Core and Advanced Thoracic Imaging Curricula to Guide Residency and Fellowship Training: A Framework From the Canadian Society of Thoracic Radiology.

RATIONALE: A well-defined curriculum with goals and objectives is an inherent part of every radiology training program. MATERIALS AND METHODS: Following a needs assessment, the Canadian Society of Thoracic Radiology Education Committee developed a thoracic imaging curriculum using a mixed- method approach, complimentary to the cardiac curriculum published as a separate document. RESULTS: The Thoracic Imaging Curriculum consists of two separate yet complimentary parts: a Core Curriculum, aimed at residents in-training, with the main goal of building a strong foundational knowledge, and an Advanced Curriculum, designed to build upon the core knowledge and guide a more in-depth subspecialty training. CONCLUSION: The curricular frameworks aim to enhance the educational experience of residents and fellows and provide an educational framework for clinical supervisors and residency and fellowship program directors. SUMMARY STATEMENT: The Canadian Society of Thoracic Radiology championed the creation of Cardiovascular and Thoracic Imaging curricula encompassing clinical knowledge and technical, communication, and decision-making skills with the goal of providing direction to a strong foundational knowledge for residents and to guide specialty training for fellowship programs.

National Core and Advanced Cardiac Imaging Curricula: A Framework From the Canadian Society of Thoracic Radiology Education Committee.

RATIONALE: Well-defined curriculum with goals and objectives is an inherent part of every radiology residency program. MATERIALS AND METHODS: Following a needs assessment, the Canadian Society of Thoracic Radiology education committee developed a cardiac imaging curriculum using a mixed method collaborative approach. RESULTS: The Cardiovascular Imaging Curricula consist each of two separate yet complimentary granular parts: a Core Curriculum, aimed at residents in-training, with the main goal of building a strong foundational knowledge and an Advanced Curriculum, designed to build upon the core knowledge and guide a more in-depth fellowship subspecialty training. CONCLUSION: The curricular frameworks aim to enhance the educational experience of trainees (residents and fellows) and provide an educational framework for clinical supervisors and residency and fellowship program directors. SUMMARY STATEMENT: The Canadian Society of Thoracic Radiology (CSTR) championed the creation of Cardiovascular and Thoracic Imaging curricula encompassing clinical knowledge and technical, communication, and decision-making skills with the goal of providing direction to a strong foundational knowledge for residents and to guide specialty training for fellowship programs.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 1: Acquisition and Safety Considerations.

Acute pulmonary embolism (APE) is a well-recognized cause of circulatory system compromise and even demise which can frequently present a diagnostic challenge for the physician. The diagnostic challenge is primarily due to the frequency of indeterminate presentations as well as several other conditions which can have a similar clinical presentation. This often obliges the physician to establish a firm diagnosis due to the potentially serious outcomes related to this disease. Computed tomography pulmonary angiography (CTPA) has increasingly cemented its role as the primary investigation tool in this clinical context and is widely accepted as the standard of care due to several desired attributes which include great accuracy, accessibility, rapid turn-around time and the ability to suggest an alternate diagnosis when APE is not the culprit. In Part 1 of this guidance document, a series of up-to-date recommendations are provided to the reader pertaining to CTPA protocol optimization (including scan range, radiation and intravenous contrast dose), safety measures including the departure from breast and gonadal shielding, population-specific scenarios (pregnancy and early post-partum) and consideration of alternate diagnostic techniques when clinically deemed appropriate.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 2: Technical Issues and Interpretation Pitfalls.

The investigation of acute pulmonary embolism is a common task for radiologists in Canada. Technical image quality and reporting quality must be excellent; pulmonary embolism is a life-threatening disease that should not be missed but overdiagnosis and unnecessary treatment should be avoided. The most frequently performed imaging investigation, computed tomography pulmonary angiogram (CTPA), can be limited by poor pulmonary arterial opacification, technical artifacts and interpretative errors. Image quality can be affected by patient factors (such as body habitus, motion artifact and cardiac output), intravenous (IV) contrast protocols (including the timing, rate and volume of IV contrast administration) and common physics artifacts (including beam hardening). Mimics of acute pulmonary embolism can be seen in normal anatomic structures, disease in non-vascular structures and pulmonary artery filling defects not related to acute pulmonary emboli. Understanding these pitfalls can help mitigate error, improve diagnostic quality and optimize patient outcomes. Dual energy computed tomography holds promise to improve imaging diagnosis, particularly in clinical scenarios where routine CTPA may be problematic, including patients with impaired renal function and patients with altered cardiac anatomy.

Prevalence and Functional Implication of Silent Coronary Artery Disease in Marathon Runners Over 40 Years of Age: The MATCH-40 Study.

BACKGROUND: Marathon participation is becoming increasingly popular among individuals ≥40 years of age. Little is known about the prevalence of subclinical coronary artery disease (CAD) and corresponding ischemia in this patient population. The study objectives are: (1) to characterize the prevalence of silent CAD in marathoners ≥ 40 years old using cardiac computed tomography angiography (CCT); and (2) if subclinical CAD was detected, to determine the functional significance of occult lesions by stress echocardiography (SE). METHODS: Marathoners aged ≥ 40 years who completed a full marathon between 2018 and 2019 were recruited to undergo a prospective CCT. Coronary artery stenosis was graded as zero, mild (1%-49%), moderate (50%-69%), or severe (> 70%). All study participants diagnosed with mild-to-severe atherosclerotic CAD on CCT further underwent functional imaging with exercise treadmill SE. RESULTS: A total of 65 individuals (53 ± 7 years, 65% males, 24 ± 3 kg/m2) underwent a prospective CCT within 12 months of marathon completion. Of the total study population, 13 participants (20%) were diagnosed with CAD, of whom 10 (77%) had mild disease, 1 (8%) had moderate disease, and 2 (15%) had severe disease by CCT. Despite the identification of subclinical CAD on CCT, none of the 13 patients had any evidence of inducible ischemia on SE. CONCLUSIONS: This is the first study to incorporate both CCT and SE in the evaluation of subclinical CAD in marathoners ≥40 years old. Although the overall prevalence of anatomic CAD was 20%, there was no evidence of functional ischemia in this highly competitive cohort.

CONTEXTE: Les marathons ont gagné en popularité auprès des individus âgés de 40 ans ou plus. On en sait toutefois peu sur la prévalence de la coronaropathie subclinique et de l'ischémie qui lui est associée dans cette population de patients. L'étude visait à 1) caractériser la prévalence de la coronaropathie silencieuse chez les marathoniens âgés de 40 ans ou plus à l'aide d'une angiographie cardiaque par tomodensitométrie (ACTDM) si une coronaropathie subclinique était détectée, à déterminer l'importance fonctionnelle des lésions occultes par une échocardiographie d'effort (EE). MÉTHODOLOGIE: Des marathoniens âgés de 40 ans ou plus ayant réalisé un marathon entre 2018 et 2019 ont été recrutés et soumis à une ACTDM prospective. Les sténoses des artères coronaires étaient classées selon une échelle allant de zéro, légère (1 à 49 %), modérée (50 à 69 %) à sévère (> 70 %). Tous les participants à l'étude ayant reçu un diagnostic de coronaropathie athéroscléreuse légère à sévère à la suite de l'ACTDM ont été soumis à une imagerie fonctionnelle avec EE sur tapis roulant. RÉSULTATS: Au total, 65 sujets (53 ± 7 ans, 65 % d'hommes, 24 ± 3 kg/m2) ont été soumis à une ACTDM prospective dans un délai de 12 mois à la suite de leur dernier marathon. Dans l'ensemble de la population à l'étude, 13 participants (20 %) ont reçu un diagnostic de coronaropathie; 10 (77 %) présentaient une maladie bénigne, 1 (8 %) présentait une maladie modérée et 2 (15 %) présentaient une maladie sévère selon l'ACTDM. Même si une coronaropathie subclinique a été diagnostiquée lors de l'ACTDM, aucun des 13 patients ne présentait de signe d'ischémie inductible à l'EE. CONCLUSIONS: Il s'agit de la première étude à utiliser l'ACTDM et l'EE pour évaluer la présence d'une coronaropathie chez des marathoniens âgés de 40 ou plus. Même si la prévalence globale de la coronaropathie anatomique était de 20 %, il n'y avait aucun signe d'ischémie fonctionnelle au sein de cette cohorte hautement compétitive.

Morphologic Analysis of the Carpal Tunnel and Median Nerve Following Open and Endoscopic Carpal Tunnel Release.

Background: Endoscopic carpal tunnel release (ECTR) has purported advantages over open release such as reduced intraoperative dissection and trauma and more rapid recovery. Endoscopic carpal tunnel release has been shown to have comparable outcomes to open release, but open release is considered easier and safer to perform. Previous studies have demonstrated an increase in carpal tunnel volume, regardless of the technique used. However, the mechanism by which this volumetric increase occurs has been debated. Our study will determine through magnetic resonance imaging (MRI) analysis the morphologic changes that occur in both open carpal tunnel release (OCTR) and ECTR, thereby clarifying any morphologic differences that occur as a result of the 2 operative techniques. We hypothesize that there will be no morphologic differences between the 2 techniques. Methods: This was a prospective study to compare the postoperative anatomy of both techniques with MRI. Nineteen patients with clinical and nerve conduction study-confirmed carpal tunnel syndrome underwent either open or endoscopic release. Magnetic resonance imaging was performed preoperatively and 6 months postoperatively in all patients to examine the volume of the carpal tunnel, transverse distance, anteroposterior (AP) distance, divergence of tendons, and Guyon's canal transverse and AP distance. Results: There was no significant difference in the postoperative morphology of the carpal tunnel and median nerve between OCTR and ECTR at 6-month follow-up on MRI. Conclusion: We conclude that there are no morphologic differences in OCTR and ECTR. It is an increase in the AP dimension that appears to be responsible for the increase in the volume of the carpal tunnel.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Consensus Statement Regarding Chest Imaging in Suspected and Confirmed COVID-19.

On March 11, 2020, the World Health Organization declared infection related to a novel coronavirus (SARS-CoV-2) a pandemic. The role and impact of imaging predates this declaration and continues to change rapidly. This article is a consensus statement provided by the Canadian Society of Thoracic Radiology and the Canadian Association of Radiologists outlining the role of imaging in COVID-19 patients. The objectives are to answer key questions related to COVID-19 imaging of the chest and provide guidance for radiologists who are interpreting such studies during this pandemic. The role of chest radiography (CXR), computed tomography (CT), and lung ultrasound is discussed. This document attempts to answer key questions for the imager when dealing with this crisis, such as "When is CXR appropriate in patients with suspected or confirmed COVID-19 infection?" or "How should a radiologist deal with incidental findings of COVID-19 on CT of the chest done for other indications?" This article also provides recommended reporting structure for CXR and CT, breaking diagnostic possibilities for both CXR and CT into 3 categories: typical, nonspecific, and negative based on imaging findings with representative images provided. Proposed reporting language is also outlined based on this structure. As our understanding of this pandemic evolves, our appreciation for how imaging fits into the workup of patients during this unprecedented time evolves as well. Although this consensus statement was written using the most recent literature, it is important to maintain an open mind as new information continues to surface.

Iatrogenic type A aortic dissection complicating percutaneous coronary intervention: a case report.

Iatrogenic type A dissection caused by percutaneous coronary intervention is a rare but life-threatening condition. Computed tomographic angiography is an excellent diagnostic tool commonly utilized if such procedural complication is clinically suspected. There are, however, potential diagnostic challenges. Herein, we present an illustrative case of iatrogenic type A dissection successfully diagnosed on computed tomography angiography along with a potential diagnostic pitfall.

Venous Diversion Surgery Revisited: A Baffling Situation.

With the increasing number of survivors with congenital heart disease (CHD) reaching adulthood, it is important for the clinician to be familiar with the various surgical options performed in this growing patient population. We describe the case of a 65-year-old female who presented with hypoxia and right-to-left shunting following a surgical repair of an atrial septal defect (ASD) secundum and anomalous pulmonary veins with a partial atrial diversion procedure in childhood. The use of multimodality cardiovascular imaging using echocardiography, computed tomography, magnetic resonance imaging, and invasive cardiac catheterization was complementary in the preoperative diagnosis and management of this unique baffling situation.

Radiographic interpretation of carpometacarpal arthroplasty: correlation between radiographic loosening and clinical outcome.

OBJECTIVE: To assess the radiographic appearance and interpretation of loosening in patients following first carpometacarpal joint pyrohemisphere arthroplasty. MATERIALS AND METHODS: A retrospective review over a 6-year period was performed identifying patients with first carpometacarpal pyrohemisphere implants. All postoperative radiographs were reviewed and compared with clinical information. Loosening was defined as greater than 1 mm of periprosthetic lucency or increasing lucency on serial studies. Adverse clinical outcome was defined as infection, complex regional pain syndrome, subluxation or an inability to return to activities of daily living. Statistical analysis included Cohen's Kappa coefficient to measure inter-reader agreement for radiographic interpretation and the agreement between radiographic loosening and an undesired or adverse clinical outcome. RESULTS: Thirty-one implants in 26 patients were reviewed. A total of 73 postoperative radiographs were reviewed. The mean age of the study subjects was 58 years. The mean radiographic follow-up was 13 months (range: 1-56). All arthroplasties were performed for osteoarthritis. Only one repeat surgery was performed. There was good agreement amongst readers with regard to radiographic interpretation, but the strength of agreement between radiographic loosening and adverse clinical outcome was poor. The sensitivity of radiography in predicting an adverse clinical outcome was 63%, specificity 65%, positive predictive value 39%, and negative predictive value 83%. CONCLUSION: Although radiography may be useful in the correct clinical context, it should not be utilized as the sole predictor of adverse clinical outcomes following carpometacarpal arthroplasty.

Effect of hydration status on atrial and ventricular volumes and function in healthy adult volunteers.

BACKGROUND: Assessment of cardiac chamber volumes is a fundamental part of cardiac magnetic resonance (CMR) imaging. While the effects of inter- and intraobserver variability have been studied and have a recognized effect on the comparability of serial cardiac MR imaging studies, the effect of differences in hydration status has not been evaluated. OBJECTIVE: To evaluate the effects of volume administration on cardiac chamber volumes. MATERIALS AND METHODS: Thirteen healthy adults underwent a baseline cardiac MR to evaluate cardiac chamber volumes after an overnight fast. They were then given two saline boluses of 10 ml/kg of body weight and the cardiac MR was repeated immediately after each bolus. RESULTS: From the baseline scan to the final scan there was a significant increase in all four cardiac chamber end-diastolic volumes. Right atrial volumes increased 8.0%, from 61.1 to 66.0 ml/m2 (P<0.001), and left atrial volumes increased 10.0%, from 50.0 to 55.0 ml/m2 (P<0.001). Right ventricular volumes increased 6.0%, from 91.1 to 96.5 ml/m2 (P<0.001), and left ventricular volumes increased 3.2%, from 87.0 to 89.8 ml/m2 (P<0.001). CONCLUSION: Hydration status has a significant effect on the end-diastolic volumes of all cardiac chambers assessed by cardiac MR. Thus, hydration represents a "variable" that should be taken into account when assessing cardiac chamber volumes, especially when performing serial imaging studies in a patient.

Right ventricular free wall dyskinesis in the setting of left ventricular non compaction: a case report.

BACKGROUND: Left ventricular non compaction is a relatively rare congenital disorder characterized by prominent trabeculations and intertrabecular recesses with the potential for thromboembolism, arrhythmias, and sudden cardiac death as adverse effects. Echocardiography has traditionally been employed as the primary mode of imaging; however, with the advent of cardiac magnetic resonance as a more precise imaging technique, the disorder known as left ventricle non compaction is becoming more broadly defined with increasing recognition of right ventricle (RV) involvement. CASE PRESENTATION: This report describes a 52-year-old Caucasian female with new onset atrial fibrillation with an unusual finding of left ventricular non compaction and right ventricular dysfunction on transthoracic echocardiogram with preserved left ventricular ejection fraction. Cardiac magnetic resonance imaging demonstrated a disproportionately affected right ventricle, with apical free wall dyskinesis. CONCLUSIONS: This case illustrates the unique occurrence of left ventricular non compaction with preserved ejection fraction alongside RV free wall dyskinesis and RV systolic dysfunction. The significance of this is yet unknown given the paucity of existing literature. This report serves to highlight the vast heterogeneity within left ventricular non compaction as we are better able to delineate this disorder using increasingly sophisticated imaging techniques.