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Rationale and Objectives: The number of international medical graduates (IMGs) entering radiology residencies and neuroradiology fellowships averaged 9.7% and 20.9% from 2021 to 2023, respectively. We aimed to determine whether IMG graduates are populating leadership roles at a proportionate rate in diagnostic radiology (DR) and neuroradiology., Materials and Methods: We surveyed 191 DR program directors, 94 neuroradiology program directors (PDs), 192 chairs of radiology, and 91 directors of neuroradiology inquiring about their original citizenship and medical school (American Medical Graduates [AMG] vs IMG). We reviewed institutional websites to obtain missing data and recorded H indices for each person using Scopus., Results: We confirmed the original citizenship and medical school location in 61-75% and 93-98% of each leadership group. We found that 16.2% of DR program directors, 43.7% of neuroradiology PDs, 28.5% of Chairs, and 40.6% of neuroradiology directors were not originally US citizens. The IMG rate was 18/188 (9.6%), 20/90 (22.2%), 26/186 (14.0%), and 19/85 (22.4%) for the same groups respectively. The most common country of origin and medical school cited was India for all leadership groups. IMGs had a median H index of 14 while AMG 10, significantly different (p = 0.021) CONCLUSION: Compared to the rate of diagnostic and neuroradiology trainees entering from 2021 to 2023, IMGs are proportionately represented at the leadership positions studied. The H index of the IMGs was higher than AMG. We conclude that IMGs have made substantial and proportionate inroads in radiology and neuroradiology leadership., Competing Interests: Declaration of Competing Interest Dr. Yousem reports royalties from Elsevier, personal fees from Medicolegal consultant, speaking and consulting fees from MRIOnline.com/Medality, outside the submitted work. The remaining authors declare that they have no conflict of interest., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: The number of international medical graduates (IMG) in radiology residencies has varied from year to year even as the number of candidates continues to grow. It is unclear from which countries the IMGs are arriving and what visas are being used to accommodate them., Materials and Methods: We sent a survey to 195 program directors (PD) in diagnostic radiology (DR) inquiring about the number and nationality of IMG residents in their program, their attitudes about IMG candidates, the performance of their IMG trainees, and the visas that are offered., Results: We received responses from 121 of 195 (62.1%) DR programs (121/149 =81.2% of actionable emails). 80/121 (66.1%) had at least one IMG in their DR residency program and the countries of origin included India (36), Iran (30), Saudi Arabia (24), Egypt (16), Canada (14), Brazil (14), and Pakistan (9), as the most common. While most programs (76/104, 73.1%) offered J1 visas, 23/99 (23.2%) provided H-1B visas to trainees. IMG DR residents overall performed as well as American graduates, with an equal number of PDs saying IMGs performed better and worse than American graduates. PDs' issues with IMGs centered on visas: (1) expense, (2) lack of familiarity, (3) Educational Commission for Foreign Medical Graduates regulations, and (4) time commitment in submitting paperwork., Conclusion: Most radiology IMG residents originate from India and Middle Eastern countries. Once enrolled, IMG residents perform similarly to US graduates. However, adding IMG candidates to the training program requires overcoming bureaucratic and monetary hurdles around visas., Summary Sentence: Most DR international medical graduate residents are from India or the Middle East. Although their performance is the same as American graduates in general, PDs note the monetary and bureaucratic hassles accompanying their recruitment., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: David M. Yousem reports a relationship with Elsevier that includes: consulting or advisory. David M. Yousem reports a relationship with Medality that includes: board membership, consulting or advisory, and speaking and lecture fees. David M. Yousem reports a relationship with Medicolegal Expert Witness that includes: paid expert testimony., (Copyright © 2023 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Transcranial magnetic stimulation (TMS) is a type of noninvasive neurostimulation used increasingly often in clinical medicine. While most studies to date have focused on TMS's ability to treat major depressive disorder, it has shown promise in several other conditions including post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). As different treatment protocols are often used across studies, the ability to predict patient outcomes and evaluate immediate and long-term changes using imaging becomes increasingly important. Several imaging features, such as thickness, connectedness, and baseline activity of a variety of cortical and subcortical areas, have been found to be correlated with a greater response to TMS therapy. Intrastimulation imaging can reveal in real time how TMS applied to superficial areas activates or inhibits activity in deeper brain regions. Functional imaging performed weeks to months after treatment can offer an understanding of how long-term effects on brain activity relate to clinical improvement. Further work should be done to expand our knowledge of imaging features relevant to TMS therapy and how they vary across patients with different neurological and psychiatric conditions., (Copyright © 2022 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: Women remain underrepresented in leadership positions in radiology. We sought to determine if 1) women are equitably represented in the senior author positions in radiology journals and 2) if women's contributions to the radiology literature and their individual productivity are proportional to their representation at senior academic rank., Materials and Methods: The gender of 3,702 first and last authors listed for manuscripts published in nine high-impact American radiology journals was assessed between 2002-2017. For the same years, the gender composition of academic faculty and ranks based on AAMC data was queried. Statistical tests were employed to detect discrepancies and changes over time., Results: First authorship by women grew from 26.9% to 37.4% and from 15.7% to 23.9% as senior author between 2002-2017 (P<.0001). Although the index of manuscript productivity rate was nearly equal for men and women over the 16-year study period, women remained under-represented in senior radiology faculty rank over the same period., Conclusions: Although women have proportionally increased their contribution to the radiology literature over the years, commensurate increased representation of women in senior authorship and faculty positions was not observed. Despite increased involvement of women in research over time, they remain disproportionately at junior faculty positions., (Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: We sought to determine (1) whether United States Medical Licensing Examination (USMLE) scores predict academic productivity in neuroradiology fellows as measured by publications and citations, and (2) what factors predict such productivity., Materials and Methods: We reviewed the USMLE scores, gender, medical school location attended, publication record before and during fellowship, fellowship evaluation ratings and subsequent practice site (private vs academic) of neuroradiology fellows from 2004 to 2014 to determine relationships with publications and citations after fellowship. Spearman's correlation and Poisson regression analyses were performed to assess the association between these factors and quantity of publications and citations per year after fellowship., Results: USMLE scores and fellowship evaluation scores correlated inversely with radiology publications and citations. There were strong correlations between publication records before or during fellowship and after fellowship. Fellows from international medical schools, with PhD degrees, and those fellows proceeding to academic practice had more publications before or during and after neuroradiology fellowship., Conclusions: The best predictors of whether a graduating neuroradiology fellow will publish and have high citation rates is prior publication record, a PhD degree, and staying in academics. USMLE scores and evaluations during the fellowship were inversely correlated with publication measures of academic productivity., (Copyright © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: We sought to determine the effect of age on functional MR imaging experiments performed with visual and motor stimulation. We hypothesized that there would be a diminution in the amplitude of fMRI activation with increasing subjects' age., Materials and Methods: We used fixed effects models to study the amplitude of activation during a block design visuomotor task in three different age groups: old (mean: 75 years; standard deviation: 6 years), middle-aged (mean: 52 years; standard deviation: 9 years) and young (mean: 29 years; standard deviation: 5 years). Each group included 7 subjects. Regions of interest (ROI) were left primary motor area (LM1), supplementary motor area (SMA), and right and left occipital (RO, LO) visual areas. Individual subjects and group statistical parametric maps (SPMs) were generated for each ROI, and then the mean amplitude of activation was compared using the group analysis and t test., Results: The young age group showed higher amplitude of activation than middle and old age groups in all ROI (P < 0.01 uncorrected). Unpaired two tailed t test results between the groups showed significant differences between middle and young, and old and young age groups in all ROIs (P < or = 0.05), with the exception of old and young age groups in RO region (P = 0.11)., Conclusion: The group analysis, and unpaired t test results reveal higher amplitude of fMRI activation in the young versus the old and middle-aged groups.

Rationale and Objectives: The authors performed this study to determine the effect a computed tomographic (CT) scanner in the emergency department (ED) has on neuroimaging case volume and positive scan rates., Materials and Methods: The total numbers of ED visits and neuroradiology CT scans requested from the ED were recorded for 1998 and 2000, the years before and after the installation of a CT unit in the ED. For each examination type (brain, face, cervical spine), studies were graded for major findings (those that affected patient care), minor findings, and normal findings. The CT utilization rates and positive study rates were compared for each type of study performed for both years., Results: There was a statistically significant increase in the utilization rate after installation of the CT unit (P < .001). The fractions of studies with major findings, minor findings, and normal findings changed significantly after installation of the CT unit for facial examinations (P = .002) but not for brain (P = .12) or cervical spine (P = .24) examinations. In all types of studies, the percentage of normal examinations increased. In toto, there was a significant decrease in the positive scan rate after installation of the CT scanner (P = .004)., Conclusion: After installation of a CT scanner in the ED, there was increased utilization and a decreased rate of positive neuroradiologic examinations, the latter primarily due to lower positive rates for facial CT scans.

Rationale and Objectives: The purpose of this study was to assess the impact on times of verification (TOVs) by a pager notification system (PNS) that informs physicians when reports are available for signature., Materials and Methods: An automated PNS was implemented in the authors' department in November 2000. Monthly report verification times of each physician were collected for 3 months in the years before and after initiation of the PNS. Radiologists enrolled in the PNS and those who were not were assigned into two groups for analysis. Mean TOVs for the two sets of 3 months and for the two groups were calculated and differences recorded. Two-tailed t tests were used to assess for statistical differences between the groups., Results: Twenty-nine of 37 radiologists voluntarily enrolled in the PNS (group 1). Mean TOV was 26.75 hours (standard deviation [SD] = 17.76) for these physicians before and 14.48 hours (SD = 11.86) after the PNS was employed (P < .01). For those physicians who did not enroll in the PNS, mean TOV was 11.53 hours (SD = 5.55) before and 9.77 hours (SD = 9.86) after the PNS was employed (P = .33). Both the absolute and percentage reductions in TOVs were significantly greater for those physicians enrolled in the PNS than for those who were not (P = .035). Twenty-three of 29 (79%) physicians who used the PNS showed a reduction in their report turnaround times., Conclusion: Linking the PNS with the radiology information system to notify physicians of unsigned reports was effective in reducing report verification times.

Rationale and Objectives: The authors performed this study to determine whether reaction times (RTs) recorded in the functional magnetic resonance (MR) imaging environment reflect the performance of the patient outside the imaging room., Materials and Methods: Fifteen healthy control subjects (mean age, 61.6 years) performed a simple reaction time (SRT) task outside the MR magnet and a visuomotor response time task inside the magnet with use of block-design and event-related paradigms. For both behavioral and functional MR imaging tests, subjects tapped the right index finger upon the appearance of a visual cue. The mean RTs for out-of-magnet and functional MR imaging paradigms were compared. Results. There was a statistically significant difference in RTs between block-design and single-event paradigms (t = 3.458, P < .004). The RT values during functional MR imaging and SRT tasks did not show significant differences (.65 < P < .7, paired t test). However, no correlation was found in RT values between event-related (p = -0.004, P = .15) or block-design (p = 0.03, P = .13) paradigms and SRT data. With the block-design functional MR imaging paradigm, the RT was significantly faster (P < .0003) at the beginning of the session than the end, illustrating the effect of anticipation., Conclusion: Functional MR imaging RTs must be used to determine the correlation between subjects' performance and the volume of brain activation in a functional MR imaging experiment. The effect of anticipation should be minimized, which could best be achieved by using event-related paradigms.

Rationale and Objectives: The purpose of this retrospective study was to estimate the economic consequences of evaluating suspected vocal cord paralysis with magnetic resonance (MR) imaging and computed tomography (CT)., Materials and Methods: Reports from MR imaging (n = 30) or CT (n = 19) studies of the neck in 49 patients were retrospectively reviewed for causes of vocal cord paralysis. The patients were divided into high-suspicion (n = 20) and low-suspicion (n = 29) groups, based on the presence or absence of a clinically detectable abnormality other than vocal cord immobility. Clinic and inpatient charts were examined to determine the work-up in all cases. The Medicare Resource-based Relative Value Scale was used to estimate the costs of most procedures., Results: The high-clinical-suspicion group included nine true-positive, four false-positive, seven true-negative, and no false-negative cases. Further work-up was performed in seven true-positive, three false-positive, and one true-negative cases. The total cost of immediate diagnostic work-up in these 20 patients, including MR imaging and/or CT, was $20,737 ($2,304 per true-positive case). The low-suspicion group included two true-positive, nine false-positive, 18 true-negative, and no false-negative cases. Further work-up was performed in both true-positive, four false-positive, and two true-negative cases. The total cost of immediate diagnostic work-up in these 29 patients was $21,698, (mean, $748; $10,849 per true-positive case)., Conclusion: The average cost of finding space-occupying lesions in patients with vocal cord paralysis is more than 4.5 times higher in patients without suspicious antecedent clinical findings than in those with such a history. The benefits of obtaining negative findings and of detecting a small number of space-occupying lesions should be weighed against the costs of such examinations and of additional work-up for false-positive findings.

Rationale and Objectives: The purpose of this study was to define the primary sites of injury in patients with posttraumatic anosmia and hyposmia with magnetic resonance (MR) imaging and to determine if these sites correlated with the results of psychophysical olfactory tests., Materials and Methods: Thirty-six patients with subjective loss in olfaction after head trauma underwent volumetric MR studies of the olfactory bulbs and tracts and temporal lobes. Pearson correlations were computed between olfactory bulb and tract and temporal lobe volumes and the patients' scores on tests of odor identification (including the University of Pennsylvania Smell Identification Test [UPSIT]), detection, and memory. Analysis of variance was used to compare volumes of the control subjects and the posttraumatic patients., Results: The olfactory bulbs and tracts (32 [89%] of 36 patients), the subfrontal lobes (22 [61%] of 36 patients), and the temporal lobes (11 [31%] of 36 patients) showed the highest incidence of posttraumatic encephalomalacia. Left olfactory bulb and tract volumes showed a statistically significant correlation with left and total UPSIT scores. A statistically significant difference (P < .001) was found in the right and left olfactory bulb and tract volumes between anosmic and hyposmic patients and between posttraumatic patients and control subjects., Conclusion: Olfactory bulb and tract damage may correlate with deficits in odor identification. Olfactory bulb and tract and frontal lobe encephalomalacia coexist in many patients.

Rationale and Objectives: The authors assessed the reliability and reproducibility of volumetric measurements of olfactory bulbs and tracts (OBTs) and temporal lobes (TLs) with magnetic resonance (MR) imaging., Methods: Repetitive MR imaging of two phantoms and OBTs and TLs of patients was performed. Regions of interest were manually drawn around the relevant structures, and their volumes were measured at workstations. Intra- and interobserver variability for the two readers were measured. Intraclass and Pearson correlation coefficients and mean percentage differences were calculated., Results: The measured phantom volumes were within 1.9%-12% of the true volumes with a variability of < or = 5%. Intraclass and Pearson correlation coefficients were > or = 0.919 for measurements by a single reader and > or = 0.924 for measurements by different readers. The inter- and intraobserver variabilities were < or = 4.2% for TL and 11.3%-14.6% for OBTs., Conclusion: Volumetric measurements of the olfactory apparatus can be reliably and accurately reproduced from MR images.