Evaluation of a Radiation Oncology Microclerkship as a Component of Medical Student Education.

Compared to most oncologic subspecialties, radiation oncology (RO) lacks a natural pathway for incorporation into the clinical clerkships, and few students ever complete a formal rotation in RO. The feasibility, and perceived value, of a 1-day "microclerkship" exposure in RO during other related clerkships was evaluated in this study. At a single institution, the RO clerkship director partnered with clerkship directors in medical oncology, palliative care, and radiology so that every 3rd or 4th year student would spend 1 day in RO during those clerkships. Afterwards, students completed an electronic survey containing multiple choice and 5-point Likert-type questions describing their experience. Descriptive statistics are reported. Ninety-seven students completed the RO microclerkship over 2 years, and 81 completed the survey (response rate 84%). Only 8 students (10%) had ever been in a RO department previously. During the microclerkship, 73 students (90%) saw at least one new patient consultation; 77 (95%) were involved in contouring or treatment planning; 76 (94%) saw treatment delivery; and 38 (47%) saw a brachytherapy procedure. Seventy-nine students (98%) felt that the microclerkship was at least moderately valuable (mean Likert-type rating 4.01, SD 0.73). Forty students (49%) were either somewhat or much more interested in participating in a longer (2-4 week) rotation in radiation oncology (mean Likert-type rating 3.59, SD 0.83). This study demonstrated the feasibility of incorporating a 1-day RO microclerkship into other related elective clerkships. Students viewed the experience favorably and found it valuable in their education.

Pulmonary hemorrhage in acute heroin overdose: a report of two cases.

Diffuse alveolar hemorrhage (DAH) is a clinical syndrome characterized by pulmonary hemorrhage, respiratory failure, and high early mortality rates. DAH typically appears on chest radiographs as bilateral parenchymal consolidations. To our knowledge, pulmonary hemorrhage associated with heroin overdose has not been reported. We report the clinical and radiographic findings in two cases of acute DAH following heroin overdose. We speculate that an adulterating agent may be the underlying etiology in these cases. While pulmonary edema as a consequence of heroin overdose is well-documented and usually first suspected when consolidations are present on a chest radiograph in a patient with a history of recent heroin use, we believe that DAH should also be considered in the proper clinical context.

Celiomesenteric and hepatosplenomesenteric trunks: characterization of two rare vascular anomalies with CT.

OBJECTIVE: The purpose of this retrospective investigation is to characterize and illustrate the appearances of celiomesenteric trunk (CMT) and hepatosplenomesenteric trunk (HSMT) using CT with three-dimensional volume-rendering with attention to the proximal branching patterns. We also correlate our results with an embryologic model and assess the accuracy of radiologists in recognizing these entities. METHODS: CT studies on 36 adult subjects with CMT and 10 with HSMT were analyzed to determine the proximal branching patterns and lengths of the common vascular trunks. The official reports in appropriately selected cases were reviewed to ascertain if the interpreting radiologists recognized the anomalies. RESULTS: Two types of CMT were found. In 29 of 36 cases (81%), the CMT bifurcated into the celiac trunk and superior mesenteric artery (Type A CMT), while in 7 cases the left gastric artery (LGA) arose from the CMT proximal to the hepatosplenic trunk and superior mesenteric artery (Type B CMT). Type A trunks (mean length = 10.4 mm) were significantly shorter (p = 0.007) than Type B trunks (mean length = 17.8 mm). Short common trunks (less than 1.0 cm) were only seen with Type A CMT. Branching patterns in all 10 cases of HSMT were identical with no short common trunks. The CMT was not mentioned in the radiology reports in 88% of the cases assessed. CONCLUSION: The location of the LGA origin distinguishes the two variants of CMT and differentiates CMT from HSMT. These anomalies are easily overlooked during evaluation of routine clinical cases.

Reducing radiation dose in body CT: a primer on dose metrics and key CT technical parameters.

OBJECTIVE: The purpose of this article is to describe how to interpret radiation dosi-metric data available on a body CT dose report and to explain the effects of key operator-chosen CT parameters on patient radiation dose. CONCLUSION: To apply dose reduction strategies in body CT, radiologists must understand the information contained in the CT dose report and know the effects of key CT technical parameters on patient radiation exposure.

Reducing radiation dose in body CT: a practical approach to optimizing CT protocols.

OBJECTIVE: The purpose of this article is to describe an approach to protocol modifications in body CT to reduce patient radiation exposure while maintaining image quality and to illustrate the effects of these modifications. CONCLUSION: One should become proficient in interpreting the CT dose report, adjusting CT technical parameters, and applying focused collimation. The goal is to intelligently use CT to answer the question of clinical concern in the most dose-efficient manner.

Hydatid cyst embolization to the pulmonary artery: CT and MR features.

Hydatid cyst embolization to the pulmonary arteries is rare especially in the Western regions of the world. However, it can be mistaken for pulmonary embolism based on the similar clinical manifestations of cough, hemoptysis, and acute onset of chest pain. We report a case of a 32-year-old man presenting with these symptoms who was initially suspected of having pulmonary embolism. Subsequent imaging with CT and MR revealed hepatic hydatid cyst embolization to the pulmonary arteries. The significance of this case lies in the recognition of the unique radiologic features of pulmonary hydatid cyst embolization on CT and MR imaging to differentiate this entity from bland pulmonary thromboembolic disease.

USMLE Step 2 CK Scores and Radiology Residency Applications: Does it Affect Diversity in Selection of Trainees?

RATIONALE AND OBJECTIVES: As residency programs in diagnostic radiology aspire to broaden trainee diversity, reliance on certain criteria may affect the selection of candidates from underrepresented groups. With the conversion of reporting of the United States Medical Licensing Examination (USMLE) Step 1 scores to pass/fail, programs may rely more on numerical USMLE Step 2 Clinical Knowledge (CK) scores. The purpose of our investigation is to assess the effects of Step 2 CK scores on the selection of underrepresented minority (URM) and female candidates. MATERIALS AND METHODS: Applications from United States senior allopathic medical students to a radiology residency program from the 2021-2023 National Residency Matching Program cycles were analyzed. Subjects were classified as male or female and URM or non-URM by self-identification. Step 2 CK scores were compared and the use of cutoff scores was examined for disparate effects. RESULTS: 1017 subjects fulfilled the entry criteria. There were 721 males and 296 females, with 164 URM and 853 non-URM candidates. Comparing males to females, there was no significant difference in the mean score (p = 0.21) and no disparate effects of cutoff scores. There was a significant difference between the mean score of URM versus non-URM candidates of eight points (p < 0.00011). The use of cutoffs showed a disparate effect on URM candidates with a cutoff score of 250 (average score for 2022 matched applicants) excluding 71% of URM candidates while excluding only 46% of non-URM candidates. CONCLUSION: Reliance on USMLE Step 2 CK scores to screen applications for radiology residency can disadvantage URM candidates. Females are not adversely affected.

Double Aortic Arch in an Asymptomatic Adult.

We present a rare double aortic arch (DAA) diagnosis incidentally on CT in a 60-year-old male who presented with pneumonia. DAA is a vascular ring that typically manifests in infants or children due to compression of the esophagus or trachea, resulting in dysphagia or dyspnea. Diagnosis of DAA in adulthood is usually due to the delayed emergence of obstructive symptoms. We present a case of DAA in an adult patient without dysphagia or dyspnea. We discuss factors that can lead to the presentation of DAA in adults. These include an absence of associated congenital disabilities, insufficient tracheal or esophageal constriction in childhood and the onset of compressive symptoms later in life from decreased vascular compliance.

Intimal tears in thoracic aortic dissection: appearance on MDCT with virtual angioscopy.

OBJECTIVE: The location, number, size, and configuration of intimal tears in aortic dissection have important therapeutic and prognostic implications. Planning of procedures to treat complications of aortic dissection may require precise delineation of the intimal tears. The purpose of this article is to illustrate the ability of MDCT using multiplanar image reformatting and virtual angioscopy to depict the location and appearance of intimal tears and fenestrations within dissection flaps in cases of thoracic aortic dissection. CONCLUSION: MDCT with virtual angioscopy can depict the configuration of intimal tears in cases of thoracic aortic dissection, which may facilitate therapeutic planning.

Left brachiocephalic vein vascular ring on CT: A rare venous anomaly.

We present a case of a vascular ring formed by the left brachiocephalic vein. A left brachiocephalic vein ring or circum-aortic left brachiocephalic vein is a rare congenital vascular variant. Although it is usually an incidental finding on chest imaging studies, left brachiocephalic vein anomalies, particularly the ring variant, can be clinically significant during procedures requiring installation of transvenous implantable devices such as pacemakers. In this report, we illustrate the appearance on computed tomography of this rare anomaly and discuss an embryological hypothesis for the etiology.

Urachal Remnant Calcification: A Rare Cause of Calcification Within the Urinary Bladder.

Calcification of the urachal remnant is a rare cause of urinary bladder calcification. We present a case of calcification of the urachal remnant found incidentally on computed tomography (CT) scan in the setting of trauma. Our case clearly illustrates that reformatting images in the sagittal plane can clearly delineate the median umbilical ligament and its relationship to the calcification for confirmation of the diagnosis. Recognition of the characteristic appearance of this entity ensures prompt diagnosis and avoids unnecessary workup for other causes of calcification within the bladder.

Embolized fibrin sheath material presenting as intraluminal calcifications within the pulmonary arteries on CT.

Fibrin sheath formation is a well-described sequela of an indwelling central venous catheter. Fibrin sheaths may also develop around other foreign bodies within the venous system. We describe a case of fibrin sheath formation within the left brachiocephalic vein secondary to automatic implantable cardioverter-defibrillator (AICD) leads with subsequent embolization of sheath material presenting as calcifications within the pulmonary vasculature on computed tomography (CT). Most of the relevant literature focuses on catheter-related sheath formation and associated complications while reports on fibrin sheaths from other foreign bodies are sparse. We advise that radiologists who encounter intraluminal calcifications within the pulmonary arteries on CT should consider the possibility of a fibrin sheath as the source and search for its remnants in the central venous system for confirmation.

Does Objective Scoring of Applications for Radiology Residency Affect Diversity?

RATIONALE AND OBJECTIVES: It is important to recognize if reliance on certain factors in applications affects selection of trainees from under-represented groups. Our purpose is to determine if objective scoring of radiology residency applications based on quantifiable data regarding academic performance, United States Medical Licensing Examination (USMLE) scores and research productivity affects selection of female and under-represented minority (URM) candidates. MATERIALS AND METHODS: We reviewed 502 applications from three successive match cycles from United States allopathic medical students. Each application was scored for academic performance, USMLE results and research productivity determining an overall score. The scores of males were compared to females and URM were compared to non-URM candidates. USMLE cutoff scores were evaluated for disparate effects. RESULTS: There were 348 male, 154 female, 73 URM and 429 non-URM candidates. For male versus female applicants, there was no significant difference in mean academic performance, USMLE Step 2 Clinical Knowledge and research productivity scores. Males had higher mean USMLE Step 1 (p = 0.005) and overall candidate scores (p = 0.02). Between URM and non-URM candidates there was no significant difference in academic performance. Non-URM applicants had higher mean USMLE Step 1 (p = 0.008), USMLE Step 2 (p = 0.002), research productivity (p = 0.001) and overall scores (p = 0.02). Use of USMLE cutoff scores demonstrated disparate effects on female and URM candidates. CONCLUSION: Objective scoring of applications and use of USMLE cutoff scores can disadvantage candidates from underrepresented groups. Screening filters can affect the diversity of candidate pools for radiology residency.

Esophageal perforation, the most feared complication of TEE: early recognition by multimodality imaging.

Esophageal perforation is the most feared complication of transesophageal echocardiography (TEE), although the overall risk is extremely low. We report a case of esophageal perforation in a 77-year-old woman who had no apparent contraindications to TEE. Chronic steroid therapy for symptoms of asthma as well as osteophytic changes of the cervical vertebrae contributed to her increased risk of perforation. Unlike in prior reports, the perforation in this case was fortuitously recognized rapidly due to ingestion of a carbonated beverage for evaluation of a hiatal hernia suspected during a subsequent transthoracic echocardiogram performed because of inadequate TEE images after a difficult intubation. The incidence of esophageal perforation in our series (1 in 5,000 TEEs, 0.02%) is similar to that reported in the literature. Early recognition and prompt surgical repair of the esophageal perforation led to favorable outcome in our patient.

Isolated Ascites on CT After Blunt Trauma: A Sign of Intraperitoneal Bladder Rupture.

We report a case of intraperitoneal bladder rupture in a 24-year-old man who was struck by a motorcycle. Initial contrast-enhanced CT scan shortly after presentation to our emergency department demonstrated simple free fluid within the upper abdomen and pelvis. Delayed CT scan of the pelvis showed contrast extravasation into the perineal cavity. CT cystography showed rupture of the bladder dome with active contrast extravasation. This case illustrates that intraperitoneal bladder rupture should be considered as an etiology for otherwise unexplained ascites after blunt abdominal trauma. Delayed CT and CT cystography should be considered for further evaluation.

Inferior vena cava filter fracture with strut migration on CT with volume rendering.

We present the computed tomography findings in a patient with a fractured IVC filter and migration of a broken strut to the right lower quadrant. The filter morphology and strut fragment are well demonstrated on volume rendered images confirming the value of volumetric 3D computed tomography imaging to evaluate IVC filter integrity and identify migrated filter fragments.

Pneumomediastinum From Vacuum Disc and Vertebral Trauma.

We present a case of pneumomediastinum associated with an endplate fracture adjacent to a vacuum disc. Pneumomediastinum from trauma can be due to damage to the lungs, airway, or esophagus. In this case, we present a unique complication of the vacuum disc phenomenon in which vertebral injury at the site of a vacuum disc releases gas bubbles into the mediastinum. We believe that compressive forces from the trauma produced a disruption of the annulus fibrosis and forced gas previously sequestered in the intervertebral disc space to escape into the mediastinum.

Computed Tomography Appearance of Unusual Nonaortic Thoracic Aneurysms and Pseudoaneurysms.

Although aneurysms of the thoracic aorta are easily recognized on computed tomography (CT), nonaortic intrathoracic aneurysms and pseudoaneurysms are unusual and not often encountered by radiologists. These lesions can result in complications such as hemorrhage or symptoms from mass effect. In some cases, patients may be asymptomatic and the aneurysms may represent incidental findings. Radiologists should be familiar with the CT appearances of these rare vascular abnormalities to enable prompt diagnosis. The goals of this pictorial essay are to: (1) illustrate and describe the CT appearances of various unusual intrathoracic nonaortic aneurysms and pseudoaneurysms; (2) discuss the etiology and clinical significance of these lesions; and (3) discuss management options where appropriate.

Clostridial Mycotic Aneurysm Leading to Emphysematous Aortitis.

Mycotic aneurysms account for less than 5% of all aneurysms of the aorta, with most cases linked to infection with either Staphylococcus or Salmonella species. Emphysematous aortitis is a rare consequence of mycotic aneurysms and is associated with high morbidity and mortality. It typically occurs from infection superimposed on already damaged endothelium, which is commonly seen in conditions such as atherosclerosis. This report discusses the presentation and relevant imaging findings of a unique case of emphysematous aortitis from Clostridial infection of the thoracic aorta. The patient was a 66-year-old male with a past medical history of end-stage renal disease, arteriovenous fistula for dialysis, hypertension, and diabetes, who presented with tachycardia and tachypnea. Computed tomography of the chest showed inflammatory changes of the thoracic aorta with gas bubbles along the aortic wall, and post-mortem aortic tissue cultures were positive for Clostridium innocuum. Although emphysematous aortitis is rare, the radiographic findings are strikingly characteristic and should prompt immediate and aggressive management.

An unusual combination of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) and a right coronary artery system with two separate ostia from the aorta in an adult.

We describe a patient with an infrequent combination of variants in both the right and the left coronary arterial ostia, namely a combination of two separate right coronary artery (RCA) ostia from the aorta, and an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). To our knowledge, such a combination has not been previously reported. Based on published statistics for individual variants, such a combination is expected to occur approximately once for every 500,000 to one million live births. ALCAPA and dual RCA anatomy was characterized in our patient by echocardiography, conventional angiography, and multidetector computed tomography before and after Takeuchi repair.