Evaluating the effect of NPO status on mucosal coating during double contrast barium esophagrams.

INTRODUCTION: Current guidelines for double contrast barium esophagography studies (BAS) suggest that patients should be nil per os (NPO) prior to completing BAS for optimal esophageal coating, although the time required varies between practices and institutions. It is believed that consumption of food or water disrupts the ability for thick barium contrast to properly coat the esophageal mucosa. Exams that are rescheduled for this reason can lead to delays in care, without substantial evidence that NPO status truly affects esophageal mucosal coating for these exams with current barium mixtures. OBJECTIVE: The study aims to identify the necessity, or lack thereof, of standard NPO protocol in patients undergoing BAS, in effort to prevent unnecessary procedural delay. MATERIALS AND METHODS: This study is an IRB-approved HIPAA-compliant study of 370 consecutive adult patients (115 male/255 female, mean age 55) who underwent BAS at our institution from January to June of 2022. Patients were divided into two groups: < 4 h NPO (n = 334), and ≥ 4 h NPO (n = 36). Four abdominal radiologists blinded to NPO interval independently reviewed a random sample of approximately 92 patients (91-94) and graded esophageal coating on a 4-point-scale with 1 being insufficient coating and 4 being optimal coating. RESULTS: No significant statistical difference in mean esophageal coating score was found between the ≥ 4 h NPO cohort (3.04 ± SD 0.78) and the < 4 h NPO cohort (2.97 ± SD 0.70; P = 0.54). Subset analysis of patients who were NPO for < 2 h (n = 9) also showed no significant difference in mean esophageal coating score (3.11 ± SD 0.6; P = 0.92), compared to the standard ≥ 4 NPO status. CONCLUSION: Non-adherence to standard NPO protocol prior to BAS studies did not result in a significant difference in esophageal coating when compared to traditional preprocedural fasting of 4 or more hours.

ACR Appropriateness Criteria® Abnormal Liver Function Tests.

Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Everyday advocacy.

When considering advocacy, many people think of the political fundraising form, and assume it is difficult to carry out, or that it requires a big investment of time, energy, or money. However, advocacy comes in many different forms, and can be implemented every day. A more mindful approach and a few small, but critical, steps can take our advocacy to a new, more intentional level; one that we can practice every day. There are many opportunities to use our advocacy skills every day to stand up for something that matters and to make advocacy a habit. It will take all of us working together to rise to the challenge and make a difference in our specialty, for our patients, in our society and in our world.

Liver Fibrosis, Fat, and Iron Evaluation with MRI and Fibrosis and Fat Evaluation with US: A Practical Guide for Radiologists.

Quantitative imaging biomarkers of liver disease measured by using MRI and US are emerging as important clinical tools in the management of patients with chronic liver disease (CLD). Because of their high accuracy and noninvasive nature, in many cases, these techniques have replaced liver biopsy for the diagnosis, quantitative staging, and treatment monitoring of patients with CLD. The most commonly evaluated imaging biomarkers are surrogates for liver fibrosis, fat, and iron. MR elastography is now routinely performed to evaluate for liver fibrosis and typically combined with MRI-based liver fat and iron quantification to exclude or grade hepatic steatosis and iron overload, respectively. US elastography is also widely performed to evaluate for liver fibrosis and has the advantage of lower equipment cost and greater availability compared with those of MRI. Emerging US fat quantification methods can be performed along with US elastography. The author group, consisting of members of the Society of Abdominal Radiology (SAR) Liver Fibrosis Disease-Focused Panel (DFP), the SAR Hepatic Iron Overload DFP, and the European Society of Radiology, review the basics of liver fibrosis, fat, and iron quantification with MRI and liver fibrosis and fat quantification with US. The authors cover technical requirements, typical case display, quality control and proper measurement technique and case interpretation guidelines, pitfalls, and confounding factors. The authors aim to provide a practical guide for radiologists interpreting these examinations. © RSNA, 2023 See the invited commentary by Ronot in this issue. Quiz questions for this article are available in the supplemental material.

Updates on LI-RADS Treatment Response Criteria for Hepatocellular Carcinoma: Focusing on MRI.

As the incidence of hepatocellular carcinoma (HCC) and subsequent treatments with liver-directed therapies rise, the complexity of assessing lesion response has also increased. The Liver Imaging Reporting and Data Systems (LI-RADS) treatment response algorithm (LI-RADS TRA) was created to standardize the assessment of response after locoregional therapy (LRT) on contrast-enhanced CT or MRI. Originally created based on expert opinion, these guidelines are currently undergoing revision based on emerging evidence. While many studies support the use of LR-TRA for evaluation of HCC response after thermal ablation and intra-arterial embolic therapy, data suggest a need for refinements to improve assessment after radiation therapy. In this manuscript, we review expected MR imaging findings after different forms of LRT, clarify how to apply the current LI-RADS TRA by type of LRT, explore emerging literature on LI-RADS TRA, and highlight future updates to the algorithm. EVIDENCE LEVEL: 3. TECHNICAL EFFICACY: Stage 2.

Disruptive Behavior: Impact on Diversity, Equity, and Inclusion (DEI) in Radiology, From the AJR Special Series on DEI.

Radiology has recognized the need to increase the diversity of its workforce for decades; however, women and people of color remain disproportionately underrepresented. A welcoming and inclusive environment is essential to physician recruitment and retention, but disruptive behavior in the workplace can be a barrier to achieving this goal. Disruptive behavior can be overt or subtle, can be intentional or inadvertent, and can occur in different settings throughout a radiologist's career, including during patient care, among colleagues, from department leadership, and even from professional societies. The purpose of this article is to provide an overview of where a radiologist may encounter disruptive behaviors, the impact that such behaviors can have on the physician's and practice's well-being, and tips for how to address and mitigate these behaviors in the future.

Accelerated Fellowships Applicable Across all Subspecialty Areas of Diagnostic Radiology as a Catalyst for Academic Recruitment.

RATIONALE AND OBJECTIVES: To build a sustainable faculty development program based on potential acceleration of all subspecialty fellowships types into the PGY 5 year. MATERIALS AND METHODS: Single center experience in programmatic change to enhance faculty recruitment. Diagnostic Radiology (DR) residents apply to subspecialty fellowships per SCARD Fellowship Embargo Guidelines. Based on projected faculty hiring needs, internal candidates are vetted and agree to enter an accelerated fellowship. The commitment is two years: the PGY5 senior year schedule prioritizes rotations in the subspecialty area while fulfilling requirements of all DR graduates, including call. Accelerated fellows (AF) participate in junior faculty development and concentrated mentoring. A subsequent instructor faculty year within our department is required to ensure professional maturity and provides financial remuneration greater than PGY 6 fellowships. RESULTS: From July 1, 2018, to June 30, 2022, 34 trainees have graduated from our DR program, and 32 have gone through the process of securing fellowships. Over this interval, our DR program has matched 7-9 residents per year. Up to four early specialization positions consisting of 2 Early Specialization in Interventional Radiology (ESIR), and 2 Early Specialization in Nuclear Medicine (ESNM), per year, are available. Over four years of the program, 8 residents participated in standard early specialization opportunities: 5 ESIR, and 3 ESNM. These 8 residents were excluded from consideration for AFs. Two additional residents declined fellowships, leaving 22 seeking standard fellowships for PGY 6 year. 6 (27%) of those were approached as potential AFs; 3 (50%) agreed to and completed the 24-month process. 2 of 3 (67%) continue to serve on faculty after the required instructor year. CONCLUSION: The novel concept of early specialization outside of ESIR and ESNM presents an opportunity to tailor the PGY 5 DR year to increase recruitment to academic faculty positions.

Equal pay for equal work in radiology: Expired excuses and solutions for change.

The gender pay gap is not a problem of the past. Women continue to receive less pay for equal work and radiology is one of four medical specialties with the largest gender pay gap. Numerous social factors contribute to the gender pay gap; however, radiology can close the gender pay gap through intentional strategies, including acknowledging the gender pay gap, eliminating bias and minority taxes through progressive compensation and parental leave models, devaluing overwork, developing longitudinal mentorship and sponsorship, and demanding transparent institutional policies. Patient care and overall organizational success will improve when the barriers resulting in the gender pay gap are eliminated.

Applications of PET/MRI in Abdominopelvic Oncology.

With PET/MRI, the strengths of PET and MRI are combined to allow simultaneous image acquisition and near-perfect image coregistration. MRI is increasingly being used for staging and restaging of abdominopelvic oncologic lesions, including prostate, hepatobiliary, pancreatic, neuroendocrine, cervical, and rectal cancers. Fluorine 18-fluorodeoxyglucose PET/CT has long been considered a cornerstone of oncologic imaging, and the development of multiple targeted radiotracers has led to increased research on and use of these agents in clinical practice. Thus, simultaneously performed PET/MRI enables the acquisition of complementary imaging information, with distinct advantages over PET/CT and MR image acquisitions. The authors provide an overview of PET/MRI, including descriptions of the major differences between PET/MRI and PET/CT, as well as case examples and treatment protocols for patients with commonly encountered malignancies in the abdomen and pelvis. Online supplemental material is available for this article. ©RSNA, 2021.

Acute pancreatitis: an update on the revised Atlanta classification.

Acute pancreatitis (AP) is the most common gastrointestinal disease resulting in hospitalization in the United States with reports of over 270,000 hospitalizations and costs up to 2.6 billion dollars per year. AP is highly variable in disease course and outcome. Established in 1992, the original Atlanta classification system aimed to categorize the wide spectrum of AP by creating consensus-based terminology for AP types, severity, and complications. Though the original system standardized terminology, certain terms and definitions (i.e. pancreatic abscess) were unclear and often misused. The 2012 revised Atlanta classification (RAC) system updated terms, clarified definitions, and incorporated the medical community's improved understanding of the physiology of AP. The resulting RAC effectively defined the morphologic types of pancreatitis, provided a more standardized system for disease severity grading, further classified the local retroperitoneal complications, and established objective measures to describe this highly variable but common disease. This review provides an update on the recent literature evaluating the RAC, discusses both the strengths and shortcomings of the RAC system (including problematic interobserver agreement), and considers improvements for future classification systems.