September EVMS Journal Competition Articles

Thoracic Imaging - It"s September and time for the 3rd set of articles! This month, we will focus on some basics.

Current Therapeutic and Monitoring Devices in the Chest

AJR - Chest Radiography in the ICU part 1; Airway, Enteric, Pleural Tubes

AJR - Chest Radiography in the ICU Part 2; Cardiovascular Lines and other Devices

Pulmonary TB - Role of the Radiologist

August EVMS (not official) Journal Club Quiz!

Welcome to the 2nd EVMS (not official) quiz. Remember if you are an EVMS resident to email your answers to the quiz master. Non residents can DM your answers to @robsradiology on Twitter.

1. Most correct statement regarding Acute Mesenteric Ischemia

A. The mortality rate on average is 23.2%
B. Typical patient is male aged 72 and complains of preprandial pain
C. Typical patient is female over 60 with postprandial pain
D. Chronic mesenteric ischemia and mesenteric arterial thrombosis are easily distinguished from each other

2. Severity of injury in acute mesenteric ischemia  depends on

A. Extent of reduction in blood flow
B. Number of vessels involved
C. Duration of ischemia and development of collaterals
D. All of the above.

3. Filling defect in the SMA with mild enlargement, this is most consistent with

A. Mesenteric arterial embolism
B. Mesenteric arterial thrombosis
C. Mesenteric Venous Thrombosis
D. Nonocclusive Mesenteric Ischemia (NOMI)

4. Paper thin wall

A. Associated with excellent outcomes.
B. Specific finding for NOMI
C. A finding associated with irreversible ischemia
D. All of the above.

5. Shearing injuries are:

A. Commonly found in ascending colon, mid jejunum, and 3rd portion of the duodenum injuries
B. Commonly found at places such as injury at the ileocecal valve
C. Both of the above
D. None of the above.

6. Pneumoperitoneum

A. Always associated with blunt bowel injury
B. Most commonly seen in the setting of 2nd portion duodenal perforation.
C. Can be seen in the setting of chest tube placement.
D. Can be seen in the setting of extraperitoneal Bladder rupture

7. Free fluid

A. Can be a normal finding in 5% of men.
B. The fluid when normal is found in Morrison's pouch
C. Even hyperattenuating free fluid should be considered physiologic in premenopausal woman
D. Free intraperitoneal fluid is the most sensitive sign of bowel injury, especially when hyperattenuating fluid is present.

8. A 2 cm long segment of bowel wall thickening are found in the jejunum

A. 90% specificity and 55-75% sensitivity for acute bowel injury
B. Finding associated with need for revascularization
C. Likely related to shock bowel.
D. In association with hyperattenuation on noncontrasted images, this is a good sign for reperfusion

9. Ovarian Torsion would more likely be diagnosed in a:

A. 15 yo Male
B. 73 yo female radiologist
C. 3 yo girl
D. 25 yo female astrophysicist

10. Which statement is true regarding ovarian torsion

A. The ovary is often small especially less than 3 cm
B.  Endometriosis increases the likelihood of ovarian torsion
C.  1st trimester pregnancy is a risk factor for ovarian torsion
D.  String of Pearls sign increases the sensitivity of ultrasound

11. In regards to gallbladder torsion, which statement is true

A. Ectopic location of the GB with anterior and inferior displacement can be seen
B. Majority of the patients are larger BMI, forty, and fertile
C. Cholelithiasis is strongly associated with this disease
D. Porcelain gallbladder is commonly seen

12. Which statement is false regarding renal transplant torsion

A. Short renal transplant ureteral length increases the risk of torsion
B.  Lack of postoperative adhesions because of steroid therapy increases the risk of torsion
C. Ascites increases the risk for torsion
D. Doppler finding includes increased peak systolic velocities or reversal of diastolic flow


Bonus
"The dreams in which I'm dying are the best I've ever had"

A. Let it be - The Beatles
B. Ana Ng - They Might be Giants
C. Please, Please, Please, Let Me Get What I Want - The Smiths
D. Mad World - Tears for Fears

The ANSWERS! for July Quiz

Thank you very much for participating. If you played, you are a winner in my book. Congratulations to Dr. Andrews for the top score and Drs Dey, Aggarwal and Bonney for a tie at 2nd place! There will be multiple more chances to take away the lead in the coming months. Below are the answers with some explanation.

1. D. Per the article on uncommon manifestations of intervertebral disc pathologic conditions -  "Massive lumbar herniations have been defined by some authors as lumbar disk herniations occupying greater than 50% of the spinal canal at axial imaging... the findings in the literature suggest that size alone is not a rational surgical indication, particularly if the symptoms are limited to sciatica or are improving... massive disk herniations have been shown to decrease in size to a greater degree than smaller herniations" 

2. B. Per the above article - "A discal cyst, also referred to as a disk cyst, is a rare condition defined as the communication of an intraspinal extradural cyst with an intervertebral disk"

3. C. Per the above article - These giant thoracic disk herniations are often densely calcified (∼95%) and tend to erode the dura...For symptomatic thoracic disk herniations, women in the 3rd to 5th decades are most often affected...Two-thirds of symptomatic thoracic disk herniations that require surgery are located between T8 and T11

4. D. Per the above article - These giant thoracic disk herniations are often densely calcified (∼95%) and tend to erode the dura...Formation of an intradural disk herniation requires a perforation of the anulus, the posterior longitudinal ligament, and the dura...A calcified disk remnant or osteophytic spur can cause a dural defect, the resultant CSF leak, and the clinical manifestations of CSF hypotension

5. B. Per the article Imaging Characteristics of Bone Graft Materials - Osteoinduction is the process through which pluripotential mesenchymal cells are recruited from the surrounding tissue and differentiate into osteoblasts. 

6. C. Per the above article - Allografts (cadaveric bone transplants) are popular substitutes for autografts but provide mainly an osteoconductive matrix that lacks osteoinductive properties

7. A. Per the above article - In the immediate postoperative period, allo-grafts have signal hypointensity on both T1- and T2-weighted MR images. 

8. A. Per the above article - Graft combinations are often used to obtain both osteoconductive and osteoinductive properties. Allografts may be mixed with autologous platelet-rich plasma, a concentration of human platelets in a small volume of plasma, which encourages osteoinduction by supplying fundamental growth proteins that are secreted by the platelets and that initiate wound healing.

9. A. Per the article - Acute Shoulder Trauma: What the Surgeon Wants to Know - All fractures not meeting the numeric criteria for displacement or angulation are classified as one-part fractures, regardless of the actual number of fracture fragments or the degree of comminution. 

10. D. Per the above article - the risk increases further when the spur of bone derived from the medial metaphyseal cortex that remains attached to the anatomic head (the medial metaphyseal segment) is shorter than 8 mm or displaced more than 2 mm, implying that the medial periosteum is disrupted. The combination of anatomic neck fracture with a short and displaced medial metaphyseal segment yields a positive predictive value of 97% for ischemia

11. C. Per the above article - concomitant rotator cuff tears are more common in elderly individuals... Although rotator cuff tear is less common in young patients...

12. C.  Per the above article - Type VI fractures are often not reconstructible and are treated nonsurgically to preserve the remaining soft-tissue supports.

Bonus: C. This is tricky - but the key is "according to no one but the test giver". D is automatically out as it is not about NYC at all. A and B are commonly found in many people's lists of best songs about NY - google and see. But I can't find C on any of these lists including wikipedia's rather exhaustive list of songs about NY. Balloon man makes references to 6th Ave, Bryant Park, jumping of the Empire State etc. I tried to help by putting a rick roll in the New York New York link.

EVMS Journal Contest Quiz July 2018

Inaugural Quiz - If you are an EVMS radiology resident - email me your answers. If you are not and want to play to be the best nonresident - DM me at twitter @robsradiology

1. At the L4-L5 level, there is a disc herniation which involves greater than 50% of the canal on axial imaging...

a. OMG... - Call the Neurosurgeon stat and tell him/her to get the scalpel ready
b. Get the priest on the line, this is horrible
c. Whatever, surgery tomorrow, next week, whenever - it is ok so long it is eventually cut out
d. calm down padawan, it is okay, the vast majority will shrink on their own

2. If I say "there is an intraspinal extradural cyst which communicates with an intervertebral disc, I am describing a...

a. Synovial cyst
b. Discal cyst
c. Paraovarian cyst
d. Epidermoid cyst

3. Symptomatic Thoracic Disc

a. Commonly found in 65 yo men
b. Most commonly seen at T2-T3 or T3-T4
c. Giant disc herniations are commonly calcified
d. Cord infarcts are common.

4. Which of these may have a dural tear:

a. Intradural disc herniation
b. Giant calcified thoracic disc
c. Disc osseous spicule
d. All of the above

5.  Process through which pluripotential mesenchymal cells are recruited from surrounding tissue and differentiate into ostoblasts

a. Osteoconduction
b. Osteoinduction
c. Osteogenesis
d. Osteosynthesis

6. Which of these is false regarding allografts

a. Balance of osteolysis and osteogenesis must be present for adequate graft incorporation
b. Can be an in vivo antibiotic delivery system
c. It has osteoinductive properties
d. Can be used for onlay graft

7. MRI obtained immediately after allograft placement is low on T1 and T2

a. Don't worry, this is a normal initial finding
b. Call the orthopedic surgeon and inform him/her that the graft will fail
c. Call the orthopedic surgeon and recommend follow up in 3 weeks
d. Tell the orthopedic surgeon that there is osteomyelitis

8. The surgeon combined the allograft with autologous platelet-rich plasma

a. This helps provide osteoconductive and osteoinductive properties
b. This provides antibiotic properties
c. This provides essential oils to the site
d. This helps provide congruity to the joint

9. There is a comminuted fracture of all four parts of the proximal humerus without displacement or angulation. How would you classify this by Neer classification:

a. 1-part
b. 2-part
c. 4-part
d. None of the above, this is actually a Wade Wilson fracture

10. This has a 97% positive predictive value for humeral head ischemia

a. Lesser tuberosity fracture with 3 cm of separation.
b. Greater tuberosity fracture with 47 degrees of angulation
c. Articular split fracture
d. Anatomical neck fracture with shorter than 8 mm medial metaphyseal segment or displacement by more than 2 mm of the attached medial metaphyseal segment

11. Anterior shoulder dislocation with torn rotator cuff is more typically seen in

a. 29 yo waitress with a single dislocation
b. 19 yo football player
c. Retired shipbuilder who fell down stairs and dislocated
d. 10 yo boy with a single dislocation.

12. Patient has a type VI glenoid fracture

a. Reverse total shoulder arthroplasty is the best option
b. Glenoid hemiarthroplasty is the best option
c. Not treated in order to preserve soft tissue supports
d. Allograft with autologous platelet rich plasma is frequently used for reconstruction.

Bonus:
Which is the best song about New York according to no one but the test giver

A. New York New York - Frank Sinatra Could it be this one?
B. Walk on the Wild Side - Lou Reed Hmmm....maybe?
C. Balloon Man - Robyn Hitchcock and the Egyptians Is it this one?
D. London Calling - The Clash Maybe it's this one

August EVMS (not official) Journal Contest Articles

Man, it is August already. We survived the sweat house of July. The second years survived their first solo call (woo!). Now on to the halcyon days of August. Don't forget to do the quiz for July. Below are the articles for August. Much like my dad bod - we are going to focus on body issues this month. So read, learn, and enjoy and prep for the forthcoming test!

Radiographics - Acute Mesenteric Ischemia

Radiographics - CT of surgically proven Blunt Bowel and Mesenteric Injury

Radiographics - Emergent and Nonemergent Nonbowel Torsion

EVMS July 2018 Articles of the Month!

The inaugural EVMS (but not official EVMS) monthly radiology journal club! Each month, we will have 3 new articles discussing something ABR related. Hope to issue 1st Sunday of each month with questions on the following month. The 1st 3 correct responses will earn points toward the EVMS Journal Club Winner! Articles will be up July, August, September, October, November, February, March, April, and May

The articles for July:

Uncommon Manifestations of Intervertebral Disk Pathologic Conditions

Acute Shoulder Trauma: What the Surgeon Wants to Know

RSNA Education Exhibits Imaging Characteristics of Bone Graft Materials

The ABR Core Study Guide MSK - Soft Tissue Infection Notes

Soft Tissue Infection

1. Etiology - many ways - inhalation, ingestion, direct inoculation, hematogenous, lymphatic, direct invasion
2. Factors that increase risk of infection - host immune system, poor vascular supply, necrotic tissue, tissue injury, collections of blood or lymph, implanted devices, foreign bodies
3. Tumors can become secondarily infected
4. Systemic disorders or immune suppression may alter how infection presents
5. Staphylococcus Aureus - most common etiology of soft tissue infection; Streptococcus A is number 2
6. Some occupations predispose to certain infections - rice field workers and meliodosis; tropical fish enthusiasts - mycobacterium marinum
7. Presentation dictated by type of infection
8. Typical - early is erythematous, warm, increased blood flood and dilated capillaries - complain of pain, swelling an heat; Febrile; subsequently may have tissue destruction and necrosis; septic shock - hypotension, tachycardia
9. Slow growth infections - local destruction and abscess formation; microcavities to larger cavities; may invade adjacent structures; sinus track to skin
10. Invade joint - can cause early irreversible articular damage; low blood supply to joint naturally
11. Chronic infections - stable or steady state; chronic reactive changes and acute infection changes; fibrous tissue adjacent an abscess; develop cloacae or sinus tracks lined by epithelium
12. Chronic - may eventually have amyloid development or malignant transformation.
13. X-ray - limited - may show nothing; may show soft tissue edema or secondary effects such as mass effect on adjacent structures, periosteal reaction in adjacent bone or bone changes from an adjacent abscess
14. Ultrasound useful for abscess versus cellulitis.
15. MRI - find abscesses, determine sinus tracks, determine involvement of adjacent bone
16. Cellulitis - superficial; can involve tendons
17. Abscesses - many sources - s. aureus, bowel flora etc; if sinus tracks can cause further spread and can be associated with Squamous Cell Carcinoma in long term skin infections
18. Acute septic arthritis - in kids most are not infectious but transient synovitis - but they look the same - so aspirate; if transient - it will help pain; If infection - will help find source
19. Acute septic arthritis - Adults - Diff Dx - acute arthropathy, gout, pseudogout, polyarthropathy and systemic arthropathies. Strep pyogenes, staph aureus, N. gonorrhea, Beta-hemolytic strep
20. Chronic Septic Arthritis - Organism must be determined; prosthesis - often skin contaminates; 
21. Pyomyositis - fever, pain with passive motion; elevated markers; A muscle or other muscles; gas gangrene is severe and often fatal; often fluid collections; staphylococcus and clostridial myonecrosis
22. Necrotizing fasciitis - group A strep or polymicrobacterial; gas is possible; fascia will be thickened; muscles and muscle groups will have abnormal signal
23. Tuberculosis - 3rd most common infection worldwide - "cold" abscess - may not have a pyrexial component; when invading bone can look like a malignancy; mycobacterium marinum - nodular lymphadenitis
24. Fungal - often immunocompromised; variable presentation 
25. Ultrasound - useful for determining if fluid collection or just soft tissue edema
26. MRI - definitive study for both dx and progression

Reference: Thomas Pope et al Expert Consult Musculoskeletal Imaging 2nd Edition