Diversity in radiology: the right thing to do, the smart thing to do.

In the 10-year period between the last two U.S. population censuses there have been significant changes in the U.S. population demography. The changes in self-reporting of racial and ethnic identity afforded by the most recent U.S. population census in 2020 have given citizens the opportunity to be represented in ways that truly reflect how they wish to be identified. At the same time, the diversity of the health care workforce in radiology has not reflected a similar change. While there have been small incremental changes for underrepresented groups (African Americans/Blacks, Hispanic ethnicity, and the group American Indian/Alaska Native/Native Hawaiian/Pacific Islander), these changes have not kept pace with the ever-changing demographics of the U.S. population. Part of the answer for these very modest gains must lie with our selection processes for identifying potential candidates from underrepresented in medicine groups (URiM) for acceptance to our medical schools, residency programs and employment opportunities as practicing physicians and faculty members. While the strategies employed have had some measure of success, our best efforts to increase diversity in our specialty, and in medicine in general, are being undermined by our biases and our traditional methods for identifying talents.

Associations of Postbaccalaureate Coursework with Underrepresented Race/Ethnicity, Academic Performance, and Primary Care Training among Matriculants at Five California Medical Schools.

Studies employing data collected over 15 years ago suggested salutary effects of postbaccalaureate (PB) premedical coursework on medical school class diversity, academic performance, and primary care training. The studies may have limited current applicability given changes in medical school admissions paradigms and population demographics. Using data from interviewees at >1 of 5 California public medical schools between 2011-2013 (N=3805), we examined associations of PB premedical coursework with underrepresented race/ethnicity; academic performance (United States Medical Licensing Examination Step 1 and Step 2 scores, clerkship Honors); and primary care residency. Adjusting for age, sex, and year, PB coursework was associated with underrepresented race/ethnicity, but not after further adjustment for self-designated disadvantage (SDA). PB coursework was not associated with academic performance or primary care residency. Holistic consideration of SDA and UIM status in admissions coupled with robust matriculant support may merit exploration as an alternative to PB coursework for increasing medical school diversity.

The Relationships among Self-Designated Disadvantage, Socioeconomic Disadvantage, and Academic Performance in Medical School: A Multi-Institutional Study.

As medical schools seek to address the growing disparity between the socioeconomic makeup of their students and the general population, it is important to understand the academic trajectory of disadvantaged students. We used a locally-developed multicomponent socioeconomic disadvantage (SED) measure and the self-designated disadvantaged (SDA) question ["yes" (+) or "no" (-)] from the American Medical College Application Service application to examine academic performance of students from three disadvantaged categories (high SED/SDA+, high SED/SDA-, and low SED/SDA+); with low SED/SDA-as the reference group across five California schools. Compared with reference, the DA+ subgroups scored lower on USMLE Step 1 and Step 2 Clinical Knowledge examinations and received fewer clerkship Honors. After adjustment for academic metrics and sociodemographic variables, high SED subgroups performed similarly to reference, but performance gaps for low SED/SDA+ students persisted. Medical schools must better understand the institutional and other drivers of academic success in disadvantaged students.

Feasibility of a Real-Time Clinical Augmented Reality and Artificial Intelligence Framework for Pain Detection and Localization From the Brain.

BACKGROUND: For many years, clinicians have been seeking for objective pain assessment solutions via neuroimaging techniques, focusing on the brain to detect human pain. Unfortunately, most of those techniques are not applicable in the clinical environment or lack accuracy. OBJECTIVE: This study aimed to test the feasibility of a mobile neuroimaging-based clinical augmented reality (AR) and artificial intelligence (AI) framework, CLARAi, for objective pain detection and also localization direct from the patient's brain in real time. METHODS: Clinical dental pain was triggered in 21 patients by hypersensitive tooth stimulation with 20 consecutive descending cold stimulations (32°C-0°C). We used a portable optical neuroimaging technology, functional near-infrared spectroscopy, to gauge their cortical activity during evoked acute clinical pain. The data were decoded using a neural network (NN)-based AI algorithm to classify hemodynamic response data into pain and no-pain brain states in real time. We tested the performance of several networks (NN with 7 layers, 6 layers, 5 layers, 3 layers, recurrent NN, and long short-term memory network) upon reorganized data features on pain diction and localization in a simulated real-time environment. In addition, we also tested the feasibility of transmitting the neuroimaging data to an AR device, HoloLens, in the same simulated environment, allowing visualization of the ongoing cortical activity on a 3-dimensional brain template virtually plotted on the patients' head during clinical consult. RESULTS: The artificial neutral network (3-layer NN) achieved an optimal classification accuracy at 80.37% (126,000/156,680) for pain and no pain discrimination, with positive likelihood ratio (PLR) at 2.35. We further explored a 3-class localization task of left/right side pain and no-pain states, and convolutional NN-6 (6-layer NN) achieved highest classification accuracy at 74.23% (1040/1401) with PLR at 2.02. CONCLUSIONS: Additional studies are needed to optimize and validate our prototype CLARAi framework for other pains and neurologic disorders. However, we presented an innovative and feasible neuroimaging-based AR/AI concept that can potentially transform the human brain into an objective target to visualize and precisely measure and localize pain in real time where it is most needed: in the doctor's office. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/13594.

Do Admissions Multiple Mini-Interview and Traditional Interview Scores Predict Subsequent Academic Performance? A Study of Five California Medical Schools.

PURPOSE: To compare the predictive validities of medical school admissions multiple mini-interviews (MMIs) and traditional interviews (TIs). METHOD: This longitudinal observational study of 2011-2013 matriculants to five California public medical schools examined the associations of MMI scores (two schools) and TI scores (three schools) with subsequent academic performance. Regression models adjusted for sociodemographics and undergraduate academic metrics examined associations of standardized mean MMI and TI scores with United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge (CK) scores and, for required clerkships, with mean National Board of Medical Examiners Clinical Science subject (shelf) exam score and number of honors grades. RESULTS: Of the 1,460 medical students, 746 (51.1%) interviewed at more than one study school; 579 (39.7%) completed at least one MMI and at least one TI. Neither interview type was associated with Step 1 scores. Higher MMI scores were associated with more clerkship honors grades (adjusted incidence rate ratio [AIRR] 1.28 more [95% CI 1.18, 1.39; P < .01] per SD increase) and higher shelf exam and Step 2 CK scores (adjusted mean 0.73 points higher [95% CI 0.28, 1.18; P < .01] and 1.25 points higher [95% CI 0.09, 2.41; P = .035], respectively, per SD increase). Higher TI scores were associated only with more honors grades (AIRR 1.11 more [95% CI 1.01, 1.20; P = .03] per SD increase). CONCLUSIONS: MMI scores were more strongly associated with subsequent academic performance measures than were TI scores.

Do Multiple Mini-Interview and Traditional Interview Scores Differ in Their Associations With Acceptance Offers Within and Across Five California Medical Schools?

PURPOSE: In single-school studies, multiple mini-interview (MMI) and traditional interview (TI) scores are associated with acceptance offers. Unexamined is whether scores at one school are associated with acceptance at other schools; such analyses would mitigate single-school design biases and better estimate how well interviews capture desired applicant attributes. Using data from the 5 California Longitudinal Evaluation of Admissions Practices (CA-LEAP) medical schools, the authors examined associations of MMI and TI scores with acceptance offers within and across schools. METHOD: The analyses included applicants who interviewed at ≥1 CA-LEAP school during the 2011-2013 admissions cycles. Three CA-LEAP schools employed TIs and 2 employed MMIs. Interview scores were standardized (z scores: mean = 0, SD = 1), and associations with acceptance offers were examined within and across schools in analyses stratified by school, adjusting for applicant sociodemographics, academic metrics, year, and total number of interviews. RESULTS: Of 4,993 applicants interviewed, 428 (8.6%) interviewed at both MMI schools, 681 (13.6%) at ≥2 TI schools, and 1,327 (26.6%) at ≥1 MMI and ≥1 TI school. For each school, acceptance was associated with interview score at that school and also with interview scores at the other 4 schools. Cross-school associations of MMI versus TI scores with acceptance did not differ statistically. CONCLUSIONS: Interview score at a given school was associated with acceptance at the other 4 schools, with no significant differences in associations for MMIs versus TIs. The findings suggest both MMIs and TIs captured attributes valued by admissions teams across CA-LEAP schools.

Medical School Applicant Characteristics Associated With Performance in Multiple Mini-Interviews Versus Traditional Interviews: A Multi-Institutional Study.

PURPOSE: To examine applicant characteristics associated with multiple mini-interview (MMI) or traditional interview (TI) performance at five California medical schools. METHOD: Of the five California Longitudinal Evaluation of Admission Practices consortium schools, three used TIs and two used MMIs. Schools provided retrospective data on 2011-2013 admissions cycle interviewees: age, gender, race/ethnicity (underrepresented in medicine [UIM] or not), disadvantaged (DA) status, undergraduate GPA, Medical College Admission Test (MCAT) score, and interview score (standardized as z score; mean = 0; SD = 1). Adjusted linear regression analyses, stratified by interview type, examined associations with interview performance. RESULTS: The 4,993 applicants who completed 7,516 interviews included 931 (18.6%) UIM and 962 (19.3%) DA individuals; 3,226 (64.6%) had only 1 interview. Mean age was 24.4 (SD = 2.7); mean GPA and MCAT score were 3.72 (SD = 0.22) and 33.6 (SD = 3.7), respectively. Older age, female gender, and number of prior interviews were associated with better performance on both MMIs and TIs. Higher GPA was associated with lower MMI scores (z score, per unit GPA = -0.26; 95% CI = -0.45, -0.06) but unrelated to TI scores. DA applicants had higher TI scores (z score = 0.17; 95% CI = 0.07, 0.28) but lower MMI scores (z score = -0.18; 95% CI = -0.28, -0.08) than non-DA applicants. Neither UIM status nor MCAT score was associated with interview performance. CONCLUSIONS: These findings have potentially important workforce implications, particularly regarding MMI performance of DA applicants, and illustrate the need for other multi-institutional studies.

Reliability of Multiple Mini-Interviews and traditional interviews within and between institutions: a study of five California medical schools.

BACKGROUND: Many medical schools use admissions Multiple Mini-Interviews (MMIs) rather than traditional interviews (TIs), partly because MMIs are thought to be more reliable. Yet prior studies examined single-school samples of candidates completing either an MMI or TI (not both). Using data from five California public medical schools, the authors examined the within- and between-school reliabilities of TIs and MMIs. METHODS: The analyses included applicants interviewing at ≥1 of the five schools during 2011-2013. Three schools employed TIs (TI1, TI2, TI3) and two employed MMIs (MMI1, MMI2). Mixed linear models accounting for nesting of observations within applicants examined standardized TI and MMI scores (mean = 0, SD = 1), adjusting for applicant socio-demographics, academic metrics, year, number of interviews, and interview date. RESULTS: A total of 4993 individuals (completing 7516 interviews [TI = 4137, MMI = 3379]) interviewed at ≥1 school; 428 (14.5%) interviewed at both MMI schools and 687 (20.2%) at more than one TI school. Within schools, inter-interviewer consistency was generally qualitatively lower for TI1, TI2, and TI3 (Pearson's r 0.07, 0.13, and 0.29, and Cronbach's α, 0.40, 0.44, and 0.61, respectively) than for MMI1 and MMI 2 (Cronbach's α 0.68 and 0.60, respectively). Between schools, the adjusted intraclass correlation coefficient was 0.27 (95% CI 0.20-0.35) for TIs and 0.47 (95% CI 0.41-0.54) for MMIs. CONCLUSIONS: Within and between-school reliability was qualitatively higher for MMIs than for TIs. Nonetheless, TI reliabilities were higher than anticipated from prior literature, suggesting TIs may not need to be abandoned on reliability grounds if other factors favor their use.

Intestinal Perforation Following Ileoscopy Through a Prolapsed Stoma in an Pediatric Intestinal Transplant Recipient With an Unrecognized Parastomal Hernia.

Ileoscopy with mucosal biopsy is fundamental in the management and surveillance of inflammatory bowel disease patients and intestinal transplant recipients. There is a paucity of data describing the risks of ileoscopy in the presence of a prolapsed stoma. Parastomal hernias are frequently associated with prolapsed stomas. We report the first case of perforation during ileoscopy in the setting of a prolapsed stoma and unrecognized parastomal hernia. Recognition of parastomal hernia associated with stoma prolapse is of paramount importance in patients undergoing ileoscopy as it may increase the risk of perforation.

Contrast-enhanced magnetic resonance venography in pediatric patients with chronic kidney disease: initial experience with ferumoxytol.

Ferumoxytol is an ultra-small superparamagnetic iron oxide (USPIO) particle that is FDA-approved for parenteral treatment of iron deficiency anemia in adults with chronic kidney disease. Because of the association between gadolinium-based contrast agents and nephrogenic systemic fibrosis in patients with severe chronic kidney disease, we sought to evaluate the diagnostic role of ferumoxytol-enhanced MR venography in children with chronic kidney disease. Twenty children underwent 22 high-resolution ferumoxytol-enhanced MR venography examinations at 3.0 T. High-resolution 3-D contrast-enhanced imaging was performed at a minimum of 3 time points following injection of ferumoxytol at a total dose of 4 mg/kg. Two blinded pediatric radiologists independently scored six named veins on ferumoxytol-enhanced MR venography examinations according to a three-point subjective score, where a score ≥2 was considered diagnostic. Additionally, all relevant venous structures in the included field of view were analyzed for occlusive or non-occlusive thrombosis, compression and presence of collaterals. All patients underwent ferumoxytol-enhanced MR venography successfully and without adverse event. The overall scores of the reviewing radiologists for all venous structures were 2.7-2.9. In all cases, the reviewers were confident basing their diagnoses on the ferumoxytol-enhanced MR venography findings. In 12 of 22 examinations, findings on follow-up imaging or invasive procedures were available to correlate with the findings on ferumoxytol-enhanced MR venography. There was complete concordance between the findings from follow-up imaging and invasive procedures with findings from ferumoxytol-enhanced MR venography. Ferumoxytol holds promise as a powerful alternative to gadolinium-based contrast agents for reliable, high-resolution MR venography in children with chronic kidney disease.

High-resolution, whole-body vascular imaging with ferumoxytol as an alternative to gadolinium agents in a pediatric chronic kidney disease cohort.

BACKGROUND: Exposure to gadolinium-based contrast agents (GBCA) in patients with chronic kidney disease (CKD) has been associated with the development of a potentially fatal disorder, nephrogenic systemic fibrosis (NSF). Although contrast-enhanced computed tomography (CT) is an alternative to magnetic resonance imaging (MRI), it carries the risk of radiation exposure and further reduction of residual renal function. Therefore we sought to assess the feasibility of ferumoxytol as an alternative to GBCA for contrast-enhanced MR angiography (MRA) in a pediatric cohort with CKD. Ferumoxytol is a parenteral iron supplement that contains ultrasmall superparamagnetic iron oxide (USPIO) and is a potent relaxivity agent for MRI. METHODS: We describe the MRI findings in ten pediatric patients who needed detailed vascular mapping. Ferumoxytol (4 mg/kg) was administered intravenously for contrast-enhanced MRA. The patients tolerated the procedure without complications. RESULTS: Resulting studies were highly diagnostic and were pivotal in guiding patient management. The images were notable for clear delineation of multiple vascular occlusions. CONCLUSIONS: Given the concerns associated with the use of GBCAs in renal failure, ferumoxytol is an excellent alternative contrast agent in pediatric end stage renal disease (ESRD) patients. Future studies are needed in order to further evaluate safety and efficacy of ferumoxytol in this patient population.

Vitamin D deficiency in children with intestinal failure receiving home parenteral nutrition.

BACKGROUND: Vitamin D plays important roles in both skeletal and nonskeletal health. Limited data suggest that patients with intestinal failure (IF) receiving home parenteral nutrition (PN) are at risk for vitamin D deficiency due to inadequate oral intake, poor absorption, and chronic illness. The purpose of this study was to document vitamin D status in pediatric patients with IF receiving home PN. MATERIALS AND METHODS: We performed a 2-year retrospective review of children with IF followed at our center who had been on home PN for ≥6 months and had ≥1 serum 25-hydroxyvitamin D (25-OHD) level checked as part of routine clinical care. Patients were then categorized as deficient (<20 ng/mL), insufficient (20-29 ng/mL), or normal (≥30 ng/mL) based on their lowest vitamin D level. Demographic data and clinical characteristics were also assessed. RESULTS: Eleven of 27 children (41%) had ≥1 insufficient 25-OHD level, including one child with vitamin D deficiency. Diagnosis of short bowel syndrome (compared with dysmotility or malabsorption syndromes) was associated with decreased likelihood of suboptimal vitamin D status, with an odds ratio of 0.12 (95% confidence interval, 0.02-0.8, P = .028). Osteopenia was noted in 59% of the cohort. There was a trend toward higher risk for osteopenia in patients with low 25-OHD levels compared with those with normal 25-OHD levels (82% vs 44%, P = .109). CONCLUSION: Suboptimal 25-OHD levels are common in children with IF on home PN. This emphasizes the critical importance of routine surveillance of serum vitamin D levels and consideration of enteral supplementation when indicated.

Osteochondral lesions in pediatric and adolescent patients.

Osteochondral lesions are acquired, potentially reversible injuries of the subchondral bone with or without associated articular cartilage involvement. Injury results in delamination and potential sequestration of the affected bone. Although an association with mechanical and traumatic factors has been established, the etiology remains poorly understood. These lesions commonly occur in the knee; articular surfaces of the elbow, ankle, hip, and shoulder are also affected. Osteochondral lesions are relatively common in children and adolescents, and the incidence is increasing. Prognosis of these lesions depends on stability, location, and size of the lesion.Imaging has an essential role in the diagnosis, staging, and management of osteochondral lesions. Many of these lesions are first diagnosed by plain film. MRI adds value by identifying unstable lesions that require surgical intervention. This review focuses on the clinical and imaging features of osteochondral lesions of the knee, elbow, and ankle. Imaging criteria for staging and management are also reviewed.

3D-neuronavigation in vivo through a patient's brain during a spontaneous migraine headache.

A growing body of research, generated primarily from MRI-based studies, shows that migraine appears to occur, and possibly endure, due to the alteration of specific neural processes in the central nervous system. However, information is lacking on the molecular impact of these changes, especially on the endogenous opioid system during migraine headaches, and neuronavigation through these changes has never been done. This study aimed to investigate, using a novel 3D immersive and interactive neuronavigation (3D-IIN) approach, the endogenous µ-opioid transmission in the brain during a migraine headache attack in vivo. This is arguably one of the most central neuromechanisms associated with pain regulation, affecting multiple elements of the pain experience and analgesia. A 36 year-old female, who has been suffering with migraine for 10 years, was scanned in the typical headache (ictal) and nonheadache (interictal) migraine phases using Positron Emission Tomography (PET) with the selective radiotracer [(11)C]carfentanil, which allowed us to measure µ-opioid receptor availability in the brain (non-displaceable binding potential - µOR BPND). The short-life radiotracer was produced by a cyclotron and chemical synthesis apparatus on campus located in close proximity to the imaging facility. Both PET scans, interictal and ictal, were scheduled during separate mid-late follicular phases of the patient's menstrual cycle. During the ictal PET session her spontaneous headache attack reached severe intensity levels; progressing to nausea and vomiting at the end of the scan session. There were reductions in µOR BPND in the pain-modulatory regions of the endogenous µ-opioid system during the ictal phase, including the cingulate cortex, nucleus accumbens (NAcc), thalamus (Thal), and periaqueductal gray matter (PAG); indicating that µORs were already occupied by endogenous opioids released in response to the ongoing pain. To our knowledge, this is the first time that changes in µOR BPND during a migraine headache attack have been neuronavigated using a novel 3D approach. This method allows for interactive research and educational exploration of a migraine attack in an actual patient's neuroimaging dataset.

Is there a need for dedicated bone imaging in addition to 18F-FDG PET/CT imaging in pediatric sarcoma patients?

PURPOSE: Many children with sarcomas undergo whole body 2-deoxy-2-((18)F)fluoro-D-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) and technetium methylene diphosphonate ((99)Tc-MDP) studies. It is unknown whether the combination of both tests results in more accurate detection of bone lesions than (18)F-FDG- PET/CT alone. METHODS: (99)Tc-MDP bone and (18)F-FDG PET/CT scans were each read by 2 "blinded" observers and then reviewed side-by-side by 3 readers. Bone lesions were graded qualitatively on a 5-point scale (from benign to malignant). Clinical and imaging follow-up (n = 21) and bone biopsy results (n = 8) served as reference standard. RESULTS: A total of 39 paired (99)Tc-MDP and (18)F-FDG-PET/CT studies (cases) performed at a mean interval 4 ± 7 days, were performed on 29 patients (mean age 12 ± 5 y). Of these, 21 patients (72%) had bone sarcoma, whereas 8 patients (28%) had soft tissue sarcoma. By patient and case-based analysis, (18)F-FDG PET/CT had an accuracy of 100%. Tc-MDP had accuracies of 90% and 82% by patient and case-based analysis. The combined interpretation had an accuracy of 97%. CONCLUSIONS: In this study, (99)Tc-MDP bone imaging does not provide an added diagnostic value for bone involvement over (18)F-FDG-PET/CT.

Discovering hidden relationships between renal diseases and regulated genes through 3D network visualizations.

BACKGROUND: In a recent study, two-dimensional (2D) network layouts were used to visualize and quantitatively analyze the relationship between chronic renal diseases and regulated genes. The results revealed complex relationships between disease type, gene specificity, and gene regulation type, which led to important insights about the underlying biological pathways. Here we describe an attempt to extend our understanding of these complex relationships by reanalyzing the data using three-dimensional (3D) network layouts, displayed through 2D and 3D viewing methods. FINDINGS: The 3D network layout (displayed through the 3D viewing method) revealed that genes implicated in many diseases (non-specific genes) tended to be predominantly down-regulated, whereas genes regulated in a few diseases (disease-specific genes) tended to be up-regulated. This new global relationship was quantitatively validated through comparison to 1000 random permutations of networks of the same size and distribution. Our new finding appeared to be the result of using specific features of the 3D viewing method to analyze the 3D renal network. CONCLUSIONS: The global relationship between gene regulation and gene specificity is the first clue from human studies that there exist common mechanisms across several renal diseases, which suggest hypotheses for the underlying mechanisms. Furthermore, the study suggests hypotheses for why the 3D visualization helped to make salient a new regularity that was difficult to detect in 2D. Future research that tests these hypotheses should enable a more systematic understanding of when and how to use 3D network visualizations to reveal complex regularities in biological networks.

Virtual reality triage training provides a viable solution for disaster-preparedness.

OBJECTIVES: The objective of this study was to compare the relative impact of two simulation-based methods for training emergency medicine (EM) residents in disaster triage using the Simple Triage and Rapid Treatment (START) algorithm, full-immersion virtual reality (VR), and standardized patient (SP) drill. Specifically, are there differences between the triage performances and posttest results of the two groups, and do both methods differentiate between learners of variable experience levels? METHODS: Fifteen Postgraduate Year 1 (PGY1) to PGY4 EM residents were randomly assigned to two groups: VR or SP. In the VR group, the learners were effectively surrounded by a virtual mass disaster environment projected on four walls, ceiling, and floor and performed triage by interacting with virtual patients in avatar form. The second group performed likewise in a live disaster drill using SP victims. Setting and patient presentations were identical between the two modalities. Resident performance of triage during the drills and knowledge of the START triage algorithm pre/post drill completion were assessed. Analyses included descriptive statistics and measures of association (effect size). RESULTS: The mean pretest scores were similar between the SP and VR groups. There were no significant differences between the triage performances of the VR and SP groups, but the data showed an effect in favor of the SP group performance on the posttest. CONCLUSIONS: Virtual reality can provide a feasible alternative for training EM personnel in mass disaster triage, comparing favorably to SP drills. Virtual reality provides flexible, consistent, on-demand training options, using a stable, repeatable platform essential for the development of assessment protocols and performance standards.

Post-transplant multiple myeloma in a pediatric renal transplant patient.

Post-transplant lymphoproliferative disease (PTLD) is a well-recognized complication of the intense immunosuppression required in solid organ and bone marrow transplant recipients. The clinical presentation is varied and can range from a benign infectious mononucleosis-like syndrome to malignant lymphoma. PTLD manifesting as multiple myeloma occurs rarely. We report the unique occurrence of Epstein-Barr virus (EBV)-associated post-transplant multiple myeloma in a 16-year-old male. In contrast to previously described cases of PTLD-myeloma type, this patient was very young, had a clear association with EBV, and an indolent clinical course.