Effectiveness of resident-prepared conferences in teaching imaging utilization guidelines to radiology residents

RATIONALE AND OBJECTIVES

The authors evaluated the effectiveness of a resident-prepared conference series for teaching imaging utilization guidelines to radiology residents.

MATERIALS AND METHODS

Brown University radiology residents (n = 17) gave 61 presentations on imaging utilization to their colleagues during 16 1-hour conferences. The residents were later examined on the topics presented and surveyed about their familiarity with the American College of Radiology appropriateness criteria, their exposure to issues of cost-effectiveness, and their degree of confidence in providing imaging consultation. The same examination and survey were administered to control residents from the University of Wisconsin (n = 14) and the Oregon Health Sciences University (n = 14). Scores were compared by using linear regression and Wilcoxon rank sum tests.

RESULTS

Controlling for years in radiology residency, residents at Brown scored on average 16.0% (standard error = 2.2%) higher than residents at the other universities (P < .001). Controlling for institution, 3rd- and 4th-year residents scored on average 7.4% (standard error = 2.1%) higher than 1st- and 2nd-year residents (P = .001). Brown residents expressed more familiarity with American College of Radiology appropriateness criteria and appeared to have more exposure to cost-effectiveness issues in conferences than residents at Wisconsin or Oregon Health Sciences University (P < .005). Residents from the three universities did not differ in their level of confidence in providing imaging consultation.

CONCLUSION

Resident-prepared conferences are an effective means of teaching imaging utilization guidelines to residents, but they do not affect the residents' perception of their ability to provide imaging consultation.

Cardiovascular disease and combined oral contraceptives: reviewing the evidence and balancing the risks

Cardiovascular risks have been a concern since combined oral contraceptives (OCs) were first introduced. In the past four years new, mostly reassuring information on the safety of modern, low oestrogen dose OCs has become available. However, in 1995 the new information showed higher venous thromboembolism (VTE) risk for OCs containing desogestrel and gestodene compared with levonorgestrel- or norethindrone-containing OCs. The controversial responses by national authorities, their scientific and public health merits were hotly debated and many considered the differences in risk small and resulted from bias and/or confounding. We discuss these arguments and conclude they lack empirical support or cannot account for the 2-fold increased risk. The risk of ischaemic stroke and myocardial infarction (MI) associated with low oestrogen dose OCs are very small in women without cardiovascular risk factors, while increased risk of haemorrhagic stroke is confined to women >35 years of age. Applying the most recent risks to models of OC-attributable events and deaths, OC-attributable mortality in women <35 years is estimated to be <3 per million users annually, rising to about 10 per million users annually among smokers. In the context of external cause mortality (about 90 per million women of reproductive age annually in the UK) such risks appear small. Over the age of 35 years, OC-attributable mortality is a more important concern, particularly among smokers. In the absence of any appreciable OC-attributable mortality in young healthy women, the additional VTE risk for third compared with second generation OCs should be considered when women choose which OC to use.

Getting residents involved in research: a challenge in the era of managed care

The changing climate of health care, with the associated increasing financial constraints, challenges faculty and residents to find time for mentoring and pursuing research. Departments and institutions can encourage residents to conduct research by assuring them that they have a supportive infrastructure. Only when the institution and faculty value research will residents do the same. More than half of academic surgeons spend less than 20% of their effort in research; how can residency programs expect residents to enthusiastically pursue research when members of the teaching faculty are themselves not writing and publishing? If the ACGME is serious about asking residents to devote their time and energy to becoming more active in research activities, we must be prepared to decrease service commitments, and we must provide clinically active mentors and visible career models.

Pregnancy outcome after successful external cephalic version

OBJECTIVE

Recent studies have suggested that the rate of cesarean delivery in patients who have undergone a successful external cephalic version is higher than expected. This study compares the incidence of cesarean delivery in patients who underwent successful external cephalic version and patients with primary cephalic presentations.

STUDY DESIGN

We identified and reviewed the charts of 92 patients who underwent a successful external cephalic version. We identified a control population of 184 patients from the delivery room logs. We collected outcome data and information on additional risk factors that may affect cesarean delivery rates.

RESULTS

There were no significant differences between study and control populations. There was no significant difference in the cesarean delivery rate between study patients (22.8%) and control patients (23.4%).

CONCLUSIONS

We could not demonstrate a significant increase in the cesarean delivery rate for women who underwent successful external cephalic version in comparison with patients in labor with primary cephalic presentations.

Extramedullary gastric plasmacytoma

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Medical students and radiology residents: can they learn as effectively with the same educational materials?

RATIONALE AND OBJECTIVES

The purpose of this study was to evaluate the effectiveness of resident-prepared, independent-learning materials for teaching chest radiology to medical students.

MATERIALS AND METHODS

Students from three U.S. medical schools enrolled in radiology clerkships between March 1998 and June 1998 were randomly divided into control (n = 27) and experimental (n = 31) groups. The experimental group studied 12 chest radiology independent-learning cases (intervention) used to teach radiology residents in a previous study. Both groups took a 36-item, multiple-choice test (previously used to test radiology residents) on three occasions (before intervention [pretest], 1 day after intervention [posttest], and 2-4 weeks after intervention [final examination]). Student scores were then compared with resident scores.

RESULTS

Mean scores were similar across institutions at pretest, but increases at posttest and final examination scores differed across time, school, and group (P < .005). Mean differences in scores between experimental and control groups at pretest, posttest, and 2-4-week final examination were -0.22, 9.79, and 9.14, respectively, demonstrating increased performance at posttesting that remained present (though slightly attenuated) 2-4 weeks later. Comparing performance, residents had mean pretest scores of 19.2 and students of 14.1, a five-point difference attributable to the residents' greater experience. Both residents and students gained approximately nine points at posttest. At final examination, the difference between residents and students was only 1.4 points, suggesting the experimental program (teaching materials) brought students close to the long-term retention shown by residents.

CONCLUSION

Independent study of resident-prepared chest radiology teaching cases increased medical student knowledge for at least 2 or 4 weeks after instruction. Although starting at lower knowledge levels, students experienced gains in knowledge comparable to those of residents, suggesting the same materials can be used to teach both students and residents.

Calretinin-immunoreactive nerves in the uterus, pelvic autonomic ganglia, lumbosacral dorsal root ganglia and lumbosacral spinal cord

Nerves containing the calcium-binding protein calretinin have been reported in several organs but not in female reproductive organs and associated ganglia. This study was undertaken to determine if nerves associated with the uterus contain calretinin and the source(s) of calretinin-synthesizing nerves in the rat (are they sensory, efferent, or both?). Calretinin-immunoreactive nerves were present in the uterine horns and cervix where they were associated with arteries, uterine smooth muscle, glands, and the epithelium. Calretinin-immunoreactive terminals were apposed to neurons in the paracervical ganglia; in addition, some postganglionic neurons in this ganglion were calretinin positive. Calretinin perikarya were present in the lumbosacral dorsal root ganglia, no-dose ganglia, and lumbosacral spinal cord. Retrograde axonal tracing, utilizing Fluorogold injected into the uterus or paracervical parasympathetic ganglia, revealed calretinin-positive/Fluorogold-labeled neurons in the dorsal root and nodose ganglia. Also, capsaicin treatment substantially reduced the calretinin-positive fibers in the uterus and pelvic ganglia, thus indicating the sensory nature of these fibers. The presence of calretinin immunoreactivity identifies a subset of nerves that are involved in innervation of the pelvic viscera and have origins from lumbosacral dorsal root ganglia and vagal nodose ganglia. Though the exact function of calretinin in these nerves is not currently known, calretinin is likely to play a role in calcium regulation and their function.

Determination of iron in solutions with the ferric-xylenol orange complex

Formation of a colored complex between ferric iron and xylenol orange has been used in a variety of applications, but there is disagreement about the number of complexes that exist, their stoichiometry, pH dependence, solvent effects, and other parameters. In this study we investigated the use of the complex to measure micromolar concentrations of iron in aqueous and alcohol solutions. The results show that the optimum wavelength for the measurement is 560 nm, that only a 1:1 ferric:xylenol orange complex forms, and that its molar absorption coefficient is affected by the solvent, the source of the xylenol orange, and the pH. Under the recommended conditions, formation of the complex is completed in less than 5 min and it is stable in several solvents. Its molar absorption coefficient in 25 mM H(2)SO(4) is 20,100 or 14,500 M(-1) cm(-1), depending on the source of the dye. A recommended protocol for the use of the assay is given.

Hydroperoxide assay with the ferric-xylenol orange complex

A range of hydroperoxides were reduced by ferrous ions in acid solutions and the amount of ferric product was measured as a xylenol orange complex at 560 nm. Dilute sulfuric acid, 50% acetic acid, and acidified 90% methanol proved to be suitable solvents. The color developed within 15 min and was stable for several hours in most solvents. The apparent molar absorption coefficients (epsilon(app)) of H(2)O(2) and of the t-butyl, cumene, bovine serum albumin, and linoleate hydroperoxides were measured, using known hydroperoxide concentrations determined independently by an iodometric assay. The epsilon(app) values differed significantly and depended on the hydroperoxide, the solvent, and the source of the xylenol orange. The numbers of Fe(3+) ions formed by a range of hydroperoxides in different solvents showed that H(2)O(2) gave 2.5, t-butyl and cumene hydroperoxides 5, and the other hydroperoxides 2 Fe(3+) ions per -OOH group. This general finding allows the determination of approximate hydroperoxide concentrations even in chemically complex systems. Accurate measurements require knowledge of the nature of the hydroperoxide and its epsilon(app) and careful control of the assay conditions. However, the convenience of the assay makes it potentially useful in a variety of applications.

Turning goals into results: the power of catalytic mechanisms

Most executives have a big, hairy, audacious goal. They write vision statements, formalize procedures, and develop complicated incentive programs--all in pursuit of that goal. In other words, with the best of intentions, they install layers of stultifying bureaucracy. But it doesn't have to be that way. In this article, Jim Collins introduces the catalytic mechanism, a simple yet powerful managerial tool that helps translate lofty aspirations into concrete reality. Catalytic mechanisms are the crucial link between objectives and performance; they are a galvanizing, nonbureaucratic means to turn one into the other. What's the difference between catalytic mechanisms and most traditional managerial controls? Catalytic mechanisms share five characteristics. First, they produce desired results in unpredictable ways. Second, they distribute power for the benefit of the overall system, often to the discomfort of those who traditionally hold power. Third, catalytic mechanisms have teeth. Fourth, they eject "viruses"--those people who don't share the company's core values. Finally, they produce an ongoing effect. Catalytic mechanisms are just as effective for reaching individual goals as they are for corporate ones. To illustrate how catalytic mechanisms work, the author draws on examples of individuals and organizations that have relied on such mechanisms to achieve their goals. The same catalytic mechanism that works in one organization, however, will not necessarily work in another. Catalytic mechanisms must be tailored to specific goals and situations. To help readers get started, the author offers some general principles that support the process of building catalytic mechanisms effectively.

Cholinergic neurons of the pelvic autonomic ganglia and uterus of the female rat: distribution of axons and presence of muscarinic receptors

Acetylcholine (ACh) stimulates contraction of the uterus and dilates the uterine arterial supply. Uterine cholinergic nerves arise from the paracervical ganglia and were, in the past, characterized based on acetylcholinesterase (AChE) histochemistry. However, the histochemical reaction for acetylcholinesterase provides only indirect evidence of acetylcholine location and is a nonspecific marker for cholinergic nerves. The present study: (1) reevaluated cholinergic neurons of the paracervical ganglia, (2) examined the cholinergic innervation of the uterus by using retrograde axonal tracing and antibodies against molecules specific to cholinergic neurons, choline acetyltransferase and the vesicular acetylcholine transporter, and (3) examined muscarinic receptors in the paracervical ganglia using autoradiography and a radiolabeled agonist. Most ganglionic neurons were choline acetyltransferase- and vesicular acetylcholine transporter-immunoreactive and were apposed by choline acetyltransferase/vesicular acetylcholine transporter-immunoreactive terminals. Retrograde tracing showed that some cholinergic neurons projected axons to the uterus. These nerves formed moderately dense plexuses in the myometrium, cervical smooth muscle and microarterial system of the uterine horns and cervix. Finally, the paracervical ganglia contain muscarinic receptors. These results clearly reveal the cholinergic innervation of the uterus and cervix, a source of these nerves, and demonstrate the muscarinic receptor content of the paracervical ganglia. Cholinergic nerves could play significant roles in the control of uterine myometrium and vasculature.

Dot immunobinding assay for detection of bovine herpesvirus 4 antibodies in rabbits

A dot immunobinding assay (DIA) was used for the detection of antibody against bovine herpesvirus 4 (BHV-4) in experimentally infected specific-pathogen-free male and female rabbits. A semipurified virus preparation was used as the antigen, and protein A/G-horseradish-peroxidase conjugate and diaminobenzidine tetrahydrochloride were used as the detection system. Results of the DIA procedure on serum samples of experimentally infected male and female rabbits were compared with those of a complement-dependent virus neutralization (VN) test. None of the tested sera (0/60 samples) from either male or female rabbits were positive by the complement-dependent VN test. Results of the DIA procedure for the same tested sera were positive in 35 of 60 samples (58%) from BHV-4 infected rabbits, indicating higher sensitivity of DIA procedure as compared with the complement-dependent VN test.

Pulmonary mucosa-associated lymphoid tissue lymphoma: CT and pathologic findings

OBJECTIVE

The objective of this study was to determine the CT findings in pulmonary mucosa-associated lymphoid tissue lymphoma and to correlate these CT findings with histologic specimens.

CONCLUSION

In the 11 patients reviewed, the most common CT appearance of pulmonary mucosa-associated lymphoid tissue lymphoma was consolidation with air bronchograms, correlating histologically with a cellular lymphocytic infiltrate expanding the interstitium and compressing adjacent alveoli, producing air bronchograms.

Choroid plexus epithelium (normal and neoplastic) expresses synaptophysin. A potentially useful aid in differentiating carcinoma of the choroid plexus from metastatic papillary carcinomas

As an incidental finding in paraffin sections of brain tissue used as positive controls for synaptophysin immunostain, the cytoplasm of choroid plexus epithelium present was found to stain strongly positively for this substance. This was subsequently found to be the case in normal choroid plexuses in autopsy material from infancy to old age, as well as in epithelial cells of papillomas and carcinomas of the choroid plexus. The latter findings may prove useful in differentiating choroid plexus carcinomas from metastatic papillary carcinomas of extracerebral origin with the exception of neuroendocrine carcinomas of various sites that are usually positive for synaptophysin.

Imaging of cardiac transplantation complications

Common complications of cardiac transplantation include infection, rejection, accelerated coronary artery atherosclerosis, and lymphoproliferative disease. The authors reviewed radiographic and computed tomographic (CT) features of cardiac transplantation and its complications in a series of 232 patients (with 89 complications and 49 deaths). Normal postoperative findings in the first few weeks after surgery included enlarged cardiac silhouette, pneumomediastinum, pneumothorax, pneumopericardium, subcutaneous emphysema, and mediastinal widening. Infection was the most common complication, with pneumonia being the leading infectious condition (28 cases, with Aspergillus [n = 11] and cytomegalovirus [n = 10] being the most common pathogens) and the cause of death in seven cases. Although many cases of pulmonary infections occur in the first 3-4 months after surgery, in this series several cases developed up to 3 years afterward. Radiographic signs of acute rejection were nonspecific in the eight patients affected who died, and endomyocardial biopsy was used to confirm the suspected diagnosis. Accelerated atherosclerosis occurred in 13 patients between 10 months and 6.5 years after transplantation and led to death in eight. Lymphoproliferative disorders, which range from benign lymphoid hyperplasia to malignant lymphoma and which are the third leading cause of death beyond the immediate perioperative period in heart transplant recipients, developed in four patients who later died. Other complications related to endomyocardial biopsy and cardiothoracic surgery (i.e., pneumothorax, hemothorax, pneumomediastinum, mediastinitis, aortic dissection, aortic pseudoaneurysm, and pulmonary embolism) occurred in 31 cases and were diagnosed with radiography and CT.

Fas-FasL interaction involved in pathogenesis of ocular toxoplasmosis in mice

Ocular toxoplasmosis is a potentially blinding intraocular inflammation. The intent of this study was to investigate the role of Fas-FasL interaction in a murine model of acquired ocular toxoplasmosis induced by intracameral inoculation of Toxoplasma gondii. Intraocular inflammation, Fas and FasL expression on lymphocytes and on ocular tissues, the occurrence of apoptosis, and the frequency of CD8(+) and CD4(+) T cells in the infected eyes were analyzed in C57BL/6 (B6) mice. Susceptibility to parasite-induced intraocular inflammation was observed in Fas-deficient (B6-lpr) and FasL-deficient (B6-gld) mice. Inoculation of 5,000 T. gondii tachyzoites induced significant intraocular inflammation associated with increase of Fas and FasL expression in the inoculated eyes of wild-type B6 mice. Flow cytometry demonstrated a significant increase of Fas and FasL expression on the splenocytes from naive mice incubated in vitro with the parasite and on the splenocytes harvested from the infected mice at day 8 after parasite inoculation. Apoptosis of inflammatory cells and cells in ocular tissues was seen, and a greater frequency of CD8(+) than CD4(+) T cells was observed in the infected eyes. The intensity of intraocular inflammation was greater in B6-lpr and B6-gld mice than in wild-type B6 mice (P < 0.05). The results suggest that Fas-FasL interaction associated with apoptosis is involved in the pathogenesis of acquired ocular toxoplasmosis in mice.

Lung transplantation for lymphangioleiomyomatosis: role of imaging in the assessment of complications related to the underlying disease

PURPOSE

To identify the complications and imaging findings related to lymphangioleiomyomatosis (LAM) after lung transplantation.

MATERIALS AND METHODS

The authors retrospectively reviewed the clinical histories and imaging studies of 13 patients from five major medical centers who underwent unilateral (n = 8) or bilateral (n = 5) lung transplantation for LAM between 1991 and 1997. Complications related to LAM, both before and after transplantation, were recorded.

RESULTS

The following LAM-related complications were found during and after transplantation: excessive pleural adhesions (n = 4), native lung pneumothorax (n = 3), chylous effusion (n = 1), chylous ascites (n = 3), complications from renal angiomyolipomas (n = 4), and recurrent LAM (n = 1). Diagnosis could be made or suggested with computed tomography (CT) in all cases. Four patients (31%) died; one patient died of complications of LAM.

CONCLUSIONS

Patients who have undergone lung transplantation for LAM have increased morbidity and mortality due to complications related to their underlying disease. These LAM-related complications can be diagnosed or suggested with CT.

The human LARGE gene from 22q12.3-q13.1 is a new, distinct member of the glycosyltransferase gene family

Meningioma, a tumor of the meninges covering the central nervous system, shows frequent loss of material from human chromosome 22. Homozygous and heterozygous deletions in meningiomas defined a candidate region of >1 Mbp in 22q12.3-q13.1 and directed us to gene cloning in this segment. We characterized a new member of the N-acetylglucosaminyltransferase gene family, the LARGE gene. It occupies >664 kilobases and is one of the largest human genes. The predicted 756-aa N-acetylglucosaminyltransferase encoded by LARGE displays features that are absent in other glycosyltransferases. The human like-acetylglucosaminyltransferase polypeptide is much longer and contains putative coiled-coil domains. We characterized the mouse LARGE ortholog, which encodes a protein 97.75% identical with the human counterpart. Both genes reveal ubiquitous expression as assessed by Northern blot analysis and in situ histochemistry. Chromosomal mapping of the mouse gene reveals that mouse chromosome 8C1 corresponds to human 22q12.3-q13.1. Abnormal glycosylation of proteins and glycosphingolipids has been shown as a mechanism behind an increased potential of tumor formation and/or progression. Human tumors overexpress ganglioside GD3 (NeuAcalpha2,8NeuAcalpha2, 3Galbeta1,4Glc-Cer), which in meningiomas correlates with deletions on chromosome 22. It is the first time that a glycosyltransferase gene is involved in tumor-specific genomic rearrangements. An abnormal function of the human like-acetylglucosaminyltransferase protein may be linked to the development/progression of meningioma by altering the composition of gangliosides and/or by effect(s) on other glycosylated molecules in tumor cells.

Chest radiology case exchange program: a paradigm for resident teaching and independent resident learning

RATIONALE AND OBJECTIVES

The purpose of this study was to test the effectiveness of resident-prepared, independent learning cases in teaching residents chest radiology.

MATERIALS AND METHODS

Three 2nd-year residents (one each from the University of Wisconsin, the Oregon Health Sciences University, and the University of Michigan) prepared four chest radiology teaching cases each (total, 12 cases). Radiology residents from each institution were randomly divided into control (n = 30) and experimental (n = 35) groups. Residents from both groups took a pretest of 36 multiple-choice questions covering the material from the 12 teaching cases. Residents in the experimental group reviewed these cases independently, and both groups took the same test (posttest) immediately after the teaching cases had been reviewed and again 3 months later (final test).

RESULTS

Test scores were similar across institutions (P > .05) but differed across time and treatment groups (experimental vs control) (P < .0001). Mean differences in test scores between the experimental and control groups at pretest, posttest, and final test were -0.4, +9.0, +4.0, respectively, demonstrating increased performance at posttesting that was still present (though somewhat attenuated) 3 months later at final testing.

CONCLUSION

Independent study of resident-prepared chest radiology teaching cases increases the resident's knowledge for as long as 3 months after instruction.

Protective role of maternal antibodies against Haemophilus parasuis infection

OBJECTIVE

To evaluate the impact of maternal antibodies after challenge exposure of baby pigs with a homologous serovar of Haemophilus parasuis.

ANIMALS

7 gilts and their litters from a high health status farm.

PROCEDURE

Gilts were vaccinated twice with a commercial bacterin that contained H parasuis serovar 4 and 5 or, as a control, adjuvant only. A group of pigs was also vaccinated similarly before challenge exposure. After early and late challenge exposure at 3 and 4 weeks, respectively, all pigs from vaccinated gilts were evaluated for clinical signs of infection, lesions, and antibody titer.

RESULTS

All pigs coming from control gilts had severe signs of H parasuis infection. Macroscopic lesions included polyserositis and pneumonia, and bacteriologic examination confirmed H parasuis as the etiologic agent. Vaccinated pigs born to vaccinated gilts did not have clinical signs of disease. However, some vaccinated pigs born to control gilts had signs of nervous system dysfunction and lameness. There was no difference in lesion scores between early or late challenge exposure, but lesions scores for pigs from vaccinated and control gilts were different (P < 0.01).

CONCLUSIONS

Under these experimental conditions, immune-naive and vaccinated pigs from vaccinated gilts were protected against systemic lesions when challenge exposed with a virulent strain of H parasuis.

CLINICAL RELEVANCE

Vaccination of the gilt and pigs protects the latter from polyserositis, but results are not different from those for nonvaccinated pigs from vaccinated gilts. Maternal antibodies did not seem to interfere with vaccination of pigs at 1 and 3 weeks of age.