A 79-year-old woman with atrial fibrillation, hypertension and hypothyroidism presented to the emergency department with syncope. She had previously experienced three minor syncopal episodes. A few months earlier, she had been prescribed rivaroxaban 15 mg/d after many years of warfarin therapy. On the day of presentation, she had woken feeling weak and fell to the floor, but managed to call 911. Following the initial assessment by emergency medical services she became unresponsive and briefly pulseless, and cardiopulmonary resuscitation was performed.In the emergency department, the patient was resuscitated with several boluses of normal saline, one unit each of packed red blood cells, platelets and prothrombin complex concentrate. Her vital signs stabilized. Diffuse abdominal guarding and tenderness were noted on examination. No prior intra-abdominal surgery was reported, and there was no definite antecedent infection.The patient's leukocyte count was 19.9 (normal 4.0-10.5) × 10 9 /L, plasma lactate level 12.4 (normal 0.5-2.2) mmol/L and hemoglobin 83 (normal 120-160) g/L; her hemoglobin level had been 121 g/L two months earlier. The international normalized ratio was 4.2 (normal 0.9-1.1). The platelet count and lipase level were within normal limits.Contrast-enhanced computed tomography (CT) showed a large intraperitoneal hematoma centred on a 3-cm pseudoaneurysm in the expected location of the pancreaticoduodenal arteries ( Figure 1). There were several smaller fusiform aneurysms arising from the celiac and superior mesenteric branch vessels. In the descending thoracic and abdominal aorta, there was an intramural hematoma, with active filling of multiple penetrating ulcerations ( Figure 2).Interventional radiology was consulted for angiography and potential transcatheter embolization. Angiography confirmed the CT findings, including a 3-cm pseudoaneurysm arising from the inferior pancreaticoduodenal artery. The artery was selected with a Progreat microcatheter (Terumo Interventional Systems), and the segments of the artery proximal and distal to the 3-cm ruptured pseudoaneurysm were embolized with five Nester embolization coils 3 mm × 14 cm (Cook Medical) and two Interlock embolization coils 3 mm × 12 cm (Boston Scientific) ( Figure 3).Angiography of the celiac and superior mesenteric arteries showed many smaller aneurysms involving several branch vessels. Given that these aneurysms were not easily accessible and did not meet the size criteria of 2 cm, they were not embolized. The interventional radiologist suspected vasculitis as the underlying cause. The smaller aneurysms were therefore expected to respond to medical therapy and did not require immediate intervention.Following endovascular coiling, investigations showed an increase in nonspecific inflammatory markers, including a C-reactive protein level of 180.1 (normal 0-1.0) mg/L and an erythrocyte sedimentation rate of 60 (normal 0-27) mm/h. Results of serologic evaluations were within normal limits, including tests for antineutrophil antibodies, anti-ex...

Purpose: All postgraduate residency programs in Canada are transitioning to a competency-based medical education (CBME) model divided into 4 stages of training. Queen’s University has been the first Canadian institution to mandate transitioning to CBME across all residency programs, including Diagnostic Radiology. This study describes the implementation of CBME with a focus on the third developmental stage, Core of Discipline, in the Diagnostic Radiology residency program at Queen’s University. We describe strategies applied and challenges encountered during the adoption and implementation process in order to inform the development of other CBME residency programs in Diagnostic Radiology. Methods: At Queen’s University, the Core of Discipline stage was developed using the Royal College of Physicians and Surgeons of Canada’s (RCPSC) competence continuum guidelines and the CanMEDS framework to create radiology-specific entrustable professional activities (EPAs) and milestones for assessment. New committees, administrative positions, and assessment strategies were created to develop these assessment guidelines. Currently, 2 cohorts of residents (n = 6) are enrolled in the Core of Discipline stage. Results: EPAs, milestones, and methods of evaluation for the Core of Discipline stage are described. Opportunities during implementation included tracking progress toward educational objectives and increased mentorship. Challenges included difficulty meeting procedural volume requirements, inconsistent procedural tracking, improving feedback mechanisms, and administrative burden. Conclusion: The transition to a competency-based curriculum in an academic Diagnostic Radiology residency program is significantly resource and time intensive. This report describes challenges faced in developing the Core of Discipline stage and potential solutions to facilitate this process.

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