2017 ACR Annual Meeting Open-Microphone Session: Navigating the Landscape of Changing Practice Models: Private Practice, Corporate Radiology, and Enterprise Systems.

Many practice groups are considering adopting new practice models, primarily to secure their practices by adapting to new payment models, government compliance and regulation, and increasing IT and infrastructure costs. As we move toward value-based care and capitation, the value equation (value = quality/cost) will lead us to also compete on cost to improve value. No matter what payment models ultimately dominate, we need to be prepared to lead in a value-based care environment. Measures of value will either be defined by radiologists or imposed by outside entities. It is critical to our continued success that practices and practice leaders continue to fully and strongly support the ACR to avoid the possibility of a decline in membership that may accompany a lack of practice engagement. Consolidation appears inevitable, but with the help of the ACR, radiologists should have a vibrant future if investments are made now in determining appropriate radiology-specific value measures that are meaningful in consolidated health care environments.

ACR CT Accreditation Program and the Lung Cancer Screening Program Designation.

The ACR recognizes that low-dose CT for lung cancer screening has the potential to significantly reduce mortality from lung cancer in the appropriate high-risk population. The ACR supports the recommendations of the US Preventive Services Task Force and the National Comprehensive Cancer Network for screening patients. To be effective, lung cancer screening should be performed at sites providing high-quality low-dose CT examinations overseen and interpreted by qualified physicians using a structured reporting and management system. The ACR has developed a set of tools necessary for radiologists to take the lead on the front lines of lung cancer screening. The ACR Lung Cancer Screening Center designation is built upon the ACR CT accreditation program and requires use of Lung-RADS or a similar structured reporting and management system. This designation provides patients and referring providers with the assurance that they will receive high-quality screening with appropriate follow-up care.

Entrustable Professional Activities: Ten Things Radiologists Do.

RATIONALE AND OBJECTIVES: Learner assessment in medical education has undergone tremendous change over the past two decades. During this time frame, the concept of Entrustable Professional Activities (EPAs) was introduced to guide the faculty when making competency-based decisions on the level of supervision required by trainees. EPAs are gaining momentum in medical education as a basis for decisions related to transitioning from residency training to clinical practice. The purpose of this article is twofold: (1) define EPAs for radiology (EPA-R) and (2) illustrate radiology-specific examples of these EPAs. MATERIALS AND METHODS: A multi-institutional work group composed of members of the Alliance of Directors and Vice Chairs of Education in Radiology convened at the 2015 Association of University Radiologists annual meeting to discuss radiology EPAs. The EPAs initially developed by the Accreditation Council for Graduate Medical Education (ACGME) Radiology milestone work group and the resultant ACGME Radiology milestones formed the basis for this discussion. RESULTS: A total of 10 radiology EPAs and illustrative vignettes were developed to help radiology educators and trainees better understand milestone assessment and how this translates to the necessary skills and responsibilities of practicing radiologists. Examples of EPA mapping to the ACGME subcompetencies and methods of assessment were included. CONCLUSIONS: EPAs offer an opportunity to improve our approach to training by increasing our focus on how we provide appropriate supervision to our residents and assess their progress. In this work, through suggested lists and vignettes, we have attempted to establish the framework for further discussion and development of EPA-Rs.

ACR CT accreditation program and the lung cancer screening program designation.

The ACR recognizes that low-dose CT for lung cancer screening has the potential to significantly reduce mortality from lung cancer in the appropriate high-risk population. The ACR supports the recommendations of the US Preventive Services Task Force and the National Comprehensive Cancer Network for screening patients. To be effective, lung cancer screening should be performed at sites providing high-quality low-dose CT examinations overseen and interpreted by qualified physicians using a structured reporting and management system. The ACR has developed a set of tools necessary for radiologists to take the lead on the front lines of lung cancer screening. The ACR Lung Cancer Screening Center designation is built upon the ACR CT accreditation program and requires use of Lung-RADS or a similar structured reporting and management system. This designation provides patients and referring providers with the assurance that they will receive high-quality screening with appropriate follow-up care.

Meningococcal carriage among Georgia and Maryland high school students.

BACKGROUND: Meningococcal disease incidence in the United States is at an all-time low. In a previous study of Georgia high school students, meningococcal carriage prevalence was 7%. The purpose of this study was to measure the impact of a meningococcal conjugate vaccine on serogroup Y meningococcal carriage and to define the dynamics of carriage in high school students. METHODS: This was a prospective cohort study at 8 high schools, 4 each in Maryland and Georgia, during a school year. Students at participating schools received quadrivalent meningococcal conjugate vaccine that uses diphtheria toxoid as the protein carrier (MCV4-DT). In each state, 2 high schools were randomly assigned for MCV4-DT receipt by students at the beginning of the study, and 2 were randomly assigned for MCV4-DT receipt at the end. Oropharyngeal swab cultures for meningococcal carriage were performed 3 times during the school year. RESULTS: Among 3311 students, the prevalence of meningococcal carriage was 3.21%-4.01%. Phenotypically nongroupable strains accounted for 88% of carriage isolates. There were only 5 observed acquisitions of serogroup Y strains during the study; therefore, the impact of MCV4-DT on meningococcal carriage could not be determined. CONCLUSIONS: Meningococcal carriage rates in US high school students were lower than expected, and the vast majority of strains did not express capsule. These findings may help explain the historically low incidence of meningococcal disease in the United States.

Thoracic diseases associated with HIV infection in the era of antiretroviral therapy: clinical and imaging findings.

The human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) pandemic has entered its 4th decade. Since the introduction of combination antiretroviral therapy (ART) in 1996, the number of AIDS-related deaths has plateaued worldwide. Today, owing to the effectiveness of ART, the HIV-infected population is aging and HIV infection has become a chronic illness. Non-AIDS comorbidities are increasing, and the spectrum of HIV-related thoracic diseases is evolving. In developed countries, bacterial pneumonia has become more common than Pneumocystis pneumonia. Its imaging appearance depends on the responsible organism, most commonly Streptococcus pneumoniae. Mycobacterium tuberculosis continues to be a major threat. Its imaging patterns vary depending on CD4 count. Primary lung cancer and Hodgkin lymphoma are two important non-AIDS-defining malignancies that are increasingly encountered at chest imaging. Human herpesvirus 8, also known as Kaposi sarcoma-associated herpesvirus (KSHV), is strongly linked to HIV-related diseases, including Kaposi sarcoma, multicentric Castleman disease, KSHV inflammatory cytokine syndrome, and primary effusion lymphoma. Immune reconstitution inflammatory syndrome is a direct complication of ART whose manifestations vary with the underlying disease. Given the high rate of smoking among HIV-infected patients, chronic obstructive pulmonary disease is another important cause of morbidity and mortality. A high degree of suspicion is required for the early diagnosis of pulmonary arterial hypertension and lymphocytic interstitial pneumonia, given their nonspecific manifestations. Finally, multilocular thymic cyst manifests as a cystic anterior mediastinal mass. Recognition of the clinical and radiologic manifestations of these less traditional HIV-related diseases can expedite diagnosis and treatment in the ART era.

Proceedings from the first Global Summit on Radiological Quality and Safety.

The ACR, the European Society of Radiology, and the International Society of Radiology held the first joint Global Summit on Radiological Quality and Safety in May 2013. The program was divided into 3 day-long themes: appropriateness of imaging, radiation protection/infrastructure, and quality and safety. Participants came from global organizations, including the International Atomic Energy Agency, the World Health Organization, and other institutions; industry and patient advocacy groups with an interest in imaging were also represented. The goal was to exchange ideas and solutions and share concerns to arrive at a better and more uniform approach to quality and safety. Participants were asked to use the information presented to develop strategies and tactics to harmonize and promote best practices worldwide. These strategies were summarized at the conclusion of the meeting.

Tumors and tumorlike conditions of the large airways.

OBJECTIVE: Large-airway tumors and tumorlike conditions are uncommon, but a systematic approach aids in narrowing the differential diagnosis. In this article, we describe an approach to dealing with large-airway lesions and discuss their imaging characteristics and clinical presentations. CONCLUSION: We have found it useful to separate these entities into groups on the basis of the distribution pattern (focal vs diffuse) and location (trachea vs bronchi).

Thoracic radiologic manifestations of melioidosis.

Melioidosis (Burkholderia pseudomallei) is a gram-negative bacterial infection that is highly endemic in Southeast Asia and Oceania. Pulmonary disease is the most common form of involvement. The clinical-radiologic thoracic manifestations of melioidosis can be classified as acute, subacute, subclinical, and chronic forms. Radiographic findings include nodular, alveolar, or mixed infiltration/consolidation with or without cavities. Pleural effusion, pneumothorax, and pericardial involvement can be seen. Melioidosis can easily be confused with other infections, especially tuberculosis. Suspicion of this disease in the proper clinical radiologic setting is important for early diagnosis and treatment. In this article, we provide a broad clinical overview of melioidosis, review the radiologic thoracic manifestations of melioidosis with appropriate clinical correlation, as well as compare and contrast the imaging findings of thoracic melioidosis with other similar pulmonary infections.

Benign metastasizing leiomyoma.

Pulmonary metastases from benign-appearing smooth muscle tumors of the uterus are rare, and are termed benign metastasizing leiomyoma (BML). Affected patients usually present with single or multiple lung nodules and are usually women who have undergone hysterectomy. Only a few cases of BML with lung cysts have been reported, with 2 patients presenting with spontaneous pneumothoraces. We report a case of BML in a 29-year-old woman with an abnormal preoperative chest radiograph who several years after hysterectomy developed spontaneous bilateral pneumothoraces.

On-demand chest radiographs for hypoxia: impact on clinical care.

PURPOSE: To determine the therapeutic yield of on-demand chest radiographs in intubated patients experiencing acute oxygen desaturation/hypoxia. MATERIALS AND METHODS: A retrospective study was conducted examining all intubated intensive care unit patients over a 2 ½-year period. Subjects were included only if the patient had undergone a comparison radiograph while intubated and if the word hypoxia or an equivalent alternative had been listed in the requisition. Radiographic findings were categorized into 3 groups: no change, minor new finding, or major new finding. A major new finding was defined as one that could result in a direct change in clinical management. Therapeutic yield was defined as any new clinical intervention documented in the electronic medical record occurring within the proximate timeframe after performing an on-demand radiograph. Interventions were recorded as appropriate or not appropriate to the expected therapy for each radiographic finding. RESULTS: A total of 676 radiographic reports were studied. 55.3%, 20.4%, and 24.3% of the radiographic findings were categorized into no change, minor new finding, and major new finding groups. A major radiographic finding was more likely to have new interventions compared with a no-change radiograph [odds ratio, 6.44 (4.16-9.78)]. Most interventions were deemed appropriate for the radiographic findings. CONCLUSIONS: On-demand radiographs performed for acute hypoxic clinical events yield a high percentage of major findings, with nearly half of them potentially influencing or resulting in new therapeutic interventions. Interventions were more likely in the major finding group, with most being appropriate. These results support the efficacy of the on-demand radiograph by providing evidence of its utility in patient management decisions.

Interactive high-resolution computed tomography digital atlas of interstitial lung disease.

High-resolution computed tomography is a necessary tool used in the diagnosis of interstitial lung disease. The interpretation of high-resolution computed tomography can be difficult given the wide spectrum of imaging appearances within the same disease and among different diseases. The authors provide a new educational method to learn about the spectrum of idiopathic interstitial lung disease through the use of a free online digital atlas and review article. This atlas can be downloaded at http://www.seattlechildrens.org/radiologyeducation/ILD.