The Late-Career Radiologist: Options and Opportunities.

More than 25% of the present radiology workforce, or nearly 8300 radiologists, are actively practicing late-career radiologists. While these individuals could decide to retire from active practice, their continued presence in the workforce helps to maintain adequate and appropriate patient imaging services. To ensure their continued participation, issues important to all late-career radiologists need to be appreciated, discussed, and addressed. These issues include call-duty requirements, compensation, physical and cognitive health, and organized phase-out programs. The gamut of these issues is addressed in this review article. ©RSNA, 2018.

Alanine aminotransferase levels and fatty liver in childhood obesity: associations with insulin resistance, adiponectin, and visceral fat.

BACKGROUND: Concurrent with the rise in obesity, nonalcoholic fatty liver disease is recognized as the leading cause of serum aminotransferase elevations in obese youth. Nevertheless, the complete metabolic phenotype associated with abnormalities in biomarkers of liver injury and intrahepatic fat accumulation remains to be established. METHODS: In a multiethnic cohort of 392 obese adolescents, alanine aminotransferase (ALT) levels were related with parameters of insulin sensitivity, glucose, and lipid metabolism as well as adipocytokines and biomarkers of inflammation. A subset of 72 adolescents had determination of abdominal fat partitioning and intrahepatic fat accumulation using magnetic resonance imaging. FINDINGS: Elevated ALT (> 35 U/liter) was found in 14% of adolescents, with a predominance of male gender and white/Hispanic race/ethnicity. After adjusting for potential confounders, rising ALT was associated with reduced insulin sensitivity and glucose tolerance as well as rising free fatty acids and triglycerides. Worsening of glucose and lipid metabolism was already evident as ALT levels rose into the upper half of the normal range (18-35 U/liter). When hepatic fat fraction was assessed using fast magnetic resonance imaging, 32% of subjects had an increased hepatic fat fraction, which was associated with decreased insulin sensitivity and adiponectin, and increased triglycerides, visceral fat, and deep to superficial sc fat ratio. The prevalence of the metabolic syndrome was significantly greater in those with fatty liver. INTERPRETATION: Deterioration in glucose and lipid metabolism is associated even with modest ALT elevations. Hepatic fat accumulation in childhood obesity is strongly associated with the triad of insulin resistance, increased visceral fat, and hypoadiponectinemia. Hence, hepatic steatosis may be a core feature of the metabolic syndrome.

Sonographic distinction between acute suppurative appendicitis and viral appendiceal lymphoid hyperplasia ("pink appendix") with pathological correlation.

The viral etiology of mesenteric lymphadenitis may also affect the lymphoid tissue of the appendix in children giving rise to symptomatic appendiceal lymphoid hyperplasia, the so-called "pink appendix." The present study used ultrasound (US) to determine if certain sonographic features correlated with appendiceal pathological findings. Our results indicate that a fluid-filled appendix always correlates with a suppurative or mixed pathological appearance that likely merits surgery. A lymphoid predominant pathological appearance occurred only in cases where appendiceal wall thickening alone was seen on US. This pilot project therefore shows that US has the potential to stratify acute appendix patients into different treatment regimens, given that lymphoid hyperplasia could be treated conservatively. Further studies correlating other clinicoradiological parameters with this sonographic appearance are warranted.

Fourth Annual Warren K. Sinclair Keynote Address: the use and misuse of radiation in medicine.

Among the many diagnostic and therapeutic uses of ionizing radiation in medicine, the potential for misuse is greatest in diagnostic imaging, particularly with computed tomography. While several technical adjustments may be made to produce a dose that is as low as reasonably achievable, appropriate utilization of these tests is a more difficult issue to address. The risks of ionizing radiation, taking into account the patient's age, sex, and body part to be examined, must be balanced with the potential benefit that comes with medical imaging. Fortunately, the benefits outweigh the risks in most clinical scenarios, particularly in patients without a confirmed diagnosis. However, the repetitive imaging of patients with known clinical conditions to assess for interval change may pose the greatest opportunity to curb over-utilization of imaging tests that may be harmful. The medical community at large must be educated in the effects of ionizing radiation. Moreover, practitioners must be inspired to differentiate imaging tests for primary diagnosis from those performed in follow-up of known pathology in common diagnostic algorithms. This metamorphosis must extend from the most senior health care administrator to the most junior healthcare professional and must include those who are charged with acquiring the necessary imaging tests. In addition, imaging professionals must avail themselves of the numerous technical advances that allow a reduction in the dose of ionizing radiation that is associated with common imaging procedures. And, dose monitoring must be performed on many levels, including the dose to an individual patient undergoing a specific imaging test.

Comparative MR study of hepatic fat quantification using single-voxel proton spectroscopy, two-point dixon and three-point IDEAL.

Hepatic fat fraction (HFF) was measured in 28 lean/obese humans by single-voxel proton spectroscopy (MRS), a two-point Dixon (2PD), and a three-point iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) method (3PI). For the lean, obese, and total subject groups, the range of HFF measured by MRS was 0.3-3.5% (1.1 +/- 1.4%), 0.3-41.5% (11.7 +/- 12.1), and 0.3-41.5% (10.1 +/- 11.6%), respectively. For the same groups, the HFF measured by 2PD was -6.3-2.2% (-2.0 +/- 3.7%), -2.4-42.9% (12.9 +/- 13.8%), and -6.3-42.9% (10.5 +/- 13.7%), respectively, and for 3PI they were 7.9-12.8% (10.1 +/- 2.0%), 11.1-49.3% (22.0 +/- 12.2%), and 7.9-49.3% (20.0 +/- 11.8%), respectively. The HFF measured by MRS was highly correlated with those measured by 2PD (r = 0.954, P < 0.001) and 3PI (r = 0.973, P < 0.001). With the MRS data as a reference, the percentages of correct differentiation between normal and fatty liver with the MRI methods ranged from 68-93% for 2PD and 64-89% for 3PI. Our study demonstrates that the apparent HFF measured by the MRI methods can significantly vary depending on the choice of water-fat separation methods and sequences. Such variability may limit the clinical application of the MRI methods, particularly when a diagnosis of early fatty liver needs to be performed. Therefore, protocol-specific establishment of cutoffs for liver fat content may be necessary.

High visceral and low abdominal subcutaneous fat stores in the obese adolescent: a determinant of an adverse metabolic phenotype.

OBJECTIVE: To explore whether an imbalance between the visceral and subcutaneous fat depots and a corresponding dysregulation of the adipokine milieu is associated with excessive accumulation of fat in the liver and muscle and ultimately with insulin resistance and the metabolic syndrome. RESEARCH DESIGN AND METHODS: We stratified our multi-ethnic cohort of 118 obese adolescents into tertiles based on the proportion of abdominal fat in the visceral depot. Abdominal and liver fat were measured by magnetic resonance imaging and muscle lipid (intramyocellular lipid) by proton magnetic resonance spectroscopy. RESULTS: There were no differences in age, BMI Z score, or fat-free mass across tertiles. However, as the proportion of visceral fat increased across tertiles, BMI and percentage of fat and subcutaneous fat decreased, while hepatic fat increased. In addition, there was an increase in 2-h glucose, insulin, c-peptide, triglyceride levels, and insulin resistance. Notably, both leptin and total adiponectin were significantly lower in tertile 3 than 1, while C-reactive protein and interleukin-6 were not different across tertiles. There was a significant increase in the odds ratio for the metabolic syndrome, with subjects in tertile 3 5.2 times more likely to have the metabolic syndrome than those in tertile 1. CONCLUSIONS: Obese adolescents with a high proportion of visceral fat and relatively low abdominal subcutaneous fat have a phenotype reminiscent of partial lipodystrophy. These adolescents are not necessarily the most severely obese, yet they suffer from severe metabolic complications and are at a high risk of having the metabolic syndrome.

A periureteric venous ring diagnosed by MRI: an unusual cause of flank pain.

We describe a pediatric patient with upper tract collecting system dilatation caused by a periureteric venous ring. The diagnosis was made after MR urography. This rare inferior vena caval anomaly has not been documented in the pediatric literature, nor have the MRI appearances been described. MRI is ideally suited for the assessment of suspected retrocaval ureters in order to identify this variant so that an appropriate surgical approach can be planned.

Perinephric cystic mesoblastic nephroma complicated by hepatic metastases: a case report.

Congenital mesoblastic nephroma (CMN) is a well-recognised renal tumour presenting in infancy, which has an excellent prognosis if completely excised. We describe the imaging appearances of an unusual, predominantly perinephric cystic CMN, with relative renal preservation but with retroperitoneal extension and bowel infiltration, which was complicated by hepatic metastases. To our knowledge, neither the appearance of the primary tumour nor the subsequent development of hepatic metastases has previously been reported. This appearance may represent a poor prognostic indicator for outcome. However, following partial hepatectomy, the patient remains disease-free at 1 year.

How to perform the perfect voiding cystourethrogram.

The voiding cystourethrogram (VCUG) examination is a difficult investigation to perform and is a stressful experience for patients and their parents, as well as for the radiologists, technicians and paediatric radiology nurses involved in the examination. Despite the VCUG being one of the most commonly performed fluoroscopic procedures in paediatric radiology practice, there is no general consensus as to the best way to perform this investigation. This is particularly concerning when one considers the potentially high gonadal radiation dose children may receive. Because of this, we have undertaken a comprehensive literature review of various aspects of the test in order to determine the best way to perform the VCUG in modern paediatric radiology practice.

Resolution of orbitocerebral aspergillosis during combination treatment with voriconazole and amphotericin plus adjunctive cytokine therapy.

Orbitocerebral aspergillosis has a very high fatality rate and cure is unusual. We describe the successful management of a child with cereberal aspergillosis who had a dramatic response to therapy with a combination of liposomal amphotericin and voriconazole with adjunctive cytokine therapy during immunosuppresive chemotherapy for acute lymphoblastic leukaemia.