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The American Board of Radiology (ABR) developed the international medical graduate alternate pathway to give foreign trained radiologists an alternate route to independent radiology practice without having to undergo radiology residency in the United States. After 4 years of fellowship/faculty experience in the same training institution, the foreign trained radiologist becomes eligible to sit for the radiology board examinations conducted by the ABR. As this pathway is not offered at every radiology training program, many training institutions are unfamiliar with the fundamentals of this pathway. At the same time, both the training institutions and the applying foreign-trained physicians face a plethora of confusing choices on the state and federal level. In this paper, we review the main factors which both the international medical graduate radiologists and training programs must consider before embarking on the diagnostic radiology ABR Alternate Pathway, namely, eligibility, visa options, state medical licensure requirements, their costs and implications for future employment opportunities.

BACKGROUND AND PURPOSE: Recently, numerous investigational studies, case series, and case reports have been published describing various MR imaging brain findings in patients with COVID-19. The purpose of this literature review was to compile and analyze brain MR imaging findings in patients with COVID-19-related illness. MATERIALS AND METHODS: Literature searches of PubMed, publicly available Internet search engines, and medical journal Web sites were performed to identify articles published before May 30, 2020 that described MR imaging brain findings in patients with COVID-19. RESULTS: Twenty-two articles were included in the analysis: 5 investigational studies, 6 case series, and 11 case reports, encompassing MR imaging of the brain in 126 patients. The articles originated from 7 different countries and were published in 14 medical journals. MR imaging brain findings included specific diagnoses (such as acute infarct, posterior reversible encephalopathy syndrome) or specific imaging features (such as cortical FLAIR signal abnormality, microhemorrhages). CONCLUSIONS: The most frequent diagnoses made on brain MR imaging in patients with COVID-19 were acute and subacute infarcts. Other common findings included a constellation of leukoencephalopathy and microhemorrhages, leptomeningeal contrast enhancement, and cortical FLAIR signal abnormality.

New persistent left bundle branch block (NP-LBBB) has been associated with adverse outcomes after TAVI but few predictors thus far reported. We sought to identify predictors of NP-LBBB after TAVI with EvolutR/PRO (ER/EP). From 1/2016 to 4/2019, 544 patients from 2 centers underwent TAVI with Evolut (54% ER, 46% EP) for severe native aortic stenosis. Patients with previous LBBB and pacemaker were excluded. Aortic root analysis was performed using 3Mensio Valves Software and membranous septal length (MSL) was determined using the standard coronal view. Clinical, anatomic and procedural characteristics of 396 Evolut were analyzed and predictors of NP-LBBB were identified. Valve Academic Research Consortium-2 outcomes were reported. At discharge, NP-LBBB was seen in 76(19.2%) patients. NP-LBBB in Evolut was associated with implant depth at left coronary cusp (p = 0.004) and 34 mm ER (p = 0.026). Independent predictors of NP-LBBB in Evolut were shorter MSL (odds ratio [OR] = 0.82 per mm septum, 95% confidence interval [CI] = 0.68 to 0.98,p = 0.030), left ventricular outflow tract (LVOT) eccentricity (OR = 1.04 per %, 95% CI = 1.01 to 1.06,p = 0.002), implant depth at noncoronary cusp (NCC) (OR = 1.28 per mm ventricular, 95% CI = 1.11 to 1.48,p = 0.001) and annular perimeter oversizing ≥20% (OR = 2.38, 95% CI = 1.20 to 4.72, p = 0.013). On ROC curve analysis, MSL ≤6.5 mm, NCC depth ≥3 mm and LVOT eccentricity ≥35% were optimal threshold values to predict NP-LBBB. In Conclusion, shorter MSL, LVOT eccentricity, annular oversizing and deeper implant depth are novel predictors of NP-LBBB in Evolut TAVI. Preprocedural CT assessment of aortic root anatomy may help identify patients at risk for NP-LBBB. In such patients, modifying procedural factors such as higher implant and less annular oversizing may reduce the risk of NP-LBBB. Further evaluation of our hypothesis is warranted.

Mucoepidermoid carcinoma is ayoung person’s lung cancer with no apparent causal connection to smoking. It exhibits slow growth, which can make it challenging to detect changes in size on serial chest imaging. Another way of describing its growth pattern is that mucoepidermoid carcinoma has an unusually long volume doubling time. We describe acase of an incidental lung nodule diagnosed as mucoepidermoid carcinoma in which aprior chest radiograph provided aclue to the indolent nature of the abnormality and therefore argued against typical lung cancer. In the same context, we underscore the value of volumetric analy-sis in improving the accuracy of nodule growth determinations, which further strengthens the argument that the importance of locating prior imaging has not diminished in contemporary pulmonary practice.

The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country.This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members.Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%.Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.

A man aged 77 years was referred to the emergency department (ED) of our hospital by his primary physician for evaluation of dyspnoea and hypoxaemia. On presentation to the ED, he reported 2 months of progressively worsening dyspnoea and non-productive cough. He also endorsed weight loss and fatigue. He had been prescribed a recent course of clarithromycin after an episode of fever, but this did not ameliorate either the dyspnoea or the cough. On the day he was referred to the ED, his primary physician found him to be hypoxemic, which is what prompted the referral. The patient’s medical history was significant for hypertension and coronary artery disease with myocardial infarction and coronary stenting 4 years prior to admission. His usual home medications included aspirin, carvedilol, losartan, rosuvastatin, sertraline and zolpidem. He was a former smoker who quit 25 years earlier after accumulating 40 pack-years. He had no occupational or environmental exposures. On admission, his hypoxaemia was confirmed with an oxygen saturation by pulse oximetry on room air of 76%. The patient was visibly dyspnoeic and had diffuse bilateral crackles on auscultation. His jugular venous pulse was normal. There was no clubbing or oedema. Routine laboratory evaluation was remarkable for a brain natriuretic peptide level of 557 pg/mL (normal

Contains fulltext : 220761.pdf (Publisher’s version ) (Open Access) Rationale: The decades-long progression of chronic obstructive pulmonary disease (COPD) renders identifying different trajectories of disease progression challenging.Objectives: To identify subtypes of patients with COPD with distinct longitudinal progression patterns using a novel machine-learning tool called "Subtype and Stage Inference" (SuStaIn) and to evaluate the utility of SuStaIn for patient stratification in COPD.Methods: We applied SuStaIn to cross-sectional computed tomography imaging markers in 3,698 Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1-4 patients and 3,479 controls from the COPDGene (COPD Genetic Epidemiology) study to identify subtypes of patients with COPD. We confirmed the identified subtypes and progression patterns using ECLIPSE (Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints) data. We assessed the utility of SuStaIn for patient stratification by comparing SuStaIn subtypes and stages at baseline with longitudinal follow-up data.Measurements and Main Results: We identified two trajectories of disease progression in COPD: a "Tissue-->Airway" subtype (n = 2,354, 70.4%), in which small airway dysfunction and emphysema precede large airway wall abnormalities, and an "Airway-->Tissue" subtype (n = 988, 29.6%), in which large airway wall abnormalities precede emphysema and small airway dysfunction. Subtypes were reproducible in ECLIPSE. Baseline stage in both subtypes correlated with future FEV1/FVC decline (r = -0.16 [P < 0.001] in the Tissue-->Airway group; r = -0.14 [P = 0.011] in the Airway-->Tissue group). SuStaIn placed 30% of smokers with normal lung function at elevated stages, suggesting imaging changes consistent with early COPD. Individuals with early changes were 2.5 times more likely to meet COPD diagnostic criteria at follow-up.Conclusions: We demonstrate two distinct patterns of disease progression in COPD using SuStaIn, likely representing different endotypes. One third of healthy smokers have detectable imaging changes, suggesting a new biomarker of "early COPD."

Rationale: Increasing awareness of the prevalence and significance of Preserved Ratio Impaired Spirometry (PRISm), alternatively known as restrictive or Global Initiative for Chronic Obstructive Lu...

Rationale and Objectives The Electronic Resident Application Service (ERAS) publishes monthly statistics before the match and the National Resident Matching Program publishes the match outcomes. We sought to determine whether early ERAS data influences applicant behavior and correlates with match outcomes. Materials and Methods We searched the 2007–2017 ERAS archives for the applicant pool size (PS), the average number of applications per program (AP), and the average number of applications per applicant (AA) in November, before radiology match, and the 2007–2017 National Resident Matching Program archives for the average number of ranked applicants needed to fill each position (ANRA) and the number of unfilled positions (UP) in radiology match. Correlation coefficients were calculated for each pair. Results PS correlated very strongly with AP (r = 0.80, p = 0.001708), UP (r = −0.92, p = 0.000063) and ANRA (r = −0.90, p = 0.000164). UP correlated strongly with ANRA (r = 0.76, p = 0.006349) and AP (r = −0.77, p = 0.005339). A trend to moderate correlation between AP and ANRA (r = 0.58, p = 0.062686) and AA (r = 0.53, p = 0.074395) did not reach statistical significance. There was no correlation between AA and PS in the same (r = −0.05, p = 0.878585) or the following year (r = 0.35, p = 0.297166), and AA and UP in the same (r = 0.13, p = 0.701983) or the following year (r = 0.32, p = 0.336136). Conclusion The real-time data reported by ERAS in November, before match, is a predictor of radiology match outcomes and can be used by all participants to limit their application and recruitment costs. Medical students applying to radiology do not consider either the real-time or historic data when submitting ERAS applications.

Contains fulltext : 194255.pdf (Publisher’s version ) (Open Access) BACKGROUND: Emphysema has considerable variability in its regional distribution. Craniocaudal emphysema distribution is an important predictor of the response to lung volume reduction. However, there is little consensus regarding how to define upper lobe-predominant and lower lobe-predominant emphysema subtypes. Consequently, the clinical and genetic associations with these subtypes are poorly characterized. METHODS: We sought to identify subgroups characterized by upper-lobe or lower-lobe emphysema predominance and comparable amounts of total emphysema by analyzing data from 9,210 smokers without alpha-1-antitrypsin deficiency in the Genetic Epidemiology of COPD (COPDGene) cohort. CT densitometric emphysema was measured in each lung lobe. Random forest clustering was applied to lobar emphysema variables after regressing out the effects of total emphysema. Clusters were tested for association with clinical and imaging outcomes at baseline and at 5-year follow-up. Their associations with genetic variants were also compared. RESULTS: Three clusters were identified: minimal emphysema (n = 1,312), upper lobe-predominant emphysema (n = 905), and lower lobe-predominant emphysema (n = 796). Despite a similar amount of total emphysema, the lower-lobe group had more severe airflow obstruction at baseline and higher rates of metabolic syndrome compared with subjects with upper-lobe predominance. The group with upper-lobe predominance had greater 5-year progression of emphysema, gas trapping, and dyspnea. Differential associations with known COPD genetic risk variants were noted. CONCLUSIONS: Subgroups of smokers defined by upper-lobe or lower-lobe emphysema predominance exhibit different functional and radiological disease progression rates, and the upper-lobe predominant subtype shows evidence of association with known COPD genetic risk variants. These subgroups may be useful in the development of personalized treatments for COPD.

Background The National Board of Medical Examiners (NBME) and the United States Medical Licensing Examination (USMLE) has convened a conference of “key stakeholders” on March 11–12, 2019 to consider reporting the results of the USMLE Step 1 as pass/fail. Discussion While the original purpose of the USMLE Step 1 was to provide an objective basis for medical licensing, the score is increasingly used in residency applicant screening and selection because it is an objective, nationally recognized metric allowing comparison across medical schools in and outside the United States. Excessive reliance on the Step 1 score in the matching process has led to “Step 1 Culture” that drives medical schools to “teach to the test,” increases medical student anxiety, and disadvantages minorities that have been shown to score lower on the USMLE Step 1 examination. The outsize role of the USMLE Step 1 score in resident selection is due to lack of standardization in medical school transcripts, grade inflation, and the lack of class standing in many summative assessments. Furthermore, the numeric score allows initial Electronic Residency Application Service filtering, commonly used by programs to limit the number of residency applications to review. Conclusion The Association of Program Directors in Radiology (APDR) is concerned that pass/fail reporting of the USMLE Step 1 score would take away an objective measure of medical student's knowledge and the incentive to acquire as much of it as possible. Although the APDR is not in favor of the Step 1 exam being used as a screening tool, in the absence of an equal or better metric for applicant comparison the APDR opposes the change in Step 1 reporting from the numeric score to pass/fail.

Rationale: The American Thoracic Society (ATS)/European Respiratory Society defines a positive bronchodilator response (BDR) by a composite of BDR in either forced expiratory volume in 1 second (FEV(1)) and/or forced vital capacity (FVC) greater than or equal to 12% and 200 ml (ATS-BDR). We hypothesized that ATS-BDR components would be differentially associated with important chronic obstructive pulmonary disease (COPD) outcomes. Objectives: To examine whether ATS-BDR components are differentially associated with clinical, functional, and radiographic features in COPD. Methods: We included subjects with COPD enrolled in the COPDGene study. In the main analysis, we excluded subjects with self-reported asthma. We categorized BDR into the following: 1) No-BDR, no BDR in either FEV(1) or FVC; 2) FEV(1)-BDR, BDR in FEV(1) but no BDR in FVC; 3) FVC-BDR, BDR in FVC but no BDR in FEV(1); and 4) Combined-BDR, BDR in both FEV(1) and FVC. We constructed multivariable logistic, linear, zero-inflated negative binomial, and Cox hazards models to examine the association of BDR categories with symptoms, computed tomography findings, change in FEV(1) over time, respiratory exacerbations, and mortality. We also created models using the ATS BDR definition (ATS-BDR) as the main independent variable. Results: Of 3,340 COPD subjects included in the analysis, 1,083 (32.43%) had ATS-BDR, 182 (5.45%) had FEV(1)-BDR, 522 (15.63%) had FVC-BDR, and 379 (11.34%) had Combined-BDR. All BDR categories were associated with FEV(1) decline compared with No-BDR. Compared with No-BDR, both ATS-BDR and Combined-BDR were associated with higher functional residual capacity %predicted, greater internal perimeter of 10 mm, and greater 6-minute-walk distance. In contrast to ATS-BDR, Combined-BDR was independently associated with less emphysema (adjusted beta regression coefficient, −1.67; 95% confidence interval [CI], −2.68 to −0.65; P = 0.001), more frequent respiratory exacerbations (incidence rate ratio, 1.25; 95% CI, 1.03–1.50; P = 0.02) and severe exacerbations (incidence rate ratio, 1.34; 95% CI, 1.05–1.71; P = 0.02), and lower mortality (adjusted hazards ratio, 0.76; 95% CI, 0.58–0.99; P = 0.046). Sensitivity analysis that included subjects with self-reported history of asthma showed similar findings. Conclusions: BDR in both FEV(1) and FVC indicates a COPD phenotype with asthma-like characteristics, and provides clinically more meaningful information than current definitions of BDR.

Rationale and Objectives The Association of Program Directors in Radiology regularly surveys its members regarding issues of importance to support radiology residency programs and their directors. Materials and Methods This is an observational cross-sectional study using two Web-based surveys posed to the Association of Program Directors in Radiology membership in the fall of 2014 (49 items) and the spring of 2015 (46 items) on the subjects of importance to the members, including the Accreditation Council on Graduate Medical Education Milestones, the Non-Interpretative Skills Curriculum, the American Board of Radiology Core Examination, the effect of the new resident testing and program accreditation paradigms on training outcomes, the 2015 Residency Match, the Interventional Radiology/Diagnostic Radiology (IR/DR) Residency, and Program Director (PD)/Program Coordinator resources. Results Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 63rd annual meeting of the Association of University Radiologists. The maximal response rate was 33% in the fall of 2014 and 36% in the spring of 2015. Conclusions PDs believed that the radiology Milestones, now largely implemented, did not affect overall resident evaluation, was not reflective of resident experience, and actually made evaluation of residents more difficult. PDs also felt that although the American Board of Radiology oral examination had been a better test for clinical practice preparedness, their new residents knew at least as much as before. There was little evidence of recall reemergence. The radiology training community saw a drop in residency applicant quality as demonstrated by the United States Medical Licensing Examination scores and clinical rotation grades. Because the new IR/DR Residency positions were to be funded at the expense of the traditional DR positions, the majority of PDs expected a negative effect of the impending IR/DR match on their DR recruitment. PDs were in favor of a unified clinical radiology curriculum similar to the Radiological Society of North America online physics modules.

Transcatheter aortic valve replacement (TAVR) is a lifesaving procedure for many patients high risk for surgical aortic valve replacement. The prevalence of chronic kidney disease (CKD) is high in this population, and thus a very low contrast volume (VLCV) computed tomography angiography (CTA) protocol providing comprehensive cardiac and vascular imaging would be valuable.52 patients with severe, symptomatic aortic valve disease, undergoing pre-TAVR CTA assessment from 2013-4 at Columbia University Medical Center were studied, including all 26 patients with CKD (eGFR30 mL/min) who underwent a novel VLCV protocol (20 mL of iohexol at 2.5 mL/s), and 26 standard-contrast-volume (SCV) protocol patients. Using a 320-slice volumetric scanner, the protocol included ECG-gated volume scanning of the aortic root followed by medium-pitch helical vascular scanning through the femoral arteries. Two experienced cardiologists performed aortic annulus and root measurements. Vascular image quality was assessed by two radiologists using a 4-point scale.VLCV patients had mean (±SD) age 86 ± 6.5, BMI 23.9 ± 3.4 kg/m(2) with 54% men; SCV patients age 83 ± 8.8, BMI 28.7 ± 5.3 kg/m(2), 65% men. There was excellent intra- and inter-observer agreement for annular and root measurements, and excellent agreement with 3D-transesophageal echocardiographic measurements. Both radiologists found diagnostic-quality vascular imaging in 96% of VLCV and 100% of SCV cases, with excellent inter-observer agreement.This study is the first of its kind to report the feasibility and reproducibility of measurements for a VLCV protocol for comprehensive pre-TAVR CTA. There was excellent agreement of cardiac measurements and almost all studies were diagnostic quality for vascular access assessment.

Background Chronic bronchitis (CB) increases risk of COPD exacerbations. We have shown that the St. George's Respiratory Questionnaire (SGRQ) CB definition identifies patients with a similar clinical phenotype as classically defined CB. Whether the SGRQ CB definition is a predictor of future COPD exacerbations is unknown. Methods We analyzed 7,557 smokers with normal spirometry and Global Initiative for Chronic Obstructive Lung Disease stage 1-4 COPD in the Genetic Epidemiology of COPD study with longitudinal follow-up data on exacerbations. Subjects were divided into classic CB+ or classic CB–, using the classic definition. In addition, subjects were divided into SGRQ CB+ or SGRQ CB–. Exacerbation frequency and severe exacerbation frequency were determined in each group. Multivariable linear regressions were performed for exacerbation frequency with either classic CB or SGRQ CB and relevant covariates. Results There were 1,434 classic CB+ subjects and 2,290 SGRQ CB+ subjects. The classic CB+ group had a greater exacerbation frequency compared with the classic CB– group (0.69 ± 1.26 vs 0.36 ± 0.90 exacerbations per patient per year; P Conclusions The SGRQ CB definition identified more subjects at risk for future exacerbations than the classic CB definition. SGRQ CB was at least a similar if not better predictor of future exacerbations than classic CB.

Spirometric Volumes and Breathlessness Across Levels of Airflow Limitation : The COPDGene Study.

BACKGROUND:Eosinophilic airway inflammation in patients with chronic obstructive pulmonary disease (COPD) is associated with exacerbations and responsivity to steroids, suggesting potential shared mechanisms with eosinophilic asthma. However, there is no consistent blood eosinophil count that has been used to define the increased exacerbation risk. OBJECTIVE:We sought to investigate blood eosinophil counts associated with exacerbation risk in patients with COPD. METHODS:Blood eosinophil counts and exacerbation risk were analyzed in patients with moderate-to-severe COPD by using 2 independent studies of former and current smokers with longitudinal data. The Genetic Epidemiology of COPD (COPDGene) study was analyzed for discovery (n=1,553), and the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study was analyzed for validation (n=1,895). Asubset of the ECLIPSE study subjects were used to assess the stability of blood eosinophil counts over time. RESULTS:COPD exacerbation risk increased with higher eosinophil counts. An eosinophil count threshold of 300cells/μL or greater showed adjusted incidence rate ratios for exacerbations of 1.32 in the COPDGene study (95% CI, 1.10-1.63). The cutoff of 300cells/μL or greater was validated for prospective risk of exacerbation in the ECLIPSE study, with adjusted incidence rate ratios of 1.22 (95% CI, 1.06-1.41) using 3-year follow-up data. Stratified analysis confirmed that the increased exacerbation risk associated with an eosinophil count of 300cells/μL or greater was driven by subjects with a history of frequent exacerbations in both the COPDGene and ECLIPSE studies. CONCLUSIONS:Patients with moderate-to-severe COPD and blood eosinophil counts of 300cells/μL or greater had an increased risk exacerbations in the COPDGene study, which was prospectively validated in the ECLIPSE study.

Rationale and Objectives The Association of Program Directors in Radiology (APDR) surveys residents' educational experiences, work responsibilities, and benefits to support radiology residency programs and their directors. Materials and Methods This is an observational cross-sectional study using three Web-based surveys posed to the APDR membership in the spring of 2013 (March 7–29, 2013; 44 items), the fall of 2013 (October 24 to November 15, 2013; 36 items), and the spring of 2014 (March 3–21, 2014; 49 items) on the American Board of Radiology (ABR) Core examination, organization of Clinical Competency Committees (CCCs), fellowship match, and interventional radiology (IR)–diagnostic radiology (DR) training programs. Results Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 60th and 61st annual meetings of the Association of University Radiologists, respectively. The maximal response rate was 35% in the spring 2013, 39% in the fall 2013, and 39% in the spring 2014. Conclusions With the ABR Core examination, radiology educators increasingly included multiple choice questions in teaching conferences. "Boards frenzy" was alive and well. The number of programs with a CCC was growing, chaired primarily by the Program Director (PD), with the most commonly used tool being the rotation evaluation. In view of "fellowship frenzy" in the third year of residency, only a minority of PDs were against a fellowship match in the National Resident Matching Program (NRMP). The majority of respondents replied that the new IR/DR pathway would negatively affect the DR residency.

OBJECTIVE. The purpose of this article is to review the origins of the classic teaching on pulmonary tuberculosis, its evolution in the modern literature, and the evidence that led to its demise. CONCLUSION. Use of molecular epidemiologic techniques that entail DNA finger-printing has led to the discovery that the radiographic appearance of pulmonary tuberculosis does not depend on the time since infection. It has been confirmed that the upper lobe cavitary disease typical in adults is the disease of the immunocompetent host, whereas lower lung zone disease, adenopathy, and effusions, which are uncommon in adults, are the hallmarks of tuberculosis in an immunocompromised host.

The heritability of chronic obstructive pulmonary disease (COPD) cannot be fully explained by recognized genetic risk factors identified as achieving genome-wide significance. In addition, the combined contribution of genetic variation to COPD risk has not been fully explored. We sought to determine: (1) whether studies of variants from previous studies of COPD or lung function in a larger sample could identify additional associated variants, particularly for severe COPD; and (2) the impact of genetic risk scores on COPD. We genotyped 3,346 single-nucleotide polymorphisms (SNPs) in 2,588 cases (1,803 severe COPD) and 1,782 control subjects from four cohorts, and performed association testing with COPD, combining these results with existing genotyping data from 6,633 cases (3,497 severe COPD) and 5,704 control subjects. In addition, we developed genetic risk scores from SNPs associated with lung function and COPD and tested their discriminatory power for COPD-related measures. We identified significant associations between SNPs near PPIC (P = 1.28 X 10(-8)) and PPP4R4/SERPINA1 (P = 1.01 X 10(-8)) and severe COPD; the latter association may be driven by recognized variants in SERPINA1. Genetic risk scores based on SNPs previously associated with COPD and lung function had a modest ability to discriminate COPD (area under the curve, similar to 0.6), and accounted for a mean 0.9-1.9% lower forced expiratory volume in 1 second percent predicted for each additional risk allele. In a large genetic association analysis, we identified associations with severe COPD near PPIC and SERPINA1. A risk score based on combining genetic variants had modest, but significant, effects on risk of COPD and lung function.

Purpose Overweight and underweight conditions are considered relative contraindications to lung transplantation due to their association with excess mortality. Yet, recent work suggests that body mass index (BMI) does not accurately reflect adipose tissue mass in adults with advanced lung diseases. Alternative and more accurate measures of adiposity are needed. Chest fat estimation by routine computed tomography (CT) imaging may therefore be important for identifying high-risk lung transplant candidates. In this paper, an approach to chest fat quantification and quality assessment based on a recently formulated concept of standardized anatomic space (SAS) is presented. The goal of the paper is to seek answers to several key questions related to chest fat quantity and quality assessment based on a single slice CT (whether in the chest, abdomen, or thigh) versus a volumetric CT, which have not been addressed in the literature. Methods Unenhanced chest CT image data sets from 40 adult lung transplant candidates (age 58 ± 12 yrs and BMI 26.4 ± 4.3 kg/m2), 16 with chronic obstructive pulmonary disease (COPD), 16 with idiopathic pulmonary fibrosis (IPF), and the remainder with other conditions were analyzed together with a single slice acquired for each patient at the L5 vertebral level and mid-thigh level. The thoracic body region and the interface between subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) in the chest were consistently defined in all patients and delineated using Live Wire tools. The SAT and VAT components of chest were then segmented guided by this interface. The SAS approach was used to identify the corresponding anatomic slices in each chest CT study, and SAT and VAT areas in each slice as well as their whole volumes were quantified. Similarly, the SAT and VAT components were segmented in the abdomen and thigh slices. Key parameters of the attenuation (Hounsfield unit (HU) distributions) were determined from each chest slice and from the whole chest volume separately for SAT and VAT components. The same parameters were also computed from the single abdominal and thigh slices. The ability of the slice at each anatomic location in the chest (and abdomen and thigh) to act as a marker of the measures derived from the whole chest volume was assessed via Pearson correlation coefficient (PCC) analysis. Results The SAS approach correctly identified slice locations in different subjects in terms of vertebral levels. PCC between chest fat volume and chest slice fat area was maximal at the T8 level for SAT (0.97) and at the T7 level for VAT (0.86), and was modest between chest fat volume and abdominal slice fat area for SAT and VAT (0.73 and 0.75, respectively). However, correlation was weak for chest fat volume and thigh slice fat area for SAT and VAT (0.52 and 0.37, respectively), and for chest fat volume for SAT and VAT and BMI (0.65 and 0.28, respectively). These same single slice locations with maximal PCC were found for SAT and VAT within both COPD and IPF groups. Most of the attenuation properties derived from the whole chest volume and single best chest slice for VAT (but not for SAT) were significantly different between COPD and IPF groups. Conclusions This study demonstrates a new way of optimally selecting slices whose measurements may be used as markers of similar measurements made on the whole chest volume. The results suggest that one or two slices imaged at T7 and T8 vertebral levels may be enough to estimate reliably the total SAT and VAT components of chest fat and the quality of chest fat as determined by attenuation distributions in the entire chest volume.

Radiology instruction is based on the principle that grouped (or massed) repetition of an intellectual activity leads to expertise. The aim of this study was to test the hypothesis that the spaced (or interleaved) method of teaching chest x-ray interpretation is more effective than the massed method.After institutional review board approval was obtained, 40 first- and second-year medical students were randomized into two groups matched by age, gender, and education experience. Both groups saw six examples of 12 common chest radiographic patterns, one grouped, the other scrambled randomly without repeating strings. After a distraction, participants took a multiple-choice test consisting of two cases in each radiographic pattern, one previously shown, one new. Results were analyzed using two-tailed Student's t test of proportion.Comparing interleaved and massed groups, the average overall score was 57% versus 43% (P = .03), the recollection score was 61% versus 47% (P = .03), and the induction score was 53% versus 40% (P = 0.10), respectively. Comparing second- and first-year students, average scores were 67% and 39%, respectively (P.01). First-year students in the interleaved and massed groups scored 55% and 36% (P = .02) in recall and 40% and 28% (P = .10) in induction. Second-year students in the interleaved and massed groups scored 71% and 63% (P = .36) in recall and 74% and 59% (P = .03) in induction.The interleaved method of instruction leads to better results than the massed method across all levels of education. A higher level of medical education improves performance independent of method of instruction.

Rationale and Objectives The Association of Program Directors in Radiology (APDR) conducts an annual survey to monitor and evaluate issues pertaining to radiology residents' educational experiences, work responsibilities, and benefits. Data are used to identify emerging trends and patterns of change to plan and provide resources that support radiology residency programs and their directors. Materials and Methods The APDR Annual Survey Committee selected 59 items for an observational, cross-sectional study using a Web-based survey. Topics of interest included program director satisfaction, resident recruitment, social media, program requirements, curriculum, the new American Board of Radiology exam process, call, and residents-as-teachers programs. All active APDR members (n = 296) were invited to participate in survey between February 20 and March 11, 2011. Results The response rate was 47% (140 of 296). Descriptive results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 59th annual meeting of the Association of University Radiologists. Conclusions Data generated by the annual survey enable the APDR to accrue data pertaining to residents' real-time educational experiences. In 2011, program directors were satisfied with their jobs but not convinced that competency-based program requirements had positive effect on residency training. Programs plan to use the Radiological Society of North America and American Association of Physicists in Medicine Web-based physics training modules. Most radiology programs do not have residents-as-teachers programs, nor do they plan to initiate them. During recruitment, programs use an applicant's location as a proxy for true interest in the program, and interest in the program is important for granting interviews and final ranking. Qualified international medical graduate applicants have access to radiology training in the United States and Canada. Almost half of radiology programs have in-house reading by attending radiologists with residents on call. Residency programs have been slow to embrace social media.

Background: Little is known about the United States diagnosis and burden of pulmonary embolism (PE) in the emergency department (ED), and their evolution over the past decade. We examined nationally representative data to evaluate factors associated with and trends in ED diagnosis of PE. Methods: We conducted a cross-sectional study using National Hospital Ambulatory Medical Care Survey (NHAMCS) data from January 1, 2001 to December 31, 2010. We identified all ED patient visits where PE was diagnosed and corresponding demographic, hemodynamic, testing and disposition data. Analyses were performed using descriptive statistics and multivariable logistic regression. Results: During the study period 988,000 weighted patient visits with diagnosis of PE were identified. Among patients with an ED visit, the likelihood of having a diagnosis of PE per year increased significantly from 2001 to 2010 (odds ratio [OR] 1.091, 95% confidence interval [CI] 1.034-1.152, P = 0.002 for trend) when adjusted for demographic and hospital information. In contrast, when further adjusted for the use of computed tomography (CT) among patients in the ED, the likelihood of having a diagnosis of PE per year did not change (OR 1.041, 95% CI 0.987-1.097, P = 0.14). Overall, 75.1% of patients seen with a diagnosis of PE were hemodynamically stable; 86% were admitted with an in-hospital death rate under 3%. Conclusions: The proportion of ED visits with a diagnosis of PE increased significantly from 2001 to 2010 and this rise can be attributed in large part to the increased availability and use of CT. Most of these patients were admitted with low in-hospital mortality. Keywords: Pulmonary embolism Emergency department Computed Tomography (CT) pulmonary angiography

This report summarizes the efficacy, safety, and feasibility of intracardiac ultrasound (ICUS) and local electrographic-guided pulmonary vein (PV)-left atrial disconnection, including the isolation of common PV trunks accomplished in 170 consecutive patients with atrial fibrillation (AF). A left common PV was found in 43% of patients with AF. During a follow-up of 549 +/- 330 days after ablation, the AF-free survival rate was 80% and comparable in paroxysmal and persistent AF. PV stenosis was detected in only 1 asymptomatic patient, who required no intervention.

Rationale and Objectives The purpose of this study was to develop objective measures of residency call frequency and difficulty, to establish mean values for the northeastern United States, and to test those values for correlation with program size. Materials and Methods A survey questionnaire was sent to 104 radiology residency programs in the northeastern United States. The programs were classified according to number of residents, as small (

Patients with congenital heart disease often require mild sedation for the performance of their examination. If adequate monitoring of systemic oxygen saturation and heart rate is performed, then these patients may be adequately studied by MR imaging. Cardiac examination using spin echo pulse sequences provides morphologic information that allows evaluation of situs, ventricular morphology, and atrioventricular and ventriculoarterial connection. Gradient reversal acquisitions display changes in the size and shape of the atria and ventricles as well as demonstration of intracardiac and extracardiac shunts and abnormal flow across the cardiac valves. This information allows evaluation of the underlying congenital abnormality as well as the pathologic sequelae of the cardiac dysmorphology. Cardiac MR examination is a useful means of minimally invasive diagnosis of congenital heart disease and evaluation of its surgical palliation.

MR imaging is helpful in the management of patients in whom the diagnosis of ARVD or RVOTT is suspected. Careful attention to cardiac rate control will minimize or eliminate ventricular extrasystolic beats during examination, which will improve image quality and confidence in diagnosis. Use of thin-section cine gradient echo acquisition provides a means of identifying regional wall motion abnormalities, characteristic of the regional dysfunction in these diseases. Furthermore, application of spin echo or double inversion recovery imaging may provide visualization of abnormally thin or fat-infiltrated regions of right ventricular free wall myocardium, providing additional diagnostic criteria for the diagnosis of these diseases.

Background: Patients undergoing transcatheter aortic valve replacement (TAVR) often have concomitant severe mitral regurgitation. A portion of these patients are not anatomical candidates for a mitraclip procedure. Transcatheter mitral valve replacement (TMVR) is a promising alternative, but has a

The Association of Program Directors in Radiology (APDR) surveys residents' educational experiences, work responsibilities, and benefits to support radiology residency programs and their directors.This is an observational cross-sectional study using three Web-based surveys posed to the APDR membership in the spring of 2013 (March 7-29, 2013; 44 items), the fall of 2013 (October 24 to November 15, 2013; 36 items), and the spring of 2014 (March 3-21, 2014; 49 items) on the American Board of Radiology (ABR) Core examination, organization of Clinical Competency Committees (CCCs), fellowship match, and interventional radiology (IR)-diagnostic radiology (DR) training programs.Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 60th and 61st annual meetings of the Association of University Radiologists, respectively. The maximal response rate was 35% in the spring 2013, 39% in the fall 2013, and 39% in the spring 2014.With the ABR Core examination, radiology educators increasingly included multiple choice questions in teaching conferences. "Boards frenzy" was alive and well. The number of programs with a CCC was growing, chaired primarily by the Program Director (PD), with the most commonly used tool being the rotation evaluation. In view of "fellowship frenzy" in the third year of residency, only a minority of PDs were against a fellowship match in the National Resident Matching Program (NRMP). The majority of respondents replied that the new IR/DR pathway would negatively affect the DR residency.

Background: There is no noninvasive method to rule out pulmonary embolism when the clinical suspicion for pulmonary embolism is high. We did a prospective observational study to determine the negative predictive value of spiral computed tomography (CT) in this situation. Methods: We performed spiral CT scans of the thorax in consecutive patients with high clinical suspicion of pulmonary embolism with intermediate or low probability ventilation-perfusion scans. Patients with negative or indeterminate spiral CT results had conventional angiography at the discretion of the attending physician. Only patients with positive spiral CT results or positive conventional angiograms were treated. All patients were observed for 6 months for evidence of venous thromboembolic disease. Clinical outcome without treatment or the results of conventional angiography were used as reference standards. False-negative results were defined as a negative spiral CT with a positive conventional angiogram or any diagnosis of venous thromboembolism within 6 months. Results: Among the 103 patients who were studied, spiral CT scans were positive in 22 patients, indeterminate in 10 patients, and negative in 71 patients. Twenty-seven (26%) patients had pulmonary embolism by clinical outcome, including 3 of the 71 patients with negative spiral CT scans and 2 of the 10 patients with indeterminate scans. A negative spiral CT result had a likelihood ratio of 0.12 (95% confidence interval [CI]: 0.04 to 0.35) with a negative predictive value of 96% (95% CI: 88% to 99%). Using conventional angiography only as the reference standard, a negative spiral CT result had a likelihood ratio of 0.08 (95% CI: 0.02 to 0.31) and a negative predictive value of 93% (95% CI: 77% to 98%). Conclusions: Spiral CT has a high negative predictive value for pulmonary embolism and may replace conventional angiography in the workup of pulmonary embolism. Patients with indeterminate spiral CT results should be considered for conventional angiography.

We recently encountered six patients with AIDS and an unusual complication of disseminated infection with Mycobacterium avium-intracellulare, which developed after the initiation of highly active antiretroviral therapy, including protease inhibitors and two new nucleoside analogues. Each patient had a febrile illness after the initiation of therapy and then developed mass lesions containing mycobacterial organisms in various organ systems, including bone, skin, and mesenteric and mediastinal nodes. All these patients suddenly experienced improvement in immunologic status as evidenced by decreasing viral loads and increasing CD4 cell counts. We chose to call this reaction "M. avium-intracellulare reversal syndrome." We describe the radiologic appearance of this unusual manifestation of infection with M. avium-intracellulare in patients with AIDS.New or enlarging lymphadenopathy or unusual musculoskeletal and cutaneous infections in patients with AIDS who are receiving highly active antiretroviral therapy may represent a response of the recovering immune system to a new or previously subclinical infection with M. avium-intracellulare.

RATIONALE AND OBJECTIVES The purpose of this study was to identify practice patterns of extrathoracic imaging in patients newly diagnosed with non-small-cell lung, cancer. MATERIALS AND METHODS The authors retrospectively reviewed the charts of 125 patients (71 men, 54 women; mean age, 67 years) from five hospitals (25 patients each) with newly diagnosed non-small-cell lung cancer. Charts were reviewed for cancer cell type, evidence of metastatic disease, and performance and results of extrathoracic imaging, including computed tomography (CT) and magnetic resonance (MR) imaging of the brain, bone scanning, and abdominal CT. RESULTS Of 125 patients, 77 (62%) underwent extrathoracic imaging. These patients included 64 (64%) of 100 patients with clinical symptoms or laboratory signs of metastatic disease and 13 (52%) of 25 patients with no such indications. Extrathoracic imaging did not differ according to cancer cell type: It was performed for 30 (60%) of 50 patients with squamous cell carcinoma, 26 (60%) of 43 patients with adenocarcinoma, and 16 (73%) of 22 patients with non-small-cell lung cancer that was not further characterized. Brain CT or MR imaging bone scanning, or abdominal CT were performed in only 48%, 39%, and 30% of patients, respectively. Brain CT or MR images or bone scans revealed metastatic disease in seven of 20 and nine of 22 patients with clinical symptoms or laboratory signs of disease, respectively. These examinations revealed disease in four of 40 and two of 27 patients without such symptoms or signs, respectively (P < .05). No significant differences emerged among the practice patterns at the five participating hospitals. CONCLUSION No consensus was found on performance of extrathoracic imaging in patients with newly diagnosed non-small-cell lung cancer.

The volume and severity of pulmonary emphysema in individual lungs were measured by means of quantitative computed tomography (CT) studies in 28 patients (14 women, 14 men, median age 65 yr) who underwent either bilateral (n = 15) or unilateral (n = 13) lung volume reduction surgery (LVRS). Spirometric, total body plethysmographic, and CT data (at TLC and RV) were correlated before and after LVRS. Lung volumes determined by CT correlated well with volumes obtained by total body plethysmography (p0.0001). For individual lungs after LVRS, CT-derived mean lung capacity decreased 13% and residual volume 20% (p0.00001 for each), while mean total functional lung volume (TFLV, defined as the volume of lung with CT attenuation greater than -910 Hounsfield units) increased 9% (p0.01), and the mean ratio of the air space to tissue space volume (V(AS)/V(TS)) decreased more at RV (23%) than at TLC (14%) (p0.0005 for each). In contrast, unilateral LVRS did not affect exhalation from the unoperated lung (2% reduction in RV, p = NS). The magnitude of the postoperative response (CT-derived TLC, RV, TFLV, V(AS)/V(TS)) of each operated lung was comparable for unilateral and bilateral LVRS. Thus, a lung's response to LVRS was independent from that of the contralateral lung. Moreover, postoperative alterations in TFLV and FEV1 correlated significantly (r = 0.80, p0.0001), which suggests that the expansion of functioning tissue may contribute to the mechanism by which LVRS palliates airway obstruction.

The authors present their experience with previously unsuspected carcinoma of the lung detected at preoperative computed tomography (CT) in patients with severe pulmonary emphysema who were scheduled to undergo lung volume reduction surgery.Preoperative chest CT was performed in 148 patients (84 men, 64 women; mean age, 65 years +/- 8 [standard deviation]) with advanced pulmonary emphysema before lung volume reduction surgery. At surgery, an attempt was made to excise any pulmonary nodule considered suspicious for carcinoma at CT.Eighteen pulmonary nodules suspicious for lung cancer were found at CT in 17 (11%) of the 148 patients. Sixteen of these 148 nodules were resected at lung volume reduction surgery. Nine non-small cell carcinomas (adenocarcinoma, n = 4, including three with bronchioloalveolar differentiation; poorly differentiated, n = 3; squamous cell carcinoma, n = 2) were found in eight (5%) patients. Eight of the cancers were stage I, and one was unstaged surgically. Maximum diameters of the cancers ranged between 1.0 and 3.8 cm (median, 1.6 cm). The seven (5%) other resected nodules were all benign.A 5% rate of stage I primary lung cancer in patients selected for lung volume reduction surgery suggests that performance of chest CT in candidates for lung volume reduction surgery is appropriate not only to identify patterns of pulmonary parenchymal destruction but also to search for stage I lung cancer.

Background It is unknown whether the observed increase in computed tomography pulmonary angiography (CTPA) utilization has resulted in increased detection of pulmonary emboli (PEs) with a less severe disease spectrum. Methods Trends in utilization, diagnostic yield, and disease severity were evaluated for 4,048 consecutive initial CTPAs performed in adult patients in the emergency department of a large urban academic medical center between 1/1/2004 and 10/31/2009. Transthoracic echocardiography (TTE) findings and peak serum troponin levels were evaluated to assess for the presence of PE-associated right ventricular (RV) abnormalities (dysfunction or dilatation) and myocardial injury, respectively. Statistical analyses were performed using multivariate logistic regression. Results 268 CTPAs (6.6%) were positive for acute PE, and 3,780 (93.4%) demonstrated either no PE or chronic PE. There was a significant increase in the likelihood of undergoing CTPA per year during the study period (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.04–1.07, P

The Association of Program Directors in Radiology (APDR) conducts an annual survey to monitor and evaluate issues pertaining to radiology residents' educational experiences, work responsibilities, and benefits. Data are used to identify emerging trends and patterns of change to plan and provide resources that support radiology residency programs and their directors.The APDR Annual Survey Committee selected 59 items for an observational, cross-sectional study using a Web-based survey. Topics of interest included program director satisfaction, resident recruitment, social media, program requirements, curriculum, the new American Board of Radiology exam process, call, and residents-as-teachers programs. All active APDR members (n = 296) were invited to participate in survey between February 20 and March 11, 2011.The response rate was 47% (140 of 296). Descriptive results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 59th annual meeting of the Association of University Radiologists.Data generated by the annual survey enable the APDR to accrue data pertaining to residents' real-time educational experiences. In 2011, program directors were satisfied with their jobs but not convinced that competency-based program requirements had positive effect on residency training. Programs plan to use the Radiological Society of North America and American Association of Physicists in Medicine Web-based physics training modules. Most radiology programs do not have residents-as-teachers programs, nor do they plan to initiate them. During recruitment, programs use an applicant's location as a proxy for true interest in the program, and interest in the program is important for granting interviews and final ranking. Qualified international medical graduate applicants have access to radiology training in the United States and Canada. Almost half of radiology programs have in-house reading by attending radiologists with residents on call. Residency programs have been slow to embrace social media.

Imaging is valuable in determining the presence, extent, and severity of myocardial ischemia and the severity of obstructive coronary lesions in patients with chronic chest pain in the setting of high probability of coronary artery disease. Imaging is critical for defining patients best suited for medical therapy or intervention, and findings can be used to predict long-term prognosis and the likely benefit from various therapeutic options. Chest radiography, radionuclide single photon-emission CT, radionuclide ventriculography, and conventional coronary angiography are the imaging modalities historically used in evaluating suspected chronic myocardial ischemia. Stress echocardiography, PET, cardiac MRI, and multidetector cardiac CT have all been more recently shown to be valuable in the evaluation of ischemic heart disease. Other imaging techniques may be helpful in those patients who do not present with signs classic for angina pectoris or in those patients who do not respond as expected to standard management. The ACR Appropriateness Criteria ® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

In a patient with acute respiratory illness (cough, sputum production, chest pain, and/or dyspnea), the need for chest imaging depends on the severity of illness, age of the patient, clinical history, physical and laboratory findings, and other risk factors. Chest radiographs seem warranted when one or more of the following are present: ageor = 40; dementia; a positive physical examination; hemoptysis; associated abnormalities (leukocytosis, hypoxemia); or other risk factors, including coronary artery disease, congestive heart failure, or drug-induced acute respiratory failure. Chest CT may be warranted in complicated cases of severe pneumonia and in febrile neutropenic patients with normal or nonspecific chest radiographic findings. Literature on the indications and usefulness of radiologic studies for acute respiratory illness in different clinical settings is reviewed.

The purpose of this study was to correlate the severity and location of aortic valve calcifications, as an incidental finding at chest CT of elderly persons, with pressure gradients across the valve.One hundred fifteen subjects who were 60 years old or older and who showed aortic valve calcification on chest CT (5-mm reconstructed section width, no IV contrast material) and who had also undergone transthoracic echocardiography within 3 months of the CT examination were identified retrospectively. Aortic valve calcification scores (Agatston and volumetric) and subjective calcification pattern scores (based on a 9-point scale) were calculated and correlated with echocardiographic gradients.Thirty patients (26%) (median age, 81 years) were identified who showed an increased pressure gradient across the aortic valve at echocardiography. Eighty-five subjects (74%), including 30 age-matched but otherwise randomly selected control subjects, showed no increase in pressure gradient. The severity of aortic valve calcification was greater for the 30 subjects with an increased gradient than for the control subjects (p0.0001). Increased mean and peak gradients across the aortic valve correlated with the subjective scores for aortic valve calcification (r = 0.69 and 0.65, respectively; p0.0001), with Agatston scores (r = 0.76 and 0.70, respectively; p0.0001), and with volumetric scores (r = 0.78 and 0.73, respectively; p0.0001). In terms of specific commissures, the greatest correlation with mean and peak gradients was for peripheral left-posterior commissural calcification (r = 0.71 and 0.65, respectively; p0.0001) and central right-left commissural calcification (r = 0.69 and 0.66, respectively; p0.0001).The severity of aortic valve calcifications on chest CT, as assessed either subjectively or objectively, correlated with increased pressure gradients across the aortic valve, particularly for calcification of the peripheral left-posterior commissure and the central right-left commissure. These results indicate that the severity and location of aortic valve calcifications on chest CT are associated with an increased pressure gradient across the aortic valve.