Publications by authors named "Roopa Ram"

34 Publications

Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

AJR Am J Roentgenol 2021 Oct 10;217(4):800-812. Epub 2021 Sep 10.

Department of Gastrointestinal Surgery, Massachusetts General Hospital Pelvic Floor Disorders Center, Harvard Medical School, 55 Fruit St, GRB 425, Boston, MA 02114.

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.
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http://dx.doi.org/10.2214/AJR.21.26488DOI Listing
October 2021

Imaging After Locoregional Therapy for Hepatocellular Carcinoma With Emphasis on LIRADS Treatment Response Assessment Criteria.

Semin Ultrasound CT MR 2021 Aug 2;42(4):390-404. Epub 2021 Apr 2.

University of Arkansas for Medical Sciences, Little Rock, AR.

The Liver Imaging Reporting and Data System (LI-RADS) is a set of algorithms designed to provide a standardized, comprehensive framework for the interpretation of surveillance and diagnostic imaging in patients at high risk for hepatocellular carcinoma. LI-RADS is the result of a multidisciplinary collaboration between radiologists, hepatologists, hepatobiliary surgeons and pathologists and has recently been incorporated into the practice guidelines for the American Association for the Study of Liver Diseases (AASLD) and made congruent with the Organ Procurement and Transplantation Network (OPTN) criteria. This manuscript illustrates the common ultrasound, computed tomography, and magnetic resonance imaging appearances of hepatocellular carcinoma and describes how these findings can be properly categorized using the LI-RADS system.
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http://dx.doi.org/10.1053/j.sult.2021.03.002DOI Listing
August 2021

Imaging After Locoregional Therapy for Hepatocellular Carcinoma with Emphasis on LIRADS Treatment Response Assessment Criteria.

Semin Ultrasound CT MR 2021 Aug 18;42(4):318-331. Epub 2021 Apr 18.

Associate professor of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR.

Radiologists play an essential role in assessing hepatocellular carcinoma treatment response and help guide further clinical management of patients. Interpretation of treatment response after locoregional therapy is challenging. The post-treatment imaging findings vary and depend on the type of treatment, the degree of treatment response, time interval after treatment and several other factors. Given the widespread use of local-regional therapies, understanding the appearance of treated lesions has become crucial to allow for a more accurate interpretation of post-treatment imaging. Several response criteria including the recently introduced Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) are currently used to assess treatment response. This review article describes the imaging assessment of HCC treatment response after several locoregional therapies using various response assessment criteria, emphasizing the LI-RADS treatment algorithm.
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http://dx.doi.org/10.1053/j.sult.2021.04.004DOI Listing
August 2021

LI-RADS treatment response lexicon: review, refresh and resolve with emerging data.

Abdom Radiol (NY) 2021 08 9;46(8):3549-3557. Epub 2021 Jun 9.

Abdominal and Cross-Sectional Interventional Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2 A209R, Ann Arbor, MI48109, USA.

The imaging findings after loco regional treatment of hepatocellular carcinoma are variable based on the type of treatment used, the timing interval of imaging after treatment, and the cross-sectional modality used for treatment response assessment. Liver Imaging Reporting and Data System (LI-RADS) Treatment Response Algorithm (TRA) is a relatively new standardized method of evaluating treatment response after loco regional therapy to hepatocellular carcinoma. In this article, we provide an overview of the evolution of the treatment response algorithm, its current applicability and its outlook for the future. We will review current guidelines and discuss proposed changes to the algorithm as a means to continually improve LI-RADS TRA as an assessment tool post-loco regional treatment of hepatocellular carcinoma.
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http://dx.doi.org/10.1007/s00261-021-03149-xDOI Listing
August 2021

Clinical applications of pelvic floor imaging: opinion statement endorsed by the society of abdominal radiology (SAR), American Urological Association (AUA), and American Urogynecologic Society (AUGS).

Abdom Radiol (NY) 2021 04 27;46(4):1451-1464. Epub 2021 Mar 27.

Department of Radiology, SAR DFP, University of Texas Southwestern Medical Center, Dallas, USA.

Pelvic floor dysfunction is prevalent, with multifactorial causes and variable clinical presentations. Accurate diagnosis and assessment of the involved structures commonly requires a multidisciplinary approach. Imaging is often complementary to clinical assessment, and the most commonly used modalities for pelvic floor imaging include fluoroscopic defecography, magnetic resonance defecography, and pelvic floor ultrasound. This collaboration opinion paper was developed by representatives from multiple specialties involved in care of patients with pelvic floor dysfunction (radiologists, urogynecologists, urologists, and colorectal surgeons). Here, we discuss the utility of imaging techniques in various clinical scenarios, highlighting the perspectives of referring physicians. The final draft was endorsed by the Society of Abdominal Radiology (SAR), American Urogynecologic Society (AUGS), and the American Urological Association (AUA).
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http://dx.doi.org/10.1007/s00261-021-03017-8DOI Listing
April 2021

Variability in utilization and techniques of pelvic floor imaging: findings of the SAR pelvic floor dysfunction disease-focused panel.

Abdom Radiol (NY) 2021 04 13;46(4):1294-1301. Epub 2021 Feb 13.

University of Texas Southwestern Medical Center, Dallas, USA.

Pelvic floor disorders are common and can negatively impact quality of life. Imaging of patients with pelvic floor disorders has been extremely heterogeneous between institutions due in part to variations in clinical expectations, technical considerations, and radiologist experience. In order to assess variations in utilization and technique of pelvic floor imaging across practices, the society of abdominal radiology (SAR) disease-focused panel on pelvic floor dysfunction developed and administered an online survey to radiologists including the SAR membership. Results of the survey were compared with published recommendations for pelvic floor imaging to identify areas in need of further standardization. MRI was the most commonly reported imaging technique for pelvic floor imaging followed by fluoroscopic defecography. Ultrasound was only used by a small minority of responding radiologists. The survey responses demonstrated variability in imaging utilization, patient referral patterns, imaging protocols, patient education, and interpretation and reporting of pelvic floor imaging examinations. This survey highlighted inconsistencies in technique between institutions as well as potential gaps in knowledge that should be addressed to standardize evaluation of patients with pelvic floor dysfunction.
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http://dx.doi.org/10.1007/s00261-021-02957-5DOI Listing
April 2021

A 15-Year Analysis of International Medical Graduates Matching Into Diagnostic Radiology Residency Programs in the United States.

Acad Radiol 2020 Nov 3. Epub 2020 Nov 3.

Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Electronic address: https://twitter.com/DrRoopaRam.

Rationale And Objectives: To analyze the trends in international medical graduates (IMGs) matching into diagnostic radiology residency programs in the United States (US).

Materials And Methods: The National Resident Match Program data was accessed for years 2005-2020 and diagnostic radiology residency-specific data was extracted for US MD, osteopathic (DO), and IMG applicants. IMGs were categorized into US-citizen IMGs and non-US citizen IMGs per the National Residency Match Program. Variables collected for each year included the number of positions, number of applicants in each group, positions filled/unfilled, and fill rate of each group. Additional data for some years included USMLE Step 1 score, United States Medical Licensing Examination (USMLE) Step 2 clinical knowledge (CK) score, number of research experiences, number of abstracts/publications, and additional degrees obtained. Trends were analyzed using simple linear regression model and p value <0.05 was considered significant.

Results: The number of diagnostic radiology residency programs increased from 203 (2006) to 212 (2020). The total number of diagnostic radiology residency positions increased from 1011 (2006) to 1113 (2020), with the peak of 1145 in 2014. The overall "match rate," that is, proportion of positions filled to positions available, increased from 96.4% (2006) to 97.3% (2020), with a brief decline to 86.7% in 2015. Among the filled positions, the proportion filled by US medical school graduates significantly declined from 89.7% (2006) to 69.2% (2020) (p < 0.001), and the proportion of positions filled by osteopathic seniors and graduates significantly increased from 2.2% (2006) to 15.1% (2020; p < 0.001). The proportion of US IMGs increased from 3.2% (2006) to 5.4% (2020), while the proportion of non-US IMGs increased from 4.4% (2006) to 9.4% (2020), with overall IMG match rate increased significantly from 7.6% to 14.9% (p = 0.009). The mean Step 1 scores of US IMGs and non-US IMGs were 238 and 237.3, and the mean Step 2 CK scores were 241.67 and 241, respectively. Cumulatively over the study period, a total of 736 US IMGs and 1051 non-US IMGs have matched into diagnostic radiology residency.

Conclusion: There is an increasing proportion of IMGs, especially the non-US citizen IMGs, matching into US radiology residency programs in the last decade. Diagnostic radiology remains a competitive specialty evidenced by average USMLE scores higher than national average and research experiences of matched candidates.
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http://dx.doi.org/10.1016/j.acra.2020.09.018DOI Listing
November 2020

Factors Influencing the Commitment of Students to Radiology as a Career Choice During Medical School Education.

Acad Radiol 2021 08 3;28(8):1174-1178. Epub 2020 Sep 3.

Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205.

Rationale And Objectives: The purpose of this study is to analyze the significance of specific factors in choosing radiology as a specialty compared to switching to/from a different specialty as reported in the Graduation Questionnaire (GQ) and Matriculating Student Questionnaire (MSQ) data provided by Association of American Medical Colleges.

Method And Materials: The study cohort included students who completed both the MSQ and GQ questionnaires in the span of 3-5 years. The cohort was divided into three groups-"Committed" (students who chose radiology in both the first and final year of medical school), "Switched Away" (students who chose radiology on the MSQ but later switched to a different specialty, and "Switched-To" (students who chose radiology on GQ after initially selecting an alternate specialty on the MSQ).

Results: Of 1965 students who chose radiology between the years 2013 and 2016, 281 were Committed, 625 Switched-Away, and 1059 Switched-To. There were significant differences among the groups for salary, length of residency, and work-life balance factors. In the Switched-Away group, more students were influenced by length of residency (18% vs. 5%, p < 0.001) and fewer were influenced by salary (21% vs. 30%, p=0.004) or work-life balance (54% vs. 66%, p = 0.001) when compared to the Committed group. The Switched-To group did not significantly differ from the Committed group (all p > 0.05) for length of residency (6% vs. 5%), salary (30% vs. 30%) and work-life balance (69% vs. 66%).

Conclusion: The data provide insight into factors that influence medical students to initially commit to, switch away from, and switch to radiology during medical school. Understanding these dynamics can inform mentors to guide medical students who are interested in a radiology career.
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http://dx.doi.org/10.1016/j.acra.2020.07.025DOI Listing
August 2021

Peritoneal Dialysis Catheter-Fallopian Tube Fistula.

Kidney Int Rep 2020 Aug 21;5(8):1356-1359. Epub 2020 May 21.

Department of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

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http://dx.doi.org/10.1016/j.ekir.2020.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403557PMC
August 2020

Diagnostic Radiology Residency Program Director Workforce in the United States: A Descriptive Analysis.

Acad Radiol 2021 04 4;28(4):579-584. Epub 2020 Jul 4.

Department of Radiology, University of Arkansas for Medical Sciences, 1 Children's Way, Slot #105, Little Rock, AR 72202. Electronic address:

Purpose: To investigate and describe the demographics, academic background, and scholarly activity of Diagnostic Radiology (DR) residency program directors in the United States.

Methods: A list of all DR residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and corresponding program directors (PD) was obtained from ACGME website. Information about each PD was obtained from publicly available sources including program websites, Healthgrades and Doximity. Demographic and academic data including age, sex, educational background, subspecialty, tenure, interval between residency completion and appointment as PD, terms served, additional degrees, academic rank, prior leadership positions and metrics of scholarly activity were recorded. Nonparametric statistics including Mann-Whitney U and Kruskal-Wallis tests were applied to compare differences between groups. Results are considered statistically significant at p < 0.05.

Results: A total of 197 PDs were included in the study of which 139 (70.6%) were male. Average age of PDs was 47.56 years (SD 8.29, median 45, range 35-77). There was no significant difference in median age of male vs female PDs (45 vs 44.5, p = 0.655). Majority of PDs attended American medical schools (181/197, 91.9%), and 16/197 attended international medical schools. Nine PDs received DO degrees (9/197, 4.6%). Academic rank was available for 137 PDs, of which 4 (2.9%) were instructors, 63 (46.0%) were assistant professors, 47 (34.3%) were associate professors and 23 (16.8%) were professors. Fellowship information was available for 183 PDs, of which the most common subspecialties were neuroradiology (24.5%), musculoskeletal radiology (15.8%), abdominal radiology (10.3%), and interventional radiology (9.8%). Female PDs had a significantly higher median publications (13.5 vs 6.0, p = 0.003), median citations (133 vs 37, p = 0.19) and median h-index compared to male PDs (6 ± 3, p = 0.005).

Conclusion: Radiology PDs are mostly males who graduated from US allopathic medical schools. Female PDs had significantly higher scholarly metrics compared to male PDs. Twenty three percent PDs were appointed in the last 1 year.
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http://dx.doi.org/10.1016/j.acra.2020.06.020DOI Listing
April 2021

Comprehensive Review of Abdominopelvic Mesenchymal Tumors With Radiologic Pathologic Correlation and Update on Current Treatment Guidelines-Part 2.

Semin Ultrasound CT MR 2020 Apr 14;41(2):239-259. Epub 2020 Mar 14.

Department of Radiology and Orthopedics, University of Arkansas for Medical Sciences, Little Rock, AR; University of Arkansas for Medical Sciences, Little Rock, AR.

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features, and treatment options available helps the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft-tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.
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http://dx.doi.org/10.1053/j.sult.2020.03.003DOI Listing
April 2020

Comprehensive Review of Abdominopelvic Mesenchymal Tumors with Radiologic Pathologic Correlation and Update on Current Treatment Guidelines - Part 1.

Semin Ultrasound CT MR 2020 Apr 15;41(2):222-238. Epub 2020 Feb 15.

Department of Radiology and Orthopedics, University of Arkansas for Medical Sciences, Little Rock, AR.

Soft-tissue sarcomas are a diverse group of rare mesenchymal malignancies accounting for only 1% of all solid adult malignancies. These have been categorized in 12 broad groups by the World Health Organization (WHO) with their recent update in 2013. Majority of them lack specific imaging features serving as imaging conundrums for a radiologist. These are often large masses at presentation as they are asymptomatic or cause vague clinical symptoms. These tumors are challenging for surgeons as well as they find it difficult to achieve complete resection because of complex intra-abdominal anatomy and their close relationship with critical structures. Often, a multidisciplinary approach is required to decide on the most appropriate management for these complex cases so as to provide optimal patient care. Knowledge of the WHO classification, pathologic features and available treatment options will help the radiologist make a meaningful contribution in multidisciplinary discussions of such cases and overall patient care. Liposarcoma (well-differentiated and dedifferentiated liposarcomas), leiomyosarcoma, and gastrointestinal stromal tumor are the 3 most common primary intra-abdominal sarcomas. In part 1 of this article, general features of soft tissue sarcomas and some of the common tumors from WHO category 1-4 found in abdomen and pelvis are discussed. Part 2 will focus on common tumors from remainder of the WHO categories.
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http://dx.doi.org/10.1053/j.sult.2020.01.002DOI Listing
April 2020

Letter from the Guest Editors.

Semin Ultrasound CT MR 2020 04 9;41(2):121. Epub 2020 Mar 9.

Department of Radiology, University of Arkansas for Medical Sciences, 4301, W. Markham Street, Little Rock, 72205 AR.

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http://dx.doi.org/10.1053/j.sult.2020.03.002DOI Listing
April 2020

Pelvic floor imaging with MR defecography: correlation with gynecologic pelvic organ prolapse quantification.

Abdom Radiol (NY) 2021 04;46(4):1381-1389

Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, 4301 W Markham Street, Slot #556, Little Rock, AR, 72205-7199, USA.

Purpose: Pelvic organ prolapse (POP) is assessed differently by gynecologists and radiologists. It is clinically staged by physical examination using the POP-Q (Pelvic Organ Prolapse Quantification) system and radiologically staged by modalities such as by Magnetic Resonance Defecography (MRD). The purpose of this study was to correlate the two methods of staging pelvic organ prolapse for each pelvic compartment by comparing correlative anatomic points and differences in technique. This understanding will help synthesize information from two different perspectives and bridge the gap between multiple specialists who participate in the care of patients with complex pelvic floor disorders.

Methods: A retrospective single institution study comparison of patients who underwent both dynamic magnetic resonance pelvic floor imaging and pelvic organ prolapse quantification (POP-Q) at our medical center was done. Two urogynecologists performed the POP-Q and one fellowship-trained radiologist interpreted the MRD and both staged pelvic organ prolapse independently.

Results: A total of 280 patients underwent magnetic resonance imaging (MRI) of the pelvic floor from 1/2013 to 12/2017, of whom 68 met our inclusion criteria. When compared to POP-Q, MRI has strong, moderate, and weak correlation for quantification of anterior, middle, and posterior compartment prolapse, respectively. POP-Q measurements Aa, Ba, C, and D are analogous to true pelvic anatomical landmarks which are directly and consistently measurable by MRI, hence accounting for the better correlation in anterior and middle compartments when compared to measurements Ap and Bp which do not correlate with true anatomical landmarks, and hence can explain the weak correlation for posterior compartment prolapse.

Conclusion: When comparing POP-Q to MRI, anterior and middle compartment prolapse have better correlation than posterior compartment prolapse. Inherent differences that exist in technique and anatomic landmarks used for staging pelvic organ prolapse by clinical exam and imaging criteria account for this. MRD, however, still provides anatomic details on static images, real time simultaneous overview of multi-compartmental prolapse, characterizes contents of cul-de-sac hernias and rectal evacuation on dynamic imaging. Corroborative information derived from both methods of staging organ will result in optimum patient care.
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http://dx.doi.org/10.1007/s00261-020-02476-9DOI Listing
April 2021

Meshy business: MRI and ultrasound evaluation of pelvic floor mesh and slings.

Abdom Radiol (NY) 2021 04;46(4):1414-1442

Department of Radiology, UT South Western Medical Center, Dallas, USA.

Pelvic floor disorders are a complex set of conditions including but not limited to stress urinary incontinence and pelvic organ prolapse that generally affect older and multiparous women. Of the several surgical options available for treatment of these conditions, synthetic mid-urethral slings for stress urinary incontinence and vaginal mesh for pelvic organ prolapse are amenable to imaging evaluation by ultrasound and magnetic resonance imaging techniques. Ultrasound can evaluate the sub- and immediate peri-urethral portions of sling due to its ability to differentiate synthetic material from native tissues with real-time imaging, while MRI is able to better depict the global pelvic floor anatomy and assess the more distant components of mesh and slings material. Given the high prevalence of pelvic floor disorders and complications after surgical repair, it is important that radiologists familiarize themselves with normal and abnormal imaging findings after these procedures. This article provides a review of the spectrum of imaging findings in patients after pelvic floor repair with synthetic mid-urethral slings and vaginal mesh.
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http://dx.doi.org/10.1007/s00261-020-02404-xDOI Listing
April 2021

MR defecography technique: recommendations of the society of abdominal radiology's disease-focused panel on pelvic floor imaging.

Abdom Radiol (NY) 2021 04;46(4):1351-1361

Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA.

Purpose: To develop recommendations for magnetic resonance (MR) defecography technique based on consensus of expert radiologists on the disease-focused panel of the Society of Abdominal Radiology (SAR).

Methods: An extensive questionnaire was sent to a group of 20 experts from the disease-focused panel of the SAR. The questionnaire encompassed details of technique and MRI protocol used for evaluating pelvic floor disorders. 75% agreement on questionnaire responses was defined as consensus.

Results: The expert panel reached consensus for 70% of the items and provided the basis of these recommendations for MR defecography technique. There was unanimous agreement that patients should receive coaching and explanation of commands used during MR defecography, the rectum should be distended with contrast agent, and that sagittal T2-weighted images should include the entire pelvis within the field of view. The panel also agreed unanimously that IV contrast should not be used for MR defecography. Additional areas of consensus ranged in agreement from 75 to 92%.

Conclusion: We provide a set of consensus recommendations for MR defecography technique based on a survey of expert radiologists in the SAR pelvic floor dysfunction disease-focused panel. These recommendations can be used to develop a standardized imaging protocol.
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http://dx.doi.org/10.1007/s00261-019-02160-7DOI Listing
April 2021

A Cadaveric Study of Cutaneous Vascular Anatomy about the Elbow Using Computed Tomography Angiography.

Clin Anat 2019 May 19;32(4):509-514. Epub 2019 Feb 19.

University of Arkansas for Medical Sciences, Little Rock, Arkansas.

The posterior approach is a commonly employed exposure of the elbow that provides excellent visualization and efficacy for various orthopedic procedures, including total elbow arthroplasty (TEA) and fracture care. The posterior approach to the elbow has been associated with an increased rate of wound complications, including infection, skin necrosis, and wound dehiscence. Despite an association between these complications and decreased elbow perfusion, data regarding the intrinsic anatomic etiology for preferential complications in this area has been scarcely reported in the literature. This study characterizes the subdermal and cutaneous vascular perfusion about the elbow by describing the predominant direction of circulation, subdermal anastomoses, and volume of perfusion through cadaveric modeling using computed tomography angiography (CTA). Fifteen upper extremity cadaver specimens were prepared with injection of radiographic contrast directly into the axillary artery immediately preceding CTA imaging of each specimen. Sectra IDS7 software for Windows was used for analysis of all images to produce superimposed axial and 3-D reconstructions of each CTA series. From these images it was discerned that the predominant direction of flow in the posterior elbow integument is anterior medial to posterior lateral. Both the posterior medial and posterior lateral subdermal vascular networks emanate from proximally derived medial arterial sources with few anastomoses and minimal collateral perfusion from the anterolateral location. Consequently, it is important to preserve medial subdermal vascular structures to prevent ischemic wound complications. This is especially true in previously incised elbow integuments. Clin. Anat. 32:509-514, 2019. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23341DOI Listing
May 2019

New Job, New Challenges: Life After Radiology Training.

AJR Am J Roentgenol 2019 03 30;212(3):483-489. Epub 2019 Jan 30.

1 Department of Radiology, Wake Forest University and Baptist Health, 1 Medical Center Blvd, Winston-Salem, NC 27157.

Objective: Beginning a new job after radiology training is exciting but can also be nerve-racking. The key challenge remains making the strange familiar and assimilating with the new practice as soon as possible. This process is complicated and may require learning new policies, getting to know new colleagues, adapting to new surroundings, and learning new skills.

Conclusion: This article provides strategies to navigate professionally and adapt to a new environment.
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http://dx.doi.org/10.2214/AJR.18.20398DOI Listing
March 2019

Gossypiboma of Axilla: Imaging Pitfalls on Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography.

Indian J Nucl Med 2018 Apr-Jun;33(2):143-144

Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) has become the standard of care in staging, restaging, and response assessment of various malignancies including malignant melanoma. However, nonspecific uptake of FDG can occur in infectious and inflammatory conditions and can mimic a tumor. We present here a case of gossypiboma of the axillary region with FDG uptake detected in a patient with malignant melanoma of the upper extremity and discuss the potential pitfalls of this entity on FDG-PET/CT.
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http://dx.doi.org/10.4103/ijnm.IJNM_140_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883434PMC
April 2018

Dedifferentiated Liposarcoma Mimicking a Primary Colon Mass.

Int J Surg Pathol 2018 Apr 26;26(2):174-179. Epub 2017 Sep 26.

1 University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Dedifferentiated liposarcoma is typically a nonlipogenic high-grade sarcoma that arises from well-differentiated liposarcoma. It most commonly presents as a large mass in the retroperitoneum. Significant involvement of the gastrointestinal tract by dedifferentiated liposarcoma is uncommon. We present a unique case of dedifferentiated liposarcoma radiographically mimicking a primary colon mass with resulting intussusception; stranding of the adjacent adipose tissue was presumed to be a secondary reactive change. On histopathologic analysis of the hemicolectomy specimen, a high-grade sarcoma was seen growing through the colonic wall, and the majority of the surrounding pericolonic adipose tissue was actually composed of well-differentiated liposarcoma with characteristic fibrous bands rather than benign fat with reactive fibrosis. This case raises awareness that well-differentiated liposarcoma and dedifferentiated liposarcoma can rarely present as a primary intestinal mass mimicking colon cancer or other more common entities. When radiographic examination shows a perigastrointestinal or retroperitoneal fatty mass and/or stranding of the fat adjacent to a solid gastrointestinal mass, this unusual scenario should be considered in the radiologic differential diagnosis. Pathologists should keep dedifferentiated liposarcoma in the initial histologic differential diagnosis for any high-grade spindle cell tumor of the retroperitoneum or intra-abdominal visceral organs.
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http://dx.doi.org/10.1177/1066896917731517DOI Listing
April 2018

Imaging of Pelvic Floor Reconstruction.

Semin Ultrasound CT MR 2017 Jun 25;38(3):200-212. Epub 2016 Nov 25.

Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR.

Stress urinary incontinence and pelvic organ prolapse are 2 common pelvic floor disorders that are important causes of pelvic pain and disability. Mesh and sling placement are some of the surgical treatment options available for treatment of these conditions. In addition to clinical assessment, imaging plays an important role in managing postoperative patients with complications such as recurrent organ prolapse and chronic pain. Role of high-resolution pelvic magnetic resonance imaging with additional advanced imaging techniques, such as magnetic resonance neurography that are invaluable in managing such patients, are discussed in this article.
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http://dx.doi.org/10.1053/j.sult.2016.11.003DOI Listing
June 2017

Malignant Triton Tumor (Malignant Peripheral Nerve Sheath Tumor With Rhabdomyoblastic Differentiation) Occurring in a Vascularized Free Flap Reconstruction Graft.

Int J Surg Pathol 2017 Aug 7;25(5):462-467. Epub 2017 Apr 7.

3 Department of Orthopedics Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Malignant peripheral nerve sheath tumor (MPNST) is a rare form of sarcoma arising from Schwann cells or pluripotent cells of the neural crest. Malignant triton tumor (MTT) is a subtype of MPNST with a component of malignant rhabdomyoblasts in addition to malignant Schwann cells. MPNST and MTT are both aggressive malignancies that most commonly arise from large deep neurofibromas in patients with neurofibromatosis type 1 (NF-1). However, sporadic non-NF-1 cases of MTT have also been reported in the literature. We present a case of a 50-year-old African American male with no stigmata of NF-1 who developed a large mass in a free flap on the right calf. The free flap had been placed by plastic surgery 15 years previously following open right tibial and fibular fractures associated with a large soft tissue defect. Biopsy of the enlarging mass, followed by wide surgical excision, confirmed the pathology to be MTT. Although the development of a high-grade soft tissue sarcoma has been previously reported as a late complication of radiation therapy following free flap reconstructions, we believe this is the first reported case of sarcomatous transformation arising in a vascularized, free muscle transfer.
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http://dx.doi.org/10.1177/1066896917700725DOI Listing
August 2017

Magnetic Resonance Enterography (MRE): The role of imaging in the management of adult patients with Crohn's disease.

J Ark Med Soc 2016 Dec;113(6):136-139

Crohn's disease, an inflammatory bowel disease with devastating complications, often requires frequent imaging to detect active disease and its complications. Endoscopy, which is the gold standard for diagnosis, is contraindicated in come patients and has limited role in detecting deep submucosal/mesenteric disease, mid small bowel disease and intra-abdominal complications. Magnetic Resonance Enterography (MRE) has evolved as a complimentary non-invasive, radiation free, high resolution imaging modality in evaluating these patients, with clinical studies haveing shown MRE to help in the diagnosis and follow up of these patients. Its major advantage over CT Enterography is the absence of radiation.
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December 2016

High Relative Expression of Pannexin 3 (PANX3) in an Axillary Sweat Gland Carcinoma With Osteosarcomatous Transformation.

Am J Dermatopathol 2016 Nov;38(11):846-851

*Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Departments of †Pathology, ‡Dermatology, and §Radiology, University of Arkansas for Medical Sciences, Little Rock, AR; ¶Division of Hematology/Oncology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Departments of ‖Orthopedic Surgery and **Pathology, University of Arkansas for Medical Sciences, Little Rock, AR.

Primary cutaneous sweat gland carcinomas (SGCs) are rare tumors that commonly involve axillae, have a high local recurrence rate, and rarely show sarcomatoid transformation. A 68-year-old man presented with rapid enlargement of a previously stable, asymptomatic pea-sized nodule in the left axilla. Initial excision (with positive surgical margins) at another institution showed characteristic histologic features of a high-grade osteosarcoma and molecular analysis using a 92-gene real-time quantitative reverse transcription-polymerase chain reaction assay confirmed a diagnosis of osteosarcoma with 96% certainty. Notably, the molecular assay demonstrated consistently high relative expression of pannexin 3 (PANX3), a gene involved in normal osteoblast differentiation which, when highly expressed, strongly predicts osteosarcoma per the assay's algorithm. However, on further histologic review, the tumor also contained focal cystic areas, nests, and ducts composed of malignant epithelial cells reminiscent of SGC; these areas directly transitioned into the osteosarcomatous component and were strongly positive for pancytokeratin, CK7, and p63. Within 2 weeks, the lesion recurred and grew rapidly, prompting complete resection, histologic sections of which showed high-grade osteosarcoma without residual epithelial elements. This is the fifth report, to our knowledge, of osteosarcomatous transformation in a SGC, and the only report to date including molecular data. This case demonstrates that osteosarcoma arising from a SGC has a similar molecular profile to de novo primary osteosarcoma of bone. It also emphasizes the importance of histopathologic findings as the established diagnostic gold standard and the need to interpret molecular results within the clinical context.
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http://dx.doi.org/10.1097/DAD.0000000000000583DOI Listing
November 2016

Magnetic resonance enterography: A stepwise interpretation approach and role of imaging in management of adult Crohn's disease.

Indian J Radiol Imaging 2016 Apr-Jun;26(2):173-84

Department of Radiology, University of Arkansas for Medical Sciences, Arkansas, USA.

Crohn's disease (CD) is a chronic inflammatory bowel disease that often requires frequent imaging of patients in order to detect active disease and other complications related to disease activity. While endoscopy is the gold standard for diagnosis, it may be contraindicated in some patients and has a limited role in detecting deep submucosal/mesenteric diseases and intra abdominal complications. In recent years, magnetic resonance enterography (MRE) has evolved as a noninvasive, radiation free imaging modality in the evaluation of patients with CD. This review article will focus on role of MRE in imaging patients with CD with emphasis on technical considerations, systematic image interpretation, differential diagnoses, and the role of imaging in deciding treatment options for patients.
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http://dx.doi.org/10.4103/0971-3026.184405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4931774PMC
July 2016

Imaging of Sarcoidosis: A Contemporary Review.

Radiol Clin North Am 2016 May 10;54(3):519-34. Epub 2016 Mar 10.

Department of Diagnostic Radiology, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 556, Little Rock, AR 72205, USA. Electronic address:

Sarcoidosis is a systemic granulomatous disorder with a variety of clinical presentations and radiological appearances. Although it primarily affects the lungs and lymphatics, sarcoidosis potentially involves essentially every organ system. On imaging, sarcoidosis can mimic different disease entities, including primary and metastatic neoplasms, vasculitis, and other granulomatous infections. Definitive diagnosis often requires a combination of clinical, radiological, and histologic information. Imaging plays a crucial role in diagnosis and evaluating response to therapy. This review covers imaging findings in sarcoidosis within each organ system, with an emphasis on the use of imaging in the diagnosis and management of this condition.
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http://dx.doi.org/10.1016/j.rcl.2015.12.009DOI Listing
May 2016
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