and multiorgan failure after stem cell transplantation: a multicenter, randomized, dose-finding trial.

Therapeutic options for severe hepatic veno-occlusive disease (VOD) are limited and outcomes are dismal, but early phase I/II studies have suggested promising activity and acceptable toxicity using the novel polydisperse oligonucleotide defibrotide. This randomized phase II dose-finding trial determined the efficacy of defibrotide in patients with severe VOD following hematopoietic stem cell transplantation (HSCT) and identified an appropriate dose for future trials. Adult and pediatric patients received either lower-dose (arm A: 25 mg/kg/day; n = 75) or higher-dose (arm B: 40 mg/kg/day; n = 74) i.v. defibrotide administered in divided doses every 6 hours for > or =14 days or until complete response, VOD progression, or any unacceptable toxicity occurred. Overall complete response and day +100 post-HSCT survival rates were 46% and 42%, respectively, with no significant difference between treatment arms. The incidence of treatment-related adverse events was low (8% overall; 7% in arm A, 10% in arm B); there was no significant difference in the overall rate of adverse events between treatment arms. Early stabilization or decreased bilirubin was associated with better response and day +100 survival, and decreased plasminogen activator inhibitor type 1 (PAI-1) during treatment was associated with better outcome; changes were similar in both treatment arms. Defibrotide 25 or 40 mg/kg/day also appears effective in treating severe VOD following HSCT. In the absence of any differences in activity, toxicity or changes in PAI-1 level, defibrotide 25 mg/kg/day was selected for ongoing phase III trials in VOD.

Venous thrombosis in an outpatient oncologic center: distribution, type, and comorbidities.

PURPOSE: To examine outpatient oncologic patients with venous thrombosis (VT) and correlate ultrasound findings with clinical characteristics and outcome. MATERIALS AND METHODS: A retrospective study of 76 patients who had upper- and lower-extremity ultrasound examinations positive for VT formed the population, drawn from a total of 509 patients who presented over a 24-month period for non-invasive imaging. Clinical indication, demographics, sonographic findings, comorbidities, and development of pulmonary embolism in these patients were recorded. The Fisher-Freeman-Halton exact test was used to determine if test characteristics varied according to the location of VT (upper or lower extremity), the level of lower-extremity thrombosis (above the knee, below the knee, or both), the presence of active disease or remission, the chronicity or acuteness of thrombosis, and the presence of a central venous catheter (CVC). RESULTS: In the study group, 64 patients had deep VT, and 12 had superficial VT. The most prevalent tumors in our study population were lymphoma and breast and lung cancers. The most common symptoms were swelling, pain, and erythema. Whereas 61 patients had active disease, 18 patients were in remission at the time of examination. Among 30 patients with upper-extremity VT, 18 had CVCs. Venous thrombosis involved the vessel containing the central venous line in 66% of studies. Pulmonary embolism developed in 8 patients who had lower-extremity VT despite an initiation of anticoagulation therapy. Patients with thrombus in the lower extremity had higher chance to develop pulmonary embolism, but there was no significant statistical difference in the level of lower-extremity thrombosis (above the knee, below the knee, or both), disease activity, and chronicity of thrombosis. CONCLUSIONS: Venous thrombosis is most commonly acute and involves the lower extremity and the deep venous system above the knee. When VT involves the upper extremity, it is usually associated with a CVC. Pulmonary embolism is almost exclusively associated with lower-extremity VT and can occur despite anticoagulation therapy.

Elevated cerebral pressure passivity is associated with prematurity-related intracranial hemorrhage.

OBJECTIVES: Cerebral pressure passivity is common in sick premature infants and may predispose to germinal matrix/intraventricular hemorrhage (GM/IVH), a lesion with potentially serious consequences. We studied the association between the magnitude of cerebral pressure passivity and GM/IVH. PATIENTS AND METHODS: We enrolled infants <32 weeks' gestational age with indwelling mean arterial pressure (MAP) monitoring and excluded infants with known congenital syndromes or antenatal brain injury. We recorded continuous MAP and cerebral near-infrared spectroscopy hemoglobin difference (HbD) signals at 2 Hz for up to 12 hours/day and up to 5 days. Coherence and transfer function analysis between MAP and HbD signals was performed in 3 frequency bands (0.05-0.25, 0.25-0.5, and 0.5-1.0 Hz). Using MAP-HbD gain and clinical variables (including chorioamnionitis, Apgar scores, gestational age, birth weight, neonatal sepsis, and Score for Neonatal Acute Physiology II), we built a logistic regression model that best predicts cranial ultrasound abnormalities. RESULTS: In 88 infants (median gestational age: 26 weeks [range 23-30 weeks]), early cranial ultrasound showed GM/IVH in 31 (37%) and parenchymal echodensities in 10 (12%) infants; late cranial ultrasound showed parenchymal abnormalities in 19 (30%) infants. Low-frequency MAP-HbD gain (highest quartile mean) was significantly associated with early GM/IVH but not other ultrasound findings. The most parsimonious model associated with early GM/IVH included only gestational age and MAP-HbD gain. CONCLUSIONS: This novel cerebrovascular monitoring technique allows quantification of cerebral pressure passivity as MAP-HbD gain in premature infants. High MAP-HbD gain is significantly associated with GM/IVH. Precise temporal and causal relationship between MAP-HbD gain and GM/IVH awaits further study.

Cerebral hemodynamic changes during intensive care of preterm infants.

OBJECTIVES: The objectives of this study were to examine the circulatory changes experienced by the immature systemic and cerebral circulations during routine events in the critical care of preterm infants and to identify clinical factors that are associated with greater hemodynamic-oxygenation changes during these events. METHODS: We studied 82 infants who weighed <1500 g at birth and required intensive care management and continuous blood pressure monitoring from an umbilical arterial catheter. Continuous recording of cerebral and systemic hemodynamic and oxygenation changes was performed. We studied 6 distinct types of caregiving events during 10-minute epochs: (1) quiet baseline periods; (2) minor manipulation; (3) diaper changes; (4) endotracheal tube suctioning; (5) endotracheal tube repositioning; and (6) complex events. Each event was matched with a preceding baseline. We examined the effect of specific clinical factors and cranial ultrasound abnormalities on the systemic and cerebral hemodynamic oxygenation changes that were associated with the various event types. RESULTS: There were highly significant differences in hemodynamics and oxygenation between events overall and baseline epochs. The magnitude of these circulatory changes was greatest during endotracheal tube repositioning and complex caregiving events. Lower gestational age, higher illness severity, chorioamnionitis, low Apgar scores, and need for pressor-inotropes all were associated with circulatory changes of significantly lower magnitude. Cerebral hemodynamic changes were associated with early parenchymal ultrasound abnormalities. CONCLUSIONS: Routine caregiving procedures in critically ill preterm infants are associated with major circulatory fluctuations that are clinically underappreciated and underdetected by current bedside monitoring. Our data underscore the importance of continuous cerebral hemodynamic monitoring in critically ill preterm infants.

Sonographic imaging of maternal complications of pregnancy.

OBJECTIVE: To show the role of diagnostic sonography in delineating pathologic conditions occurring during and immediately after pregnancy. METHODS: Cases illustrative of a broad range of pathologic conditions were collected primarily from personal experience in a busy ultrasound clinic serving high-and low-risk pregnancies over the past 15 years, with supplemental cases drawn from departmental teaching files. Sonography was the primary diagnostic tool, with confirmation obtained from other imaging modalities in select instances. RESULTS: Cases were organized on an anatomic and time-of-onset basis. For conditions occurring during pregnancy, the following anatomic areas are considered: the liver and biliary tree, urinary tract, bowel, ovary, and uterus and placenta. For postpartum complications, the following conditions are discussed: subfascial and bladder flap hematomas, retained products of conception, and ovarian vein thrombophlebitis. Although the main imaging modality in these conditions was sonography, correlation with computed tomography and magnetic resonance imaging was also made in several cases. CONCLUSIONS: A broad variety of conditions can affect the pregnant patient, both during and immediately after pregnancy. Sonography can show many of these disease processes, with computed tomography and magnetic resonance imaging useful selectively as supplementary tools.