Abstract
The aim of this self-assessment program is to assist radiologists in acquiring continuing professional development (CPD) credits through reading educational articles in the Canadian Association of Radiologists Journal (CARJ) and completing the accompanying test. The goals are to raise your awareness of the research and clinical issues in radiology and to help you evaluate your knowledge and learning needs for various imaging modalities. You can read the articles before or after completing the self-assessment test and consult with other materials as appropriate.
The Insights4Imaging Part 38 program is valid from November 2011 to October 2012. Tests returned after October 2012 will not be scored or returned. Study credit letters for submissions will be sent to participants in December 2011.
Instructions
This program is supported in part by the CAR and is free to members of the CAR. If you want to receive CPD credits and are not a member of CAR, then you must complete the registration information and include a check payable to the CAR for CAD$100 with your mailed submission.
To receive CPD credits, complete this self-assessment test form and return it to the editor of the CARJ. The self-assessment forms are available online at http://www.cpd.car.ca.
You will receive your graded test; an individual score report, including a percentile ranking, with the aggregated score of the other participants; the answers to the test question items; and your CPD credit letter. Your personal scores will be released only to you.
Related learning activities, such as researching the literature, reading relevant articles, recording practice changes, and discussing the topic with other colleagues, can be documented and used as a structured learning project for additional credits under Section 2 of the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada.
Self-assessment Program: Insights4Imaging, Part 38
Educational Objectives
To evaluate your knowledge and learning needs for various imaging modalities, patient problems, practice management, and research methods.
Self-assessment Test
The CAR Guidelines for the Prevention of Contrast-induced Nephropathy: A Critical Appraisal (p 238)
Appraisal of Guidelines Research and Evaluation (AGREE) is:
An international collaboration whose goal is to improve the quality and effectiveness of clinical practice guidelines. A committee struck by the CAR to assess the applicability of clinical practice guidelines. An informal association of clinical nephrologists whose purpose is to assess the evidence for contrast-induced nephropathy. A Canadian collaboration whose goal is to review the CAR guidelines on the prevention of contrast-induced nephropathy. The AGREE instrument:
Assesses the quality of the evidence used to elaborate the guidelines. Is a questionnaire that consists of 23 key items organized into 6 domains. Must be completed by at least 10 appraisers. Does not include the possibility to comment on the items in the instrument. Which of the following categories or domains is not part of the AGREE instrument?
Stakeholder involvement Rigor of development Applicability Meta-analysis of the pertinent data In the appraisal of the CAR guidelines presented in this article:
The lowest score was for applicability of the guidelines in the clinical setting. The highest score was for rigor of development. The scores for all the dimensions evaluated were higher than 90%. The scores for all the dimensions evaluated were lower than 50%. With regard to stakeholder involvement and applicability:
The strongest aspects related the inclusion of patients’ views and preferences. The weakest aspects related the absence of a pilot program to evaluate the guidelines before general dissemination. The guidelines specifically address the logistics of outpatient examinations for computed tomography (CT) with intravenous infusion. Specific guidelines are presented for intravenous and intra-arterial administration of contrast.
Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk (p 243)
6. In bone densitometry, T scores measure:
The standard deviation of a series of bone measurements. The amount by which the bone density in a given patient differs from the measured peak bone mass in a reference population. The bony attenuation of a given x-ray flux. The fracture risk in a given patient independently of age. The precision of a series of measurements of bone. 7. A 70-year-old women with a long-standing spondylolysis-spondylolisthesis has the following findings on dual-emission x-ray absorptiometry (DXA):
L1 T −2.6 L2 T −2.8 L3 T −2.9 L4 T +0.2 L1-L4 T–2.2 You conclude that the patient has which of the following additional diagnoses? Low bone mass Osteoporosis Osteopenia Established osteoporosis A low fracture risk 8. In the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) model for fracture risk assessment, an increased 10-year fracture risk is predicted by which of the following?
Alcohol consumption of 3 or more units a day. A history of rheumatoid arthritis. A femoral neck T score of −2.5 or less. Increasing age. All of the above. 9. Least significant change is:
Specific to a given densitometer. Specific to a given technologist or group of technologists. Specific to a group of patients representative of those in whom it is to be used. Used to determine if change is statistically significant at a given confidence level. All of the above. 10. Change in the projected area of a vertebral segment on successive DXA examinations:
May reflect poor technologist performance. Impacts on measurements of precision. Should not exceed 2% on 90% of examinations. May result from a vertebra becoming involved in Paget disease of bone. All of the above.
Bowel Preparation Suitable for Same-day CT Colonography and Colonoscopy (p 256)
11. Incomplete evaluation of the colon or failing to reach the cecal pole at endoscopy:
Occurs less than 1% of the time. Is seen only with inexperienced endoscopists. Varies but is commonly reported as 5%. Occurs more than 40% of the time in teaching hospitals. 12. After incomplete colonoscopy:
If the bowel is clean, then immediate CT colonography (CTC) is indicated. CTC is dangerous because of the risk of overdistending the colon. CTC can be done the same day if oral-tagging agents were used. Barium enema is more accurate than CTC. 13. When CTC is done first on average-risk adults:
Fewer than 5% of patients have lesions that need endoscopic evaluation. More than 20% of patients require follow-up colonoscopy. Same-day colonoscopy is contraindicated. About 13% have suspicious lesions identified. 14. The fecal- and fluid-tagging agents used in this study:
Frequently caused endoscope clogging. Often impaired mucosal visualization. Cost more than CAD$30 per patient. Were well tolerated and caused no problems at endoscopy. 15. Same-day colonoscopy and CTC:
Is a dangerous and unrealistic goal. Should only be done if no tagging agents were used. May be an important part of any screening program that uses CTC. Is not recommended for patients with diverticulosis.
Pancreatic Tuberculosis: Role of Multidetector CT (p 260)
16. Which of the following CT findings are found in patients with pancreatic tuberculosis (TB)?
Diffuse pancreatic calcification Dilatation of the pancreatic duct Distal pancreatic atrophy Cystic mass with peripheral rim of calcification All of the above 17. Which of the following can extra-abdominal findings with TB can be found in?
Diffuse randomly distributed micronodular opacities in the lungs (miliary TB) Loculated pleural effusions Chest masses Axillary masses None of the above 18. What is the most common location of nonpulmonary TB?
Pancreas Terminal ileum Colon Liver Bone 19. What is the cause of the hypoattenuating appearance of pancreatic TB on CT?
Adenopathy Central necrosis Hematogenous spread Lymphangitic spread None of the above 20. Which of the following are ancillary findings of pancreatic TB?
Pulmonary TB Pleural effusions Enlarged celiac nodes Ascites Subcutaneous oedema
Percutaneous Excision: A Viable Alternative to Manage Benign Breast Lesions (p 265)
21. A 42-year-old woman has a circumscribed 6-mm mass in the left breast on mammography and ultrasound. She has a normal breast clinical examination and a history of a previous core biopsy of the right breast 2 years earlier, which revealed a fibroadenoma. Reasonable management options would include all of the following except:
Follow-up imaging with mammography and/or ultrasound in 6 months. Ultrasound-guided core biopsy to determine histopathology. Referral to a surgeon for possible excision. Percutaneous excision by using a vacuum device. Follow-up clinical breast examination. 22. When performing percutaneous excision of a benign-appearing mass, it is important to:
Inform the patient that the procedure has been shown to be 98%-100% effective in all studies. Tell the patient that percutaneous excision has been shown to be better than surgical excision based on multiple large prospective studies. Obtain the patient's consent for placement of a marking clip at the biopsy bed, even if the mass has undergone a prior core biopsy that confirmed a benign diagnosis. Mention to the patient that he or she will experience substantial pain and discomfort for 48 hours after the procedure. Remind the patient that it is not necessary to send the removed tissue to pathology for analysis if the lesion was previously biopsied. 23. Approximately what percentage of biopsy-proven fibroadenomas enlarges over time?
Less than 10% 11%-30% 31%-50% 51%-75% More than 76% 24. Percutaneous excision would be a reasonable option for which of the following patients?
A 27-year-old woman with history of 3 prior surgeries for fibroadenomas who presents with a new tender lump on examination; ultrasound results are suggestive of fibroadenoma. A 65-year-old woman with a circumscribed 1-cm mass in the right breast and enlarged axillary lymph node on mammography. A 77-year-old woman with a 8-mm spiculated mass in the upper outer left breast on mammography. A 54-year-old woman with linear branching calcifications in the central inner right breast that span 2 cm in largest dimension. A 35-year-old woman with bloody nipple discharge, found, on galactography, to have an 5-mm filling defect 1 cm from the nipple. 25. In this study, the “success” rate (as defined as complete removal of a mass at follow-up imaging and/or relief of symptoms) of percutaneous excision of benign breast masses was approximately:
10%. 30%. 50%. 70%. 90%
Fluid Levels in Pediatric Imaging: A Pictorial Review (p 272)
26. The observation of fluid levels in imaging requires the presence of a cavity and immiscible fluids identified on an image that is vertically oriented.
True False 27. If air-fluid level is seen on CT of the peritoneal cavity, then it means gastrointestinal tract perforation or abscess collections.
True False 28. Fluid-fluid levels in musculoskeletal lesions can be seen in which of the following?
Aneurysmal bone cyst Synovial sarcoma Unicameral bone cyst All of the above 29. Congenital lesions with fluid-level appearance are encountered more frequently in the neonatal age group, whereas the acquired and the neoplastic diseases associated with the fluid-level sign are more common among the older children.
True False 30. Intrapulmonary cavitary lesions with air-fluid levels are usually due to communication with the tracheobronchial tree or the presence of gas-forming organisms.
True False
Postlobectomy Chest Radiographic Changes: A Quantitative Analysis (p 280)
31. What is the imaging modality of choice to monitor a patient after lobectomy with an uncomplicated postoperative course?
Serial chest films CT of the chest without contrast CT of the chest with contrast Magnetic resonance imaging of the chest 32. Which of the following is not an expected radiographic finding after a right-sided lobectomy?
Reduction in width of right hemithorax Depression of right hemidiaphragm Mediastinal shift to the right None of the above 33. The decrease in size of the ipsilateral hemithorax is least pronounced after resection of which lobe?
Right upper lobe Right lower lobe Left upper lobe Left lower lobe 34. Which of the following best describes the changes that may be seen on a chest radiograph after a lobectomy?
Elevation of the ipsilateral hemidiaphragm Shift of mediastinal structures towards the operated side An ipsilateral pneumothorax An ipsilateral pleural effusion All of the above 35. Shift of the upper mediastinum is more common after:
Left upper lobectomy. Left lower lobectomy.
Chest Radiographs Are Valuable in Demonstrating Clinically Significant Pacemaker Complications That Require Reoperation (p 288)
36. When evaluating a pacemaker lead position, review of prior chest radiographs is irrelevant.
True False 37. Immediate postoperative complications that can typically be detected on chest radiography after pacemaker placement include all of the following EXCEPT?
Pneumothorax Lead malpositioning Infection Lead fracture 38. Which of the following is a correct description of the expected course of a right ventricular lead on frontal chest radiographs?
The right ventricular apical lead should course smoothly along the right heart border with the tip directed inferiorly to the left of the spine. The right ventricular apical lead should be directed medially and superiorly, just to the left of the spine. The right ventricular septal lead should course smoothly along the right heart border with the tip directed inferiorly to the left of the spine. The right ventricular septal lead should traverse the coronary sinus. 39. How is myocardial lead perforation diagnosed on chest radiography?
When the lead tip is in within 5 mm of the radiolucent stripe of epicardial fat When there is a translucency through the lead When there is pneumopericardium When there is a loculated left pleural effusion When the lead tip is within 3 mm of the radiolucent stripe of epicardial fat 40. In this study, chest radiographs demonstrated pacemaker complications in what percentage of patients who required reoperation for pacemaker complications?
15% 37% 57% 75% None of the above
How long did it take to read the articles and complete this test?
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Registration
If you have submitted an Insights4Imaging Program in 2006–2010, then you are registered in the CARJ database. However, the editors greatly appreciate you completing the entire registration form below. Please print clearly.
Name:___________________________________________
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Send the completed test to:
Dr Peter L. Munk
Department of Radiology, Vancouver General Hospital, University of British Columbia, 899 W 12th Avenue, Vancouver, British Columbia V5Z 1M9, Canada