Sandra A. A. Oldham

Clinical Presentation and Outcome of Patients with HIV Infection and Tuberculosis Caused by Multiple-Drug-resistant Bacilli

OBJECTIVE To determine the clinical manifestations of patients with human immunodeficiency virus (HIV) infection and tuberculosis caused by multiple-drug-resistant bacilli compared with those with single-drug-resistant or susceptible bacilli. DESIGN Descriptive, case-control, and cohort studies. SETTING A large urban teaching hospital. PATIENTS Sixty-two patients with tuberculosis caused by multiple-drug-resistant bacilli (cases) and 55 patients with tuberculosis caused by single-drug-resistant or susceptible bacilli (controls). MEASUREMENTS Characteristics of clinical presentation, radiographs, pathologic abnormalities, antituberculosis treatment, and clinical course. RESULTS Twenty cases (32%) had concomitant pulmonary and extrapulmonary disease at presentation compared with 9 controls (16%; odds ratio, 2.4; 95% CI, 1.0 to 5.9). More cases had alveolar infiltrates (76%; odds ratio, 3.6; CI, 1.2 to 11.4), interstitial infiltrates with a reticular pattern (67%; odds ratio, 7.8; CI, 1.0 to 83.5), and cavitations (18%; odds ratio, 6.6; CI, 0.8 to 315.3) on initial chest radiographs compared with controls (49%, 19%, and 3%, respectively). Pathologic specimens from cases showed extensive necrosis, poor granuloma formation, marked inflammatory changes with a predominance of neutrophils, and abundant acid-fast bacilli. Twenty-five cases received two or more effective antituberculosis drugs for more than 2 months. Only 2 cases had three consecutive negative cultures for Mycobacterium tuberculosis; one patient died within 1 day of the last negative culture, and the other had positive cultures 496 days later. The remaining 23 cases had persistently or intermittently positive cultures despite therapy. The clinical course of these cases suggested overwhelming miliary tuberculosis with involvement of the lungs (77%), pleura (15%), stool (34%), meninges (13%), bone marrow (16%), blood (10%), lymph nodes (10%), and skin (8%). The median survival time was 2.1 months for cases compared with 14.6 months for controls (P = 0.001, log-rank test). CONCLUSIONS Tuberculosis caused by multiple-drug-resistant bacilli in patients with HIV infection is associated with widely disseminated disease, poor treatment response with an inability to eradicate the organism, and substantial mortality.

The next accreditation system in radiology: A report from the APDR residency structure committee

In a move to emphasize the educational outcomes of training programs, the ACGME has created the Next Accreditation System (NAS). The stated goals of NAS include aiding the ACGME in the accreditation of programs based on educational outcome measures, decreasing program burdens associated with the conventional process-based approach to ACGME accreditation, allowing good programs to innovate while enabling struggling programs to steadily improve, and providing public accountability for outcomes. Diagnostic radiology is among the first group of specialties to undergo NAS implementation and began operating under the NAS in July 2013. This article describes the various components of the NAS and explains the new elements, including the clinical learning environment review program, the milestones, the clinical competency committee, and the self-study visits.

CT imaging of complications of catheter ablation for atrial fibrillation.

The complication rate following radiofrequency catheter ablation for atrial fibrillation is low (<5%). Complications include pericardial effusion, cardiac tamponade, pulmonary vein stenosis, oesophageal ulceration or perforation, atrio-oesophageal fistula formation, stroke/transient ischaemic attack, phrenic nerve injury, haematoma at the puncture site, and femoral arteriovenous fistula. Among available imaging tools, computed tomography (CT) can be very useful in diagnosing complications of the procedure, particularly in the subacute and delayed stages after ablation. This review illustrates CT imaging of several of the common and uncommon complications of radiofrequency catheter ablation.

ICU chest radiographs - ICU calamities: evaluation of the portable chest radiograph.

Familiarity with anatomy and anatomic variants, with tubes and catheters and their correct positioning, as well as complications of these positionings, is critical for the radiologist interpreting plain film radiographs taken in the intensive care unit.

Kaposi sarcoma in a renal transplant patient

The radiographic abnormalities of primary Kaposis sarcoma of the lung in a patient with a renal transplant are reported. The findings are similar to other malignancies and infections that are well recognized in the renal transplant population. In the appropriate clinical setting, the radiologist should consider the diagnosis of Kaposis sarcoma even in the absence of cutaneous lesions as reducing immunosuppression can be curative therapy.

THE RADIOLOGY OF THE THORACIC MANIFESTATIONS OF AIDS

The thoracic manifestations of AIDS have undergone a gradual metamorphosis, partly due to more awareness about the disease leading to earlier diagnoses and partly due to the fact that research has produced more effective prophylaxis as well as treatment for these patients. Many patients now demonstrate partial or complete clinical response which prolongs the length and quality of life of individuals positive for the Human Immunodeficiency Virus (HIV+). Also, with the large number of infected individuals coming to medical attention, and the years of experience in diagnosing and treating these AIDS patients, we now recognize not only the usual but also less usual manifestations of thoracic illnesses in AIDS, including infections, non-infectious diseases such as HIV associated Lymphocytic Interstitial Pneumonia and the neoplasms associated with AIDS. A section will be devoted to HIV infection in children. We will finish the article with a discussion of the current role of Nuclear Medicine in the diagnosis of HIV associated thoracic diseases. These topics are the subject of this article.

Fundamentals course for 1st-year radiology residents

RATIONALE AND OBJECTIVES The authors set out to provide 1st-year residents with basic knowledge to make conferences more useful, to make their knowledge more uniform, and to assess their competency to begin night call. MATERIALS AND METHODS Faculty taught three afternoon sessions a week in subspecialty areas of radiology, including physics, during the 1st 6 months of residency. Material selected was believed to be essential for the understanding of that subspecialtys didactic lecture series. Emphasis was also placed on diagnoses residents would be expected to make once they began taking night call. Material was presented through lectures, images, and unknown cases. An examination was administered at the end of the course. Residents were allowed to begin night call only after completing the course and passing the final examination. RESULTS All 1st-year residents completed the course and passed the examination. Their scores ranged from 70% to 83.3%. CONCLUSION Residents liked the course and reported feeling ready to begin call. Faculty reported the residents who completed the course were more knowledgeable prior to formal rotations than residents from previous years who had not taken the course.

Developing a Job Description for a Vice Chair of Education in Radiology: The ADVICER Template.

RATIONALE AND OBJECTIVES The newly formed Alliance of Directors and Vice Chairs of Education in Radiology (ADVICER), a group within the Alliance for Clinician Educators in Radiology, identified an acute need for a generic job description template for Vice Chairs of Education in Radiology, a role that is being developed in many academic Departments of Radiology. Eighty-three percent of current members who responded to a survey had no detailed job description, and over half had no job description at all. Having a comprehensive and detailed job description is vital to developing this key position. MATERIALS AND METHODS Using the results of a survey sent to ADVICER members and seven Education Vice Chair job descriptions provided by members, the authors developed a detailed job description encompassing all potential elements of this position. RESULTS Only 17% of survey respondents had a detailed job description. The role of an Education Vice Chair varies significantly between institutions in its scope and level of responsibilities. The resultant generic job description that was devised is intended to provide a template that would be modified by the candidate or the Department Chair. It is unlikely that any one individual would perform all the described activities. CONCLUSIONS ADVICER has developed a comprehensive, flexible job description for Vice Chair of Education in Radiology that can be adapted by institutions as appropriate. It can be downloaded from http://aur.org/ADVICER/.

Resident Education in the Radiological Sciences: What Now?

OBJECTIVE With the dizzying changes in the rapidly evolving profession of radiology, the structure of resident education in the associated sciences of imaging, physics, radiobiology, and radiation effects must be reevaluated continually. What roles do these basic radiologic sciences play in bolstering the neophyte radiologist on a career of patient care? How should we define the spectrum of material that should be learned? How should that spectrum be taught? Who decides these things? With the impending changes in the radiology board certification process, questions have been raised as to how these changes will affect education in a residency program. Should the basic science curriculum be enhanced or scaled back? With the emphasis on practical applied physics, what is considered old school and what is new school material? CONCLUSION This article describes one approach adopted by a large residency program to address these issues.

Beyond Metastatic Disease: A Pictorial Review of Multinodular Lung Disease With Computed Tomographic Pathologic Correlation

Multinodular lung disease is routinely encountered on chest computed tomography (CT). Pulmonary nodules may be categorized as perilymphatic, random, or centrilobular, based on their CT distribution. Recognition of the pattern of distribution allows the differential diagnosis to be narrowed to a few common diseases. This review illustrates the CT appearance and provides a practical differential diagnosis of each pattern of nodules.