Great Job everybody that participated - Dr. Dey, Dr. Trace, Dr. Bonney and Dr. Vosburg each scoring high marks!
1. Right atrium, right ventricle, coronary sinus. 3 pts
2. Swan Ganz Catheter - it is in a branch of the right pulmonary artery. It should be retracted. 2 pts
3. NG tube in a right lower lobe bronchus. 1 - reposition it. but they should be prepared for pneumothorax and possible need for chest tube placement and get a chest x-ray. 4 pts
4. Notice the right atrial lead is displaced from its position in the second image. So it needs to be resecured. 1 pt
5. Mediport - should have tip in the distal SVC. This is in an internal mammary vein. 2 points
6. Left subclavian line with tip near the coronary sinus in a retained left SVC. 2 points
7. Right mainstem intubation. 1 pt
8. Right sided PICC line with tip going into the neck. It should be in the SVC. 2 pts
9. C - 1 pt. They are MR unsafe
10. LVAD (several answers acceptable); pericardial - 2 pt
11. Heart transplant (but could be resolution of prior problem). Used as a bridge. 2 pt
12. LA appendage clip (LAA closure device). Used for a. fib so doesn't need anticoagulation. yes; 3 pt
13. c - 1 pt
14. D - 1 pt
15. False - latent has positive lab findings with negative imaging and clinical findings - 1 pt
16. D - a and b - 1 pt
Bonus - George Ezra
Thursday, October 11, 2018
Sunday, October 7, 2018
September EVMS (unofficial) Journal Club Quiz
What Time is It? Time for a Quiz! This quiz is based on the articles from September. May the best person win! Remember - EVMS residents - email me. Nonresidents - DM me on Twitter!
This month will be a little more visual based and will have more variable points.
1. Looking at these films - Where are the 3 leads placed?
2. Ignore the pacemaker. What is the other catheter? Is it placed appropriately? Where is it recommended to be?
3. Ignore the pigtail drain and ekg leads. There is an abnormally placed tube. What is it? Where is it? What do you tell the care team to do after removing and/or repositioning (2 things)?
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4. Patient is symptomatic. The second image was obtained 1st. The images are separated by hours to a day. What is the finding?
5. What type of catheter is this? Where is it supposed to be? Is it where it is supposed to be?
6. Left Subclavian Line - Where is the tip? Why?
7. Ignore the mediport and EKG leads - What is wrong? What complication is present?
8. What is going on? Where should this line be?
9. Which of the following is false regarding LVAD?
A. Can be used as a bridge to recovery.
B. Axial flow VADs are associated with nonsurgical bleeds such as GI bleed in avms or acquired von Willebrand disease.
C. The majority of currently used versions are MR compatible
D. All of the above
10. What kind of device is this? Is the device pericardial or preperitoneal?
11. The next image is the same patient as in 10 several months later. What do you think happened? How do you think the device in 10 was used?
12. What is the marked device? What is it used for? Is it MR compatible?
13. Primary Tuberculosis
a. Thoracentesis of pleural effusions in TB commonly isolates m. tuberculosis
b. Ghon focus is an acute finding in primary TB.
c. Commonly involves right paratracheal and hilar lymph nodes
d. Empyema necessitatis is the result of an enteropleural fistula.
14. Postprimary Tuberculosis
a. Cavitation is rare postprimary tuberculosis.
b. Air-fluid level in a cavitation is almost always a sign of severe tuberculosis
c. Miliary tb is nosocomially spread
d. Poorly marginated opacities in the upper lobes and superior segment lower lobes are common
15. True or false: Latent tuberculosis has negative lab findings with positive imaging and negative clinical findings of tuberculosis.
16. Tuberculosis
a. Inactive tuberculosis may have fibronodular changes in the upper lung fields but no evidence of active disease
b. Miliary tuberculosis can be seen in primary and postprimary tuberculosis especially in the setting of HIV.
c. Bronchial involvement can happen in primary or postprimary but especially postprimary
d. A and B
e. B and C
Bonus: Which of the following artists was endorsed by Magneto/Dumbledore? The songs are not the answer - but simply examples of the artists in action. I personally like all these artists especially Robert Post for personal reasons even though I should sue for using my name. We are both on instagram but I think mine is better - @robsradiology
A. Kongos Hey I Don't Know
B. George Ezra Shotgun
C. Robert Post Got None
D. Vampire Weekend Giving Up the Gun
E. Dashboard Confessional Hands Down
October EVMS Journal Competition Articles
It is October - Pink Ribbon Month - In honor of this month, let's review some articles in the field of Breast Imaging!
Multimodality Imaging of Single Lumen Silicone Breast Implants
Assessment and Management of Challenging BI-RADS 3 Lesions
What Radiologists Need to Know about Inflammatory Breast Cancer
Multimodality Imaging of Single Lumen Silicone Breast Implants
Assessment and Management of Challenging BI-RADS 3 Lesions
What Radiologists Need to Know about Inflammatory Breast Cancer
Thursday, September 6, 2018
Answers August Journal Club Quiz
Great job everyone - Drs. Dey, Lazarow, Bulzan, and Trace got 12/13 possible points. Dr. Bonney got 11/13 points. Also congrats to @hopeforfuture3 who got 11/13. Thank you for your work and dedication! The current standings - 1. Dey (24/26), 2. Dr. Bonney (23/26). 3. Dr. Hampton (13/26). Everyone else is still in the hunt! On the nonresident hunt - Congrats to @hopeforfuture3 with 11/26 points.
1. C - per the article regarding Acute Mesenteric Ischemia- "The imaging findings are similar to and indistinguishable from acute superior mesenteric arterial thrombosis" that throws out option D. "Typically, patients over 60 (female predominant) with postprandial pain" - that rules out B and rules in C. Notice - B has preprandial pain
2. D - per the above article - "The severity of the injury depends on the extent of reduction of blood flow, number of vessels involved, the duration of the ischemia, and the development of collateral circulation".
3. A - per the above article - "Emboli...often enlarge the SMA...the diameter of the SMA is often larger than that of the SMV...relationship is reversed in normal healthy individuals"
4. C. - at multiple points in the above article - it is listed as a finding associated with irreversible ischemia.
5. B - per the Multidetector CT of Surgically Proven Blunt Bowel and Mesenteric Injury - Shearing forces are most pronounced at locations where the bowel is fixed, including the Ligament of Treitz, the ileocecal valve, and sigmoid colon. This rules in option B but excludes A, C and D.
6. C. - Granted this is tricky - but A is out as you could have pneumoperitoneum from penetrating injury in addition to blunt and many other options as described in the article; B is retroperitoneal; D is extraperitoneal and unless air was present in the bladder at the time of injury shouldn't have air to track to the peritoneum - intraperitoneal rupture in the setting of a Foley in bladder is associated with pneumoperitoneum as per article; Therefore C is left over as mentioned in the article as an acceptable answer.
7. D. - fluid should be simple to be possibly normal. It is only normal in 3% of normal males. Morrison's pouch is between the liver and kidney - it is a place to look for abnormal fluid in setting of trauma or other etiologies.
8. C - per the article - "When diffuse small bowel wall thickening of more than 10 mm is seen, it should be considered a sign of shock bowel"
9. D. Per Emergent and Nonemergent Nonbowel Torsion article - "Although ovarian torsion occurs in women of all ages, it most commonly affects the reproductive age group". I realize, there is a discussion of torsion of the normal ovary is more common prior to puberty - but abnormal ovaries torse more commonly than normal ovaries etc.
10. C. per the article, ovaries are usually greater than 4 cm, string of pearls increases specificity, endometriosis decreases the likelihood of torsion. "Pregnancy, particularly in the 1st trimester, is a risk factor for ovarian torsion."
11. A - Per the article - It is associated with elderly women with kyphoscoliosis and cystic artery calcification. No mention of obesity or fertility. Porcelain gallbladder and gallstones are not mentioned as associated per the article.
12. A - long ureteral length is associated with torsion as are the other listed items.
Bonus - D. Mad World by Tears for Fears
1. C - per the article regarding Acute Mesenteric Ischemia- "The imaging findings are similar to and indistinguishable from acute superior mesenteric arterial thrombosis" that throws out option D. "Typically, patients over 60 (female predominant) with postprandial pain" - that rules out B and rules in C. Notice - B has preprandial pain
2. D - per the above article - "The severity of the injury depends on the extent of reduction of blood flow, number of vessels involved, the duration of the ischemia, and the development of collateral circulation".
3. A - per the above article - "Emboli...often enlarge the SMA...the diameter of the SMA is often larger than that of the SMV...relationship is reversed in normal healthy individuals"
4. C. - at multiple points in the above article - it is listed as a finding associated with irreversible ischemia.
5. B - per the Multidetector CT of Surgically Proven Blunt Bowel and Mesenteric Injury - Shearing forces are most pronounced at locations where the bowel is fixed, including the Ligament of Treitz, the ileocecal valve, and sigmoid colon. This rules in option B but excludes A, C and D.
6. C. - Granted this is tricky - but A is out as you could have pneumoperitoneum from penetrating injury in addition to blunt and many other options as described in the article; B is retroperitoneal; D is extraperitoneal and unless air was present in the bladder at the time of injury shouldn't have air to track to the peritoneum - intraperitoneal rupture in the setting of a Foley in bladder is associated with pneumoperitoneum as per article; Therefore C is left over as mentioned in the article as an acceptable answer.
7. D. - fluid should be simple to be possibly normal. It is only normal in 3% of normal males. Morrison's pouch is between the liver and kidney - it is a place to look for abnormal fluid in setting of trauma or other etiologies.
8. C - per the article - "When diffuse small bowel wall thickening of more than 10 mm is seen, it should be considered a sign of shock bowel"
9. D. Per Emergent and Nonemergent Nonbowel Torsion article - "Although ovarian torsion occurs in women of all ages, it most commonly affects the reproductive age group". I realize, there is a discussion of torsion of the normal ovary is more common prior to puberty - but abnormal ovaries torse more commonly than normal ovaries etc.
10. C. per the article, ovaries are usually greater than 4 cm, string of pearls increases specificity, endometriosis decreases the likelihood of torsion. "Pregnancy, particularly in the 1st trimester, is a risk factor for ovarian torsion."
11. A - Per the article - It is associated with elderly women with kyphoscoliosis and cystic artery calcification. No mention of obesity or fertility. Porcelain gallbladder and gallstones are not mentioned as associated per the article.
12. A - long ureteral length is associated with torsion as are the other listed items.
Bonus - D. Mad World by Tears for Fears
Sunday, September 2, 2018
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
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
Wednesday, August 8, 2018
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.
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.
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