Christian W. Cox

National Ultrasound Curriculum for Medical Students

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

Improvement in Quality of Life after Therapy for Mycobacterium abscessus Group Lung Infection. A Prospective Cohort Study.

RATIONALE Mycobacterium abscessus group lung infection is characterized by low cure rates. Improvement in quality of life may be a reasonable treatment goal. OBJECTIVES The objective of this study was to evaluate change in quality of life in response to therapy, predictors of improvement in quality of life, and association of quality of life with traditional outcome measures. METHODS Forty-seven patients were treated for Mycobacterium abscessus group lung infection (including one with Mycobacterium chelonae) and were followed prospectively for 2 years between December 2009 and May 2012. St. Georges Respiratory Questionnaire (SGRQ) was administered, chest computed tomography (CT) imaging was carried out, and culture data were collected at multiple time points. Predictors of improvement in the SGRQ total score greater than or equal to a minimal clinically important difference (MCID) at 12 months were evaluated. MEASUREMENTS AND MAIN RESULTS Patients were 85% female and 94% white, with a mean age of 65 years. Nine (20%) had a genetic diagnosis of cystic fibrosis (none F508del homozygous). Coinfection with Mycobacterium avium complex occurred in 28% and Pseudomonas in 26%. Chest CT imaging universally indicated bronchiectasis and nodules; 51% had lung cavities. Treatment included a mean of 17 months of antibiotics, and lung resection in 34%. Seventeen patients with M. avium complex (36%) and one with Mycobacterium kansasii were treated for coinfection. The mean SGRQ total score (SD) at baseline was 35 (20). At all follow-up time points, the mean SGRQ total score (SD) was significantly lower (better) than at baseline: 27 (17) at 3 months, P < 0.01; 27 (19) at 6 months, P < 0.01; 27 (20) at 12 months, P < 0.01; and 30 (22) at 24 months, P = 0.02. At 12 and 24 months, respectively, 60% and 56% had improvement greater than or equal to the MCID in SGRQ total score. Improvement greater than or equal to the MCID at 12 months was positively associated with a history of respiratory exacerbation, isolate susceptible to imipenem-cilastatin, and lung resection surgery, and negatively associated with nodules >4 mm in diameter on chest CT imaging, but these associations were not statistically significant in multivariable analysis. At 24 months, 16 patients (48%) with complete data were culture negative for 1 year and had discontinued M. abscessus group treatment. CONCLUSIONS Quality of life was a sensitive indicator of treatment response and has the potential to be a useful parameter to guide treatment.

ACR Appropriateness Criteria Blunt Chest Trauma

Imaging is paramount in the setting of blunt trauma and is now the standard of care at any trauma center. Although anteroposterior radiography has inherent limitations, the ability to acquire a radiograph in the trauma bay with little interruption in clinical survey, monitoring, and treatment, as well as radiographys accepted role in screening for traumatic aortic injury, supports the routine use of chest radiography. Chest CT or CT angiography is the gold-standard routine imaging modality for detecting thoracic injuries caused by blunt trauma. There is disagreement on whether routine chest CT is necessary in all patients with histories of blunt trauma. Ultimately, the frequency and timing of CT chest imaging should be site specific and should depend on the local resources of the trauma center as well as patient status. Ultrasound may be beneficial in the detection of pneumothorax, hemothorax, and pericardial hemorrhage; transesophageal echocardiography is a first-line imaging tool in the setting of suspected cardiac injury. In the blunt trauma setting, MRI and nuclear medicine likely play no role in the acute setting, although these modalities may be helpful as problem-solving tools after initial assessment. 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.

State of the Art: Imaging of Occupational Lung Disease

Imaging of occupational lung disease, often perceived as a static discipline, continues to evolve with changes in industry and imaging technology. The challenge of accurately identifying an occupational exposure as the cause of lung disease demands a team approach, requiring integration of imaging features with exposure type, time course, and severity. Increasing use of computed tomography has demonstrated that specific occupational exposures can result in a variety of patterns of lung injury. The radiologist must understand the spectrum of expected imaging patterns related to known occupational exposures and must also recognize newly described occupational exposure risks, often related to recent changes in industrial practices.

The dark lymph node sign on magnetic resonance imaging: a novel finding in patients with sarcoidosis.

Purpose: The purpose of this study was to describe a characteristic magnetic resonance imaging (MRI) appearance of lymphadenopathy in sarcoidosis—the dark lymph node sign (DLNS)—and to determine its prevalence in a retrospective review of cardiopulmonary MRI examinations obtained in patients with sarcoidosis. Materials and Methods: Fifty-one adult patients with a clinical history of sarcoidosis were evaluated with thoracic MRI during a 15-month span; 29 patients were men, and 22 patients were women. The average age of patients was 53.7±11.2 years. Patients were considered to have the DLNS on MRI if mediastinal or hilar lymph nodes demonstrated internal low intensity with a peripheral circumferential rim of hyperintensity (relative to paraspinal muscle) on post–gadolinium volume-interpolated 3-dimensional gradient echo (3D-GRE/VIBE) and fat-saturated T2-weighted fast spin echo (T2-FSE/BLADE) sequences. Univariate analyses and a logistic regression were used to determine how variables of interest related to the DLNS. Results: Of the 51 patients with sarcoidosis, 49% (25 patients) demonstrated the DLNS. Nodal calcification was present on computed tomography in 45.7% (16/35) of patients with computed tomography scans obtained within 90 days of MRI. The DLNS sign was not more common in those with nodal calcification. When the DLNS occurred in conjunction with calcified nodes, the extent of hypointensity on MRI was not strictly limited to the calcified portions of the lymph node in 71.4% (5/7) of such cases. Conclusions: The DLNS is commonly present on MRI examinations of patients with sarcoidosis, occurring in approximately half of the participants in our study.

Clinical Predictors of a Diagnosis of Common Variable Immunodeficiency-related Granulomatous-Lymphocytic Interstitial Lung Disease

RATIONALE Granulomatous-lymphocytic interstitial lung disease (GLILD) has emerged as a major cause of morbidity in patients with common variable immunodeficiency (CVID). While GLILD is among the most serious noninfectious pulmonary complications of CVID, risk factors for this condition have not been reported. OBJECTIVES To identify clinical, physiologic, and serologic risk factors for GLILD in adults with CVID. METHODS Of 345 consecutive adult patients with CVID, we identified 34 in the National Jewish Health research database who had a radiographic-pathologic diagnosis of GLILD evaluated between 2002 and 2014. Each case was age and sex matched to 52 CVID control subjects. We used logistic regression to determine independent predictors of GLILD. A mixed effects model was used to estimate the longitudinal change in percent predicted FVC. MEASUREMENTS AND MAIN RESULTS The mean time from CVID diagnosis to GLILD detection was 7.8 years. Compared with matched control subjects, cases were more likely to have a history of autoimmune cytopenia, hypersplenism, polyarthritis, lower marginal zone and switched memory B cells, and restrictive lung function. Multivariate analysis revealed that hypersplenism (odds ratio [OR], 24; 95% confidence interval [CI], 4.5-179.1), polyarthritis (OR, 19; 95% CI, 2.3-206.8), and percent predicted FVC (OR, 0.93; 95% CI, 0.87-0.98) were independently associated with the development of GLILD. The rate of change of percent predicted FVC (slope, P = 0.48) did not vary significantly in patients with GLILD over a mean follow-up of 7 years after diagnosis. CONCLUSIONS Hypersplenism and polyarthritis are strong risk factors for GLILD in patients with CVID. Percent predicted FVC remained stable over time in patients with GLILD.

Medical imaging in occupational and environmental lung disease.

Purpose of review The purpose of this review is to provide an up-to-date summary of developments in medical imaging in the diagnosis, surveillance, treatment, and screening of occupational and environmental lung diseases, focusing on articles published within the past 2 years. Recent findings Many new exposures resulting in lung disease have been described worldwide; medical imaging, particularly computed tomography (CT), is often pivotal in recognition and characterization of these new patterns of lung injury. Chest radiography remains important to surveillance studies tracking the long-term evolution of disease and effectiveness of air quality regulation. Finally, studies are proving the utility of screening with low-dose CT, and technical advances offer the prospect of further CT dose reduction with ultra-low-dose CT. Summary In understanding the best practices and new developments in medical imaging, the occupational and environmental medicine clinician can optimize diagnosis and management of related lung diseases.

Andragogic Approaches to Continuing Medical Education

C onsider two very different approaches to radiology continuing medical education (CME) meetings. At meeting number one, radiologists receive a program book, determine which lectures they are interested in attending, and move from room to room, witnessing a succession of instructor-generated presentations. All decisions about what is taught, how it is taught, and how learning is assessed are made by the instructors, and learners function in a largely passive role, simply listening to what the speakers have to say. The attendees are there primarily because they need to receive a certain number of CME credits each year. At meeting number two, the curriculum, instructional methods, and assessment techniques are largely learner generated. Radiologists draw on their own clinical experiences to formulate questions or design educational projects. The instructors help participants accomplish their goals, promoting collaboration between peers. Learners attend not primarily because they want to earn CME credits but because they have specific questions, the answers to which they believe will help them do their work better. At meeting number one, only one person does all the talking, but at meeting number two, multiple people in the room share their questions and suggestions.

Embracing the Unknown in Radiology Education

Most radiology education— especially the learning that takes place around high-stakes tests such as the American Board of Radiology exams—is focused on the known. The learner or candidate may not know the answer to a particular question, but the entire enterprise is based on the presumption that someone—an expert in the field, a faculty member, or an examination question writer—does. In the setting of the known, the learner’s objective is generally straightforward—to anticipate what the teachers know, or at least what they think they know. In theory, every well-written multiple-choice question has one correct response and several incorrect ones, often referred to as “distractors,” and the best learners are the ones who ferret out the correct responses most reliably. We believe that this model of education—focusing on the known—has important limitations that deserve careful exploration. We’d all agree that many questions have correct answers and that knowing the right from the wrong has clear benefit in many situations. In fact, knowing the right answer

Coaching: A key model of leadership

There are two principal ways to fall short. One is to fail at what we attempt. The other is to fail to attemptwhat really needs to be done. Much of the discussion around leadership today represents a failure of the second type.We thinkweknow what leadership needs to be and criticize ourselves and others when we fail to deliver on it. In fact, however, the real problem with much leadership education today is a mismatch between needs and leadership models. A defective model of leadership is the leader as commander. Many people assume that leaders, almost by definition, know what needs to be done and how it should be done and simply assign other people the task of doing it. When things don’t work out, such leaders say to themselves, “If only thesepeoplewoulddo exactly what I tell them, everything would work out fine.” The major problem with this model is its failure to grasp the full extent of what leaders cannot know. Most organizations as sprawling as a radiology department, a hospital, or a health systemare simply too complex for one individual to understand in depth. The decisions to bemade on a daily basis number at least in the hundreds, perhaps the thousands, and no single leader can be sufficiently informed, let alone in the right place at the right time, to make them. At some point, colleagues must make important decisions without their leader’s input. Another defective model of the leader is that of mentor. Mentor was an experienced andwise counselor inwhose care the Greek hero Odysseus left his young son Telemachus when he departed Ithaca to fight in the Trojan War. In contemporary terms, a mentor is someone who helps guide a more junior colleague’s development and career.