0:33

Hey, everyone, uh, nice to meet you in this setting,

0:37

um, and thank you, Ryan, very much for that intro.

0:40

And I want to thank

0:41

Dr. Collins and MRI Online for inviting me.

0:45

I'm going to do a slightly unusual case series.

0:48

I want to talk about, um, things that

0:52

are hard to pick up in radiology.

0:55

So, more I'm going to be looking at almost kind

0:58

of like a stylistic approach to reading scans

1:03

and certain things that radiologists need, uh,

1:05

uh, look out for, because it's very easy to miss,

1:09

especially when you're reading a high volume.

1:12

So the title of my talk is The Hidden Curriculums.

1:15

I'm just curious, and I want

1:17

everyone to feel really comfortable.

1:18

You can turn off your mics or turn on your

1:20

mics if you want and answer the question.

1:24

It's a small group of us.

1:25

Um, anybody have any idea what

1:28

the hidden curriculum means?

1:30

Has anybody ever heard of that term?

1:32

Okay, so the hidden curriculum, they like to talk

1:36

about this in the educational setting that,

1:40

you know, when you're in lecture, let's say you're

1:43

in lecture learning about pancreatic cysts,

1:46

the curriculum is to learn about pancreatic cysts,

1:49

but there are nuances that occur, um, during the lecture

1:55

or let's say during read-out, people's interaction

1:59

with technologists or other referring physicians.

2:03

And we learn a lot from those interactions.

2:06

And those types of interactions

2:07

are called the hidden curriculum.

2:10

Um, and sometimes there's an agenda, you know,

2:14

that somebody is teaching something but also

2:16

wants to, you know, uh, teach something else.

2:20

Not so obvious other times it's just real life,

2:24

and you not only learn what the attending or resident

2:28

or whoever is teaching you, um, when you're

2:31

reading out, but their interactions with people.

2:34

So I chose this title because.

2:42

I'm going to look at two things.

2:44

The clinical part of this talk is we're

2:47

going to look at findings which are easy

2:49

to miss or overlook, and they're important.

2:52

Um, and these are things that

2:55

I've noticed over my career.

2:57

Um, and also working with residents and students.

3:01

But I also want to start a small

3:04

conversation on healthcare disparities.

3:07

So in the past couple of years, healthcare

3:10

disparities, um, have become more evident.

3:14

It's always been there, but it's

3:16

definitely more in the media now.

3:18

Um, and I just want to, I want people to

3:21

think about if does it happen in radiology

3:24

or does it not happen in radiology?

3:26

So think about that.

3:28

Um, I don't know which ones of you are

3:30

radiologists or students or residents, but,

3:33

you know, we're going to go over case one.

3:36

And after that, I'm going to ask you guys to let me

3:40

know if you have any thoughts or ideas on if you think

3:42

actually healthcare disparities occur in radiology.

3:47

Okay.

3:48

So our first case is an 89-year-old, status

3:52

post fall, came into the emergency room.

3:55

They did a trauma series, um,

3:57

you know, chest, abdomen, pelvis.

4:00

Um, and it happens to be the person

4:02

has a history of lung cancer.

4:06

So the first thing I'm going to tell you is,

4:10

you have to stick to your search

4:12

pattern precisely for every case.

4:16

It doesn't matter what the history is because

4:20

if you allow the history to dictate your

4:23

search pattern, you will end up missing things.

4:26

Now, yes, you can use the history

4:28

to help you make a diagnosis.

4:30

Um, but you really want to try

4:32

to stick to your search pattern.

4:33

And then the other thing is,

4:35

you're going to make mistakes.

4:36

So, when you make a mistake, you want to

4:40

rearrange your search pattern so you can try to

4:42

catch yourself and won't have that mistake again.

4:46

So, okay.

4:48

So this is just Aaron Povis.

4:52

Okay.

4:54

And so essentially we're looking, you know,

5:02

for trauma, you're looking for, you're going to

5:03

be looking for fractures, lacerations,

5:05

you're going to look for blood, pleural effusions.

5:09

So I'm just going to scan through, uh, this patient.

5:13

We did, like I said, chest, abdomen, pelvis,

5:16

and then I'm going to show you some more subtle

5:19

things that, um, could easily be missed if you

5:25

just concentrate on the, uh, trauma history.

5:29

So, we're almost through the pelvis.

5:33

Let's speed this up a little bit.

5:39

Okay, so.

5:41

So, the first thing I want to point

5:43

out to you guys is that, remember,

5:44

this person has a history of lung cancer.

5:51

So, here's our lung cancer.

5:54

So, that's one of those things

5:56

you probably wouldn't miss.

6:02

As I scroll down,

6:05

I notice a couple of other things.

6:09

I mean, there's a lot of things to notice,

6:10

but two things that I'll point out to you.

6:13

If you look in the stomach,

6:17

you hit this hypodense area.

6:20

Now, it doesn't look like it's really anything,

6:22

but I'm going to show you coronal images where

6:24

it actually looks like it might be something.

6:26

And I'm not saying I know what it is.

6:28

I just know it might be something

6:30

that needs to be looked at.

6:34

The next thing is, although this is the cortical

6:37

medullary phase of enhancement, meaning that it's

6:42

easy to miss renal lesions, there very well may be a

6:46

renal lesion right here in the left kidney anteriorly.

6:50

Because if you see, you see very little cortex,

6:52

so the cortex will be whiter than the pyramids.

6:57

And here,

6:58

this, uh, essentially gray color is, is

7:01

involving both the cortex and, uh, pyramids.

7:03

So it's a little suspicious that

7:05

something is going on over here.

7:10

So let's go to the coronal.

7:11

On these coronal images,

7:24

that thing in the stomach actually now

7:26

really looks like it could be something.

7:28

Now, it's probably fluid in attenuation, um,

7:32

but I don't know how much, uh, to trust that.

7:34

And given that the patient has a history of lung

7:36

cancer, yes, it would be unusual to get a metastasis there.

7:39

They should still look into it and, uh,

7:42

scope the patient if clinically it's going

7:45

to, you know, make a difference with respect

7:47

to staging and things of that nature.

7:51

So we look at that kidney

7:58

and I'm going to show you liver windows,

8:02

but here's that lesion that I was talking to you

8:05

guys about that you saw on the axial images here

8:08

also looks like it might be a little bit more real.

8:12

And again, I'm not saying I know

8:14

what they are.

8:16

I'm just saying that they need to be worked up.

8:20

So we're going to look at liver windows.

8:25

So as some of you may know, there are

8:28

many different window settings on CT.

8:31

So we typically look at bone windows,

8:33

lung windows, soft tissue windows, but there

8:35

are also something called liver windows.

8:38

They're actually pretty useful on non-contrast images,

8:41

but they can even be useful on contrast images.

8:43

It just gives a different, uh,

8:45

gray-white differentiation and

8:47

sometimes helps out to bring out lesions.

8:49

Let's go back to the stomach.

8:56

So that lesion I was talking

8:57

to you about, we see over here.

8:59

It's kind of dark.

9:07

And now we're going to go down to that left kidney.

9:15

And again,

9:19

we see that lesion, and you have a better sense

9:22

of the cortical-medullary differentiation.

9:24

The cortex is whiter than the pyramids.

9:28

And in that anterior portion of the

9:30

left kidney, the cortex is either

9:33

involved by something or extremely thin.

9:40

So, so far right off the bat, this is a

9:42

trauma series, but we already found two things

9:45

that may have nothing to do with trauma that

9:47

you could argue are incidental findings.

9:50

Um, but in the setting, even in not the setting

9:53

of lung cancer, they need to be worked up.

9:55

So for the stomach, you want to

9:57

get an endoscopy. For the kidney,

9:59

you could do a renal MRI.

10:01

Um, those would be things that

10:03

could definitely be helpful.

10:05

Again, a lot of this is contingent

10:07

on, you know, the patient's staging.

10:10

Is it necessary to do it or not necessary to do it?

10:13

If it's not necessary, there's no reason to.

10:18

Okay.

10:20

So this is going to be liver windows on coronal.

10:23

Again, the things will jump out a little nicer.

10:34

So we're going to go to the stomach first.

10:39

Here we see that lesion pretty nicely.

10:42

Again, I don't know what that lesion is, and it happens

10:44

to be, CT is not very good for gastric pathology.

10:47

If there's obvious gastric

10:49

pathology, then it, then it's good.

10:51

Um, but something more subtle like this,

10:54

again, this might be some kind of benign

10:56

process, but I just don't know what it is.

11:02

And then if we look at that kidney,

11:08

you kind of can get a sense of this rounded

11:12

grayish structure, um, that, that kind of

11:18

stands out with, uh, adjacent regular cortex.

11:22

Again, I don't know what this is necessarily.

11:25

Could it be a proteinaceous or hemorrhagic

11:27

cyst or some kind of benign process?

11:29

Absolutely.

11:30

Could it be a primary renal cell carcinoma?

11:33

Yes, it could be.

11:34

Could it be a MET?

11:35

Yes, it could be.

11:36

It's unusual, but it doesn't mean that it can't happen.

11:40

That's the one thing, you know, when you read the

11:41

books, they will always tell you where the different

11:45

cancers commonly metastasize to, but in real life,

11:49

sometimes you find some, you know, interesting things.

11:54

So now we're going to look at bone

11:58

windows, and for some reason, I'm not sure

12:01

why it comes up so grainy on, on this.

12:06

Because when I downloaded it, it didn't

12:08

come grainy but we'll be able to

12:14

deal with it.

12:18

So, this is a perfect case of,

12:20

if you look at the left pelvis,

12:24

followed down, uh, from the superior

12:26

ramus to the inferior ramus.

12:30

And we'll stop in a sec.

12:33

Okay.

12:36

And right here, we have a fracture.

12:41

Now in this case, this was the

12:43

only fracture the person had.

12:44

This was the only traumatic injury that the person had.

12:47

So the first thing I would like to tell you is,

12:50

you know, uh, if you stick to your five-millimeter

12:53

slices, it's pretty easy to miss these

12:56

non-displaced fractures, especially rib fractures.

12:59

My suggestion, if you're reading trauma,

13:02

um, is to number one, do the bones first.

13:06

And, uh, number two, to do them on the

13:09

thin slices, because you'll pick up a lot

13:12

more non-displaced fractures that way.

13:15

So, you could have satisfaction of search.

13:19

Let's say we looked at the whole scan,

13:21

and I find this fracture, but there's

13:24

more to the picture than that, right?

13:27

We found something in the stomach,

13:28

we found something in the kidney.

13:30

Again, we don't know if they're

13:32

really important, but as we

13:35

scroll back up,

13:42

if you look at the right sacrum,

13:44

it's kind of irregular, eroded.

13:49

Um, again, the picture is not very good.

13:51

I'm not sure why it uploaded this way.

13:53

Um, but it looks angry in that area.

13:58

And then again, given the history of lung cancer,

14:01

this would be suspicious for a lytic metastasis.

14:04

I mean, highly suspicious.

14:06

So, it has nothing to do, again, with the trauma,

14:11

and I'll even venture to say that if you go to

14:16

around, that doesn't show up so well, oh, here we go.

14:22

If you go to this vertebral body, you have

14:23

this sclerotic focus here, and there was

14:25

another sclerotic focus a little bit higher up.

14:28

Again, suspicious for neoplastic involvement.

14:32

Could it be a Schmorl's node?

14:34

Could it be, uh, some other benign process?

14:36

Yes, but given the history of lung cancer,

14:39

you can't exclude metastatic disease.

14:41

So at minimum in this case, that if you're going to

14:45

concentrate on trauma, um, yeah, you'll hopefully

14:50

pick up that inferior ramus fracture, but you very

14:53

well might miss, uh, the sacral, uh, met and these

14:59

lower lumbar spine mets and then those indeterminate

14:02

lesions in the kidney and in the stomach.

15:06

However, if you follow your search pattern

15:08

to a T, and you're not going to let

15:11

the history distract you, you're

15:14

going to catch these things.

15:15

And in some cases, it's going to make a

15:17

you know, a very big difference.

15:21

So here we go.

15:24

Okay.

15:24

These are better images.

15:25

So here we see the inferior ramus fracture very nicely.

15:36

And then here you see that blown-out lytic lesion,

15:46

which you may not miss.

15:48

But then again, this is not simple trauma.

15:50

This is a true lesion.

15:55

And then as we scroll up, we have

15:57

one potential blastic focus here.

15:03

And then two over here, one, two.

16:06

So again, if you're reading fast and

16:10

you're going through things and you

16:12

know, a veer from your search pattern,

16:15

there's a better chance of you missing things.

16:21

Okay.

16:21

So again, in the setting of

16:23

trauma, I look at bones first.

16:25

Reason being, there could be a lot of non

16:27

displaced fractures, which are easy to miss.

16:30

So I just want my, uh, mind to be at its sharpest.

16:34

So when I opened a case, I feel like,

16:37

you know, um, at my sharpest.

16:39

Um, and in this situation, we have to follow

16:44

up these, you know, renal gastric lesions,

16:46

as well as the multiple sacral lesions.

16:48

Now, again, if the person has known metastatic disease

16:51

and the patient's not getting any treatment for

16:53

it, then there's no reason to work these things up.

16:56

So it really depends on, on the, on the patient.

17:00

Okay.

17:01

So earlier on, I asked about healthcare disparities.

17:07

So does anybody have any comments

17:14

you can put in the chat box

17:19

or question answers?

17:22

Does anyone think that healthcare

17:24

disparities occur in radiology?

17:27

And the, and the reason why I asked that is you

17:29

can understand in internal medicine or pediatrics.

17:32

When a patient comes into your office,

17:35

you know, okay, you can see where bias or

17:39

certain issues might come into play, but most

17:42

radiologists are reading in their reading rooms.

17:45

So you might question it.

17:47

Anybody have any thoughts?

17:49

Yeah, I say healthcare disparities

17:50

may occur and whether a patient gets a

17:52

follow up for the incidental lesions.

17:55

So that is a true statement.

17:57

So there are studies have shown that there are, uh,

18:02

healthcare disparities, uh, with respect to that.

18:05

Um, you know, for two reasons, one being

18:08

that, um, people in the lower socioeconomic

18:12

class don't get follow-up as often.

18:15

So if there's an incidental lesion, um,

18:18

they very well could be, uh, lost to follow-up.

18:21

But, you know, that's a very, very good example.

18:24

And the reality is healthcare disparities

18:27

occur in all fields of healthcare.

18:29

Radiology is no exception, although it's a little

18:33

bit surprising in some of the studies that have

18:35

been done, uh, that healthcare disparities, uh, um, occurs.

18:45

So, uh, that's a definitely a good point.

18:48

And we'll talk a little bit about

18:53

why healthcare disparities matter.

18:55

So, you know, uh, some of the research that

18:58

I did by the year 2060, they say that about

19:01

60 percent of the American population will

19:04

be made up of underrepresented minorities.

19:06

So that's a large part of the population.

19:08

So we have to be aware of to make

19:10

sure that we treat everybody equally.

19:14

They also looked at the health

19:16

care savings from 2003 to 2006.

19:20

If people avoided healthcare disparities, um,

19:24

they would have saved over about 200 billion in direct

19:28

and over 1 trillion in indirect medical expenses.

19:35

So Dan said, I read for several Native American

19:39

communities in Arizona, there are limitations

19:41

as to equipment and specialty services.

19:43

So this is another very good point.

19:46

This is a, uh, a critical part

19:49

to healthcare disparities.

19:50

So if you go out into certain areas in the United States

19:53

or anywhere in the world, you know, the more

19:56

rural or, uh, the further away from bigger cities,

19:59

it's harder to get the resources that are needed.

20:03

They may be, uh, you know, a further drive.

20:07

They may be only a couple standing facilities,

20:11

um, and it might be hard to get, uh, appointments.

20:14

So that is very true, not only for

20:15

Native Americans, but it could be, uh, you know,

20:19

in an area, uh, a poor neighborhood.

20:22

Uh, it could be, um, you know, in a population

20:28

that has poor mental health, you know, many times,

20:32

uh, there's the resources are just not available.

20:35

And then clearly, you know, anywhere in the world,

20:38

some places have more resources than others.

20:41

Okay.

20:42

So we will go to the next case and thank

20:46

you guys for, uh, putting stuff out there.

20:50

Okay, so case two and we'll continue to talk

20:54

a little bit about healthcare disparities

20:55

and we'll try to give some examples.

20:57

So just to make it a little bit real to you.

21:00

Okay, so this patient case number two, it's an

21:04

inpatient, 86 years old with a drop in hemoglobin.

21:07

So for anybody who's a resident, uh, you know,

21:11

we're looking for a retroperitoneal hematoma.

21:13

It happens to be this patient is admitted

21:15

for shortness of breath and chest pain.

21:19

So they did a CT scan.

21:24

So we have a good reason why they're short of breath.

21:27

They got pleural effusions

21:28

and bi-basilar lung opacities.

21:30

Retroperitoneal hematomas, uh, can be venous or arterial.

21:39

Um, I'm, I'm pretty sure venous is much more common.

21:42

I have seen, um, so as we're, uh, scanning through this

21:51

abdomen pelvis, there's no retroperitoneal hematoma,

21:55

or I apologize, there is a retroperitoneal hematoma.

21:59

Um, there's this obturator hematoma, and

22:06

give me one sec, this wasn't the reason why

22:08

I'm showing you, might as well show you.

22:11

There's also a hip hematoma, so if you

22:14

see the differential attenuation,

22:16

so not truly a retroperitoneal,

22:18

but a hip hematoma, and then the obturator,

22:23

uh, hematoma.

22:24

So, but again, you know, you have to be careful

22:29

not to let the satisfaction of search get you.

22:31

If you have your search pattern,

22:32

you have to follow your search pattern.

22:34

So yes, this operator is bigger

22:37

and heterogeneous than this one.

22:38

Um, so there's, uh, blood products

22:42

here and then we showed him the hip.

22:44

Um, But as I scroll up

22:50

and we're looking at the aorta, we see that

22:54

there's an infernal abdominal aortic aneurysm.

22:57

Okay.

22:58

We see those, uh, all the time,

23:00

but this one's slightly unique.

23:03

And if you're scanning through, uh, your study

23:06

fast and not necessarily following your search

23:09

pattern, you might just dictate infernal abdominal

23:11

aortic aneurysm measuring whatever, but if you see

23:16

here, there's a little outpouching to the right.

23:19

Maybe it's two centimeters, uh,

23:22

in size, and most aortic aneurysms don't do that.

23:29

And my question to you is, why do you

23:33

think that that would be important?

23:36

Anybody want to venture a guess?

23:38

Why I'm pointing this out.

23:41

Yeah.

23:41

So it could be a pseudoaneurysm.

23:44

Um, it could be mycotic, except a

23:49

pseudo aneurysm would be a better, uh, uh,

23:51

a better aneurysm or a better answer.

23:54

The other thing it could be is

23:55

it could be a penetrating ulcer.

23:56

Again, we don't have IV contrast on board.

23:59

Um, so we're not evaluating it very well, but in either

24:03

case, there's probably very, uh, there's thinning of

24:07

the wall, so impending rupture, uh, can't be excluded.

24:12

And it's not the reason why we got the CT scan, and it

24:17

may be an incidental finding, but it clearly can be an

24:20

incidental finding that, um, can be, uh, life or death.

24:27

So this person needs to get this

24:29

worked up and worked up right away.

24:31

Um, and vascular surgery or interventional

24:35

radiology, depending on the hospital

24:37

that you're in, should be involved in it.

24:40

Okay,

24:45

here I'm just showing, uh,

24:46

coronal because it kind of brings it

24:47

out a little bit better.

24:56

I've seen this type of

24:58

thing, uh, missed a few times, uh, in my career.

25:02

Um, and like I said, there's definitely a risk, uh, for

25:06

death depending on what that thing ends up becoming.

25:14

Someone was asking, how would you describe all

25:16

the fat stranding in the subcutaneous tissues?

25:18

So let's just go back to the axial.

25:21

Um, this is where history does come into play.

25:29

If they're going to tell you that

25:30

that specific area is red and hot.

25:35

Um, and the person has fever, then yes,

25:39

that area could be, uh, cellulitis.

25:41

Absolutely.

25:43

On the other hand, in this person who

25:45

has a drop in hemoglobin, and this is the

25:47

way I dictated it, maybe it's hemorrhage.

25:50

I haven't ever seen hemorrhage do this, but You

25:55

know, if somebody has a drop, conceivably it

25:58

could be blood within the subcutaneous tissues.

26:00

Now you'd be able to see that, right?

26:02

Anybody, how would you see that on a physical exam?

26:07

Anyone want to throw a chat in

26:08

or, uh, yeah, you'd see bruises.

26:11

Um, so that'd be pretty easy to see.

26:14

The other thing is in a lot of inpatients and,

26:17

um, this would be unusual because it's anterior,

26:22

but you can get a lot of subcutaneous edema and

26:25

those would be more in the dependent portions,

26:27

like in the back or adjacent to the hips.

26:30

You really wouldn't get it anteriorly.

26:32

Um, so you would see it,

26:39

you'd see it in the flanks over here.

26:42

Lots of times you'll get some subcutaneous edema.

26:44

I mean, some of this is muscle.

26:45

Also, you get some subcutaneous edema, uh, in

26:49

the back too. Somebody has anasarca, all their

26:52

subcutaneous tissues could be infiltrated.

26:55

Um, so, but for me.

26:58

Given the history of blood products,

27:01

and if you see actually there's some hyperdense

27:03

nodules, which are non-specific again,

27:07

but they could be, you know, blood products.

27:09

I mean, it could be simply small hematomas

27:11

for, you know, heparin injections.

27:13

Um, but because there was no concern

27:16

for, uh, cellulitis, you know,

27:19

I said it may represent blood products.

27:21

Whatever it is, it's not going to be overly clinically

27:25

significant, again, unless they give you the

27:27

history of cellulitis, but that's a very good point.

27:30

Right, so pseudoaneurysm versus penetrating ulcer.

27:35

This is suggestive of wall

27:37

thickening or some compromise.

27:38

And you want to consult with vascular surgery

27:41

because even though that's not what's going

27:43

to affect the patient this moment in any

27:47

few moments, it could affect the patient.

27:50

So this is a follow-up that

27:52

was done on the same patient.

27:55

Uh, and this time it was done with contrast.

27:57

I mean, it was a few days later for something else.

28:00

Um, but it's actually useful for us because we

28:03

can get a, a decent look at that, uh, aorta.

28:08

So we're getting close to it.

28:11

And as we get to it, we see

28:13

the whole thing is thrombosed.

28:15

So it's less worrisome at this point because whatever

28:22

it is, if it's a pseudoaneurysm, it's thrombosed.

28:25

You know, vascular surgery should still

28:27

be on board because this may change

28:29

their algorithm for, for treatment.

28:31

But from our standpoint, it'd be a

28:34

little less worrisome than if that

28:36

whole thing filled in with IV contrast.

28:39

Okay.

28:39

So before we get to case three, so I just want

28:43

to throw out, uh, some interesting statistics,

28:46

uh, because it kind of blew me away when

28:49

I was doing some of my research and stuff.

28:51

And you guys let me know what you think about it.

28:53

You know, there was a study that was done in 2013,

28:57

where they looked at 150 patients who had missed

29:01

breast cancers, and they figured this out by,

29:04

uh, you know, they diagnosed the breast cancer

29:06

on mammogram, and then they went back and looked

29:09

at old mammograms to see if there were misses.

29:11

So they picked 150 of these misses.

29:16

And what was interesting is this study actually

29:20

looked at the demographics as opposed to,

29:24

you know, other reasons for, uh, for the misses.

29:27

And the demographics were, uh,

29:31

all statistically significant.

29:32

And really were surprising.

29:36

Uh, the misses were greater amongst minorities, um,

29:40

greater in patients with incomes below 30,000, uh,

29:45

greater in patients with less education, um, and

29:48

greater in patients without private health insurance.

29:52

And it's a little bit shocking because most of us, I,

29:58

I believe in radiology, you know, don't necessarily

30:02

look for those things when we're trying to make

30:04

a diagnosis, but clearly it creeps in somehow.

30:08

Um, and again, I don't know the exact reasons,

30:11

you know, for this, but clearly it happens.

30:14

Now someone might argue that, you know,

30:17

mammography is more patient-facing.

30:20

You get to meet the patient, talk to the patient.

30:22

Maybe that's how a bias and

30:25

things like that can creep in.

30:27

Um, but after the next case, I'll talk about another

30:31

study where it talks about all radiological images.

30:34

So I'm just gonna throw it at you guys.

30:37

Anybody have any thoughts or, uh, ideas about that?

30:41

I was a little surprised when

30:42

I saw that, uh, research article.

30:46

Okay, we'll go to case three.

30:48

Anybody has any points?

30:50

You can always, uh, put it out there.

30:54

Okay, so case three, um, and let's just remember case

30:57

one, we found an incidental gastric lesion, renal

31:01

lesion, and we found metastatic disease to the bones.

31:04

Case two, we found a pseudoaneurysm

31:07

with an infarenal abdominal aneurysm.

31:10

This is a person who comes

31:11

in with bilateral flank pain.

31:13

He has a history of kidney stones.

31:15

So it's a stone study.

31:19

So we'll get to that in a second, Fahad,

31:21

but thank you very much for throwing that in there.

31:24

Okay, so this is, let's finish this case first.

31:27

Uh, so this is CT scan non-con,

31:29

which is what we do for a stone hunt.

31:32

Um, as I move down,

31:39

you start seeing some plump lymph nodes.

31:43

Now, generally speaking, you know, if a

31:46

lymph node is, uh, less than one centimeter

31:49

in shortest dimension, in most areas of the

31:51

body, it's not anything to be concerned about.

31:55

But if I have something to compare to,

31:59

and it was much smaller in the past,

32:01

that means some kind of process happening.

32:03

It could be reactive, inflammatory,

32:05

or it could be something more serious.

32:07

And as we scroll down a little bit more,

32:13

we got some big external iliac lymph nodes

32:17

on the left, and we actually have on the right also.

32:23

And by size criteria, this is

32:25

considered lymphadenopathy.

32:27

Again, the patient is coming in for a stone study.

32:30

So this is essentially an incidental finding.

32:34

Um, but it could be very critical.

32:37

So I had a patient that was, uh, like

32:40

this, but it was a solitary lymph node.

32:42

Um, and I guess they kind of followed it,

32:46

but at some point they biopsied it and it

32:48

was essentially like a low-grade lymphoma.

32:51

I'm not saying that everybody, you know,

32:54

is like that, but when something, appears abnormal.

32:59

It's okay to bring up to the referring physician.

33:03

You know, this is not what I would

33:05

typically anticipate, and I'm not

33:08

saying this has been a static disease.

33:09

A person doesn't have a primary,

33:12

but let's look into it and let's work it up.

33:15

Um, it happens to be this

33:16

patient had a lot of prior CTs.

33:19

This has been stable over time.

33:21

So the other thing I, you know, going back

33:24

to when I said that, you know, the books

33:26

tell you where metastatic disease occurs,

33:28

the books tell you how big lymph nodes should be.

33:30

But in some people, the lymph nodes might be

33:33

a little bit more prominent than expected.

33:36

And again, maybe something is happening.

33:38

But if it's been stable over many, many years,

33:40

then there's really nothing to worry about.

33:42

But again, in a, in a stone study,

33:44

you're going to concentrate on the kidney stones.

33:46

You may not be following your pelvic lymph node chain.

33:50

So just one thing that I do because, uh, I find it's

33:55

very easy to miss peritoneal nodules, carcinomatosis,

33:59

uh, serosal implants and things like that.

34:01

So just in my search pattern, when I, uh, look

34:06

at every CT scan, uh, I really divide up the

34:09

body into, uh, thirds so that I can evaluate

34:14

each section, uh, you know, relatively carefully.

34:18

Um, and, and in that way, for me, uh, uh,

34:23

uh, there's less often that I'll miss an

34:25

isolated mesenteric enlarged lymph node or,

34:28

you know, a carcinoid or things of that nature.

34:30

So again, you have to see what works for you,

34:34

but lymph nodes, uh, are very commonly missed, uh, areas.

34:42

So this person had retroperitoneal

34:45

and pelvic lymphadenopathy.

34:46

Okay, so let's go to what Fahad said.

34:49

Fahad said, Maybe those mammographic misses

34:53

were because of low-income population

34:56

are provided with suboptimal medical

34:58

services in terms of doctor's education.

35:01

Look, I mean, it, I think anything is a possibility.

35:06

Again, you'd hope that, uh,

35:09

you know, we're all doctors.

35:10

We're all relatively well-educated that

35:13

that really shouldn't come into play.

35:16

But clearly something came into play in those

35:19

situations, uh, that would need to be evaluated.

35:24

So it could be, you know, maybe in underserved areas,

35:29

the only people they can hire are people who maybe

35:32

don't have as strong of a background.

35:35

You know, the other thing is, is that in underserved

35:38

areas, sometimes the volumes are higher because

35:42

these people haven't been able to get the imaging

35:45

that they need, and then things get really busy,

35:49

so all of a sudden, the physicians have to work faster

35:51

and faster, you know, if you work really fast,

35:54

there's an increased chance of making a mistake.

35:57

So, you know, that's another possibility.

35:59

It's interesting because I spoke to some

36:01

people, um, and I think this is a great idea.

36:04

Um, some organizations have like a mammogram,

36:09

a van that drives out to, uh, underserved areas to

36:14

get mammograms, uh, to offer mammograms to people.

36:18

And that's really a, a great idea and things like that.

36:22

These kinds of innovative ideas.

36:24

can help us in radiology try to tackle

36:28

what's going on, uh, from, from our

36:30

standpoint with healthcare disparities.

36:33

So I told you I was going to talk

36:35

about another, uh, research article.

36:39

So there was a retrospective review

36:41

that was done from 2015 to 2016.

36:45

Um, And it looked at something that they

36:49

called imaging miscare opportunities.

36:52

This is, uh, you know, a person made an

36:55

appointment, um, and they missed their appointment.

36:58

And they looked at those missed

37:00

appointments, and then they looked at the

37:01

demographics of those missed appointments.

37:03

They looked at about 60,000 patients,

37:06

and they looked at all imaging.

37:09

So it wasn't just mammogram.

37:10

And again, in this study, they found that

37:14

there was disparate, uh, things going on.

37:17

They found that the median household

37:21

income was less than 50,000 were more likely to

37:25

have a missed, uh, care opportunity as opposed

37:28

to somebody who had an income of over 100,000.

37:32

There was higher rates in

37:33

minorities or non-English speakers.

37:36

So, you know, just based on these two quick studies,

37:40

healthcare disparities definitely occur in radiology.

37:44

So it's incumbent upon us to, you know, try to work on

37:48

what we can do now for people who live, like I said,

37:51

in other countries, sometimes it's much more obvious.

37:54

Um, and, and there's a lot of work that would

37:59

need to be done to conquer healthcare disparities.

38:01

But again, if, uh, you know, we're cognizant

38:05

of it, then we can actually make an impact.

38:08

So let's go to case number four.

38:14

So this patient, 57-year-old, presents with

38:18

vomiting, abdominal pain, and diabetic ketoacidosis.

38:24

So by itself, the DKA could

38:29

be causing the vomiting.

38:31

So your index of suspicion may be very

38:35

low for this CT scan, but again, you want

38:38

to make sure you follow your pattern.

38:41

So I'm going to show two things here.

38:46

The first thing is back to my

38:48

favorite thing, which is lymph nodes.

38:55

Right in along the left

38:57

internal iliac chain right here.

39:01

There's an enlarged lymph node.

39:03

Now, it's not huge, but it's

39:06

definitely an enlarged lymph node.

39:08

There's no fatty hilum.

39:10

Um, it's problematic.

39:12

What's causing it?

39:14

I don't know.

39:15

It could be, for example, although in this patient,

39:18

you know, it's not the case if the person has cystitis,

39:21

or prostatitis, maybe the person has proctitis,

39:24

you know, all those kinds of inflammatory infectious

39:27

things can cause some reactive lymphadenopathy.

39:29

On the other hand, it could be an early sign of

39:32

cancer or something, so it needs to be worked up.

39:36

Now sometimes, you know, let's say they do tumor

39:41

markers or whatever, and everything comes back negative.

39:45

And you can't biopsy.

39:46

This one is not really in the location to biopsy.

39:49

So then you get a short-term interval follow-up CT.

39:51

You just want to make sure that

39:52

it, you know, stays stable in size.

39:55

And maybe it's, you know, it's one of these

39:57

patients that just has a big lymph node.

40:00

Um, the other thing in this patient,

40:04

so another area that's kind of hard, and I'm

40:07

going to show another case, uh, later on,

40:09

I'll try to speed things up a little bit.

40:11

Is, uh, the small bowel.

40:13

That's an area that

40:15

it's easier to miss things.

40:17

So in this left abdomen right here, there's a small

40:20

bowel-to-small bowel intussusception without obstruction.

40:24

And you'll actually see this commonly, uh,

40:28

or not so commonly, but definitely commonly

40:31

without obstruction in older people.

40:33

But it clearly can be a cause of pain.

40:37

The reason why I know it's a small bowel-to-

40:39

small bowel intussusception is this little

40:41

curvilinear hypodensity is an area of fat,

40:45

and that's classic, uh, for having fat within two

40:50

bowel loops, um, to be, uh, intussusception.

40:54

So in this case here, we found an intussusception.

40:57

We found an enlarged lymph node.

40:59

We got some things to, you know, to work up.

41:02

Let's go to case five, so 65-year-old with constipation.

41:10

So this one I, I like, and it goes a little

41:15

bit along with my, uh, lymph node concerns.

41:22

So in this person, person's

41:25

status was ventral hernia repair.

41:28

So, ventral hernia repair anteriorly, there's

41:32

inflammatory changes, um, we see the mesh.

41:37

Which is this white line over here.

41:41

And all that makes sense that there'll be postoperative

41:45

changes, even if surgery was done a long time ago.

41:47

But what doesn't make sense is if

41:50

you look a little bit to the left,

41:55

it's a little bit too infiltrative

41:58

and nodular away from the hernia.

42:04

This whole area is kind of nodular.

42:08

And then if you start looking

42:10

a little bit more carefully,

42:15

anterior to the cecum right

42:17

here, kind of hard to see here.

42:20

I apologize.

42:21

There's some nodularity as well.

42:24

And then

42:26

region of the left sacrum.

42:34

So there's a little free fluid

42:36

here and there's some.

42:37

soft tissue nodularity here.

42:39

So anybody have any thoughts when I'm trying to get at?

42:43

Yeah, peritoneal carcinomatosis.

42:45

And, uh, this person actually

42:48

has a history of ovarian cancer.

42:50

And again, remember the patient

42:51

is coming in for constipation.

42:53

Um, if you follow your search pattern,

42:57

you're going to pick up those things, although

42:59

you weren't expecting those things at all.

43:02

Um, so that's why search pattern is very important.

43:07

And let me tell you, you know, the times I miss

43:09

things every time I do, I readjust my search pattern

43:13

slightly, just tinker with it a little bit to start

43:16

including that area that I, uh, had a miss with.

43:20

Um, and it tends to help.

42:22

So if we continue with this case.

43:30

So we got our common femoral vein here.

43:32

We have a common femoral vein here.

43:35

And if you look, there looks like

43:37

there may be a filling defect here.

43:39

Now it's only on a couple of slices,

43:46

but it's, it's real enough that, you know,

43:51

you have to suggest, you know, maybe it's on the side

43:53

also that you should suggest a, an ultrasound.

43:56

Now, one thing you have to watch out for is

43:58

sometimes there's mixing artifact that can occur.

44:01

So usually mixing artifact will be pretty symmetric

44:05

on, on both sides, but if there's any concern

44:08

at all for a DVT, then an ultrasound doesn't

44:12

hurt to get, they did an ultrasound on this person

44:14

and they had a right common femoral vein DVT.

44:18

You could see there's, you know,

44:20

let's say these are the thin slices.

44:22

500 pictures and you're all the way at the bottom

44:27

of your scan and then you pick up something.

44:31

There's maybe 10 slices left and you pick this up.

44:34

So, um, again, if you follow your search pattern,

44:38

there's less of a chance of missing it.

44:42

So possible carcinomatosis.

44:44

So again, they should do tumor markers.

44:46

Um, somebody asked, I use a

44:50

search pattern when I read cases.

44:52

However, when I come to the end of the

44:53

case, I often can't sign off the report

44:55

because I think I may have missed something.

44:56

So I re-scroll again and again, any suggestions?

44:59

So I think this is a common thing,

45:02

uh, amongst, uh, radiologists.

45:05

Um, I can tell you, you know, one thing that I

45:10

started doing is, uh, after each area of the body,

45:16

I kind of put an extra period because then I know

45:21

that I've, uh, looked at it because everything

45:23

is a template now when, you know, when I first

45:25

started doing radiology, I freely dictated.

45:27

So I, if I freely dictated, I knew I

45:30

looked at it because otherwise they

45:31

wouldn't have said the kidneys are normal.

45:33

Now everything is a template.

45:35

So I go an extra mile and you know,

45:40

for when it says liver colon, unremarkable.

45:43

Then I'll add another period to it.

45:45

Then I know when I go back, especially when

45:47

you get interrupted a hundred times, that,

45:50

you know what, I did look at the liver.

45:51

I don't need to, you know, uh, to go back.

45:55

Um, that's one solution.

45:58

Um, the rest of it, you, you have

46:02

to be willing to trust yourself.

46:05

Um, I don't know if that answers your question,

46:09

but so 60-year-old for pre-op evaluation.

46:14

Okay.

46:15

I just wanted to show a couple of chest X-rays

46:16

because this is another place where people

46:18

tend to miss things, especially pre-op chest

46:22

X-rays because they tend to always be negative.

46:25

But the whole point of getting a pre-op chest

46:27

X-ray is those few times that they're positive.

46:30

So in this case here, if you look at the

46:33

chest X-ray, it doesn't look overly exciting.

46:36

Um, I'm going to show you a close-up and right in

46:40

this left lower lobe, there's a rounded density.

46:44

Now it could be a nipple shadow.

46:47

So anybody, what would you do if

46:49

you thought it was a nipple shadow?

46:50

What would you recommend?

46:53

Any thoughts?

46:56

Nipple markers.

46:56

Perfect.

46:57

So repeat the chest X-ray with nipple

46:59

markers, frontal and lateral view.

47:03

If it is a nipple, the marker will be there.

47:05

And, um, that answers the question.

47:09

Um, and if it's not, then it's a pulmonary

47:11

nodule and the patient needs to get a chest CT.

47:15

Does it mean it's malignant?

47:16

No, it doesn't necessarily mean it's malignant.

47:19

Um, but the point is, if it's greater than eight millimeters,

47:23

you probably do want to get a PET scan to see

47:25

if, uh, you find an incidental lung cancer.

47:28

So I'm going to show another case.

47:33

This is another person for pre-op evaluation.

47:38

And this one was a weird case.

47:39

I actually consulted one of our thoracic radiologists.

47:42

I'm a body imager, so I consulted

47:43

one of the thoracic radiologists.

47:45

Uh, anybody see anything abnormal?

47:48

And you can just type it in.

47:51

Right lung base is good.

47:53

If you were talking about this thing over here,

47:56

I'm not sure you were, that's just the end of a rib.

47:58

So sometimes those can look scary.

48:01

So what I'm going to point out to you,

48:04

it's a little weird, but this is a female.

48:07

So we have a breast shadow here.

48:10

Um, and we have a breast shadow here.

48:13

And if you actually look, the left

48:15

breast shadow is higher up than the right.

48:17

So this person actually had a history

48:19

of partial mastectomy on the left side.

48:22

But if you go back to the right axilla,

48:24

you have this rounded structure over here,

48:30

and I'll show you up here,

48:35

you have this rounded structure.

48:36

So it's a chest wall thing.

48:40

I'm not going to call it a lesion

48:41

because I don't know what it is.

48:42

Um, clearly on physical examination,

48:46

they should be able to see it.

48:48

Uh, the reason why it's important is

48:50

first of all, it wasn't there on prior

48:52

chest X-rays that you have to trust me.

48:54

Second of all, it's not on the other side.

48:57

Um, so if it were excess fat or something,

49:00

usually that would be symmetric.

49:02

Um, and my concern was the person

49:05

did have left breast cancer.

49:08

Could it somehow be some axillary adenopathy

49:10

or something going on in that location?

49:13

Um, so what would you do next?

49:17

You could do an MRI or CT.

49:19

The easiest thing to do is,

49:25

give me one sec, is a physical.

49:28

You could do a physical and

49:30

see if you see anything there.

49:32

And if at that point you have some suspicion,

49:34

I'd probably go to a CT first because if it's

49:37

lymphadenopathy, it's an easy way of diagnosing it.

49:40

MRI would be a little bit extreme.

49:42

But yeah, I think a physical exam would

49:43

be the first thing that you'd want to do.

49:48

Let's see if we have time for

49:51

this is a 49-year-old with abdominal pain.

49:59

There's this little lesion hanging off of the

50:01

small bowel.

50:03

It was a really good pickup by one of the radiologists.

50:06

Now it could be maybe a diverticulum,

50:08

but it could be some kind of mass.

50:12

So they actually ended up getting an MR

50:14

enterography, which I had to read, and I'm

50:18

looking all over the left side for this lesion

50:20

because that's where it was on the CT scan.

50:25

And it's here on the right side on the MRI.

50:30

And look, small bowel is not tacked down.

50:34

It can be, it can move to different areas.

50:37

But again, if you're working up

50:39

something, don't just give up.

50:42

Um, um, And to me, this was a very good

50:46

example of it was an unexpected location.

50:49

I was looking all over on the left side

50:50

and it was actually on the right side.

50:55

So I don't know if anybody has any other questions

50:58

because I think we're running out of time.

50:59

I hope that you guys enjoy this.

51:02

I know we weren't talking about complex

51:04

cases, but I really feel these types of things

51:06

will help you become a better radiologist.

51:08

The other thing is, um, yeah,

51:10

I think, you know, all of us should start

51:12

considering healthcare disparities and

51:15

what we can do to help the situation.

51:17

If you start doing some research with articles,

51:19

you'll see some very interesting studies out there.

51:22

Uh, anybody have any questions?

51:26

This is my contact information.

51:28

You can write it down, my cell,

51:30

my Twitter handle, my email addresses.

51:33

Anybody have any questions?

51:34

Uh, somebody just wrote, I've been in practice

51:38

for 10 years and I keep promising that I

51:40

won't miss cases, but it happens on and off.

51:42

I don't find radiology is enjoyable anymore.

51:44

Any advice?

51:45

Look, I mean, I think we all miss cases.

51:49

Um, but there's more often than not, you're

51:54

doing a lot to help some patient out there.

51:58

Um, and I use the missed cases as a very good learning

51:02

opportunity, um, to make myself a better radiologist

51:05

and then also to try to educate other people.

52:08

So there are other radiologists out there

52:10

who won't necessarily make the same mistake.

52:12

And in that way, you'll have a very big impact.

52:16

I've been practicing for a little over 10 years also.

52:19

Um, and one other thing I would say is the literature

52:22

does say that people should spend about 20%

52:25

of their time doing something else in their primary

52:30

field, let's say, which is, you know, radiology.

52:33

Um, and that could be academics.

52:35

It could be scholarly research.

52:36

It could be, you know, radiology.

52:38

There's so many cool things, artificial

52:39

intelligence, um, global health, maybe try to,

52:44

you know, have another outlet, uh, as well.

52:48

Um, but I try to use the missed case opportunities

52:51

to develop myself and to develop either my

52:55

residents, students, or friends or whatever it is.

52:59

Nice question.

53:00

Thank you.

53:01

Thank you.