Thriving In and Out of the Reading Room: A Faculty Development Workshop.

RATIONALE AND OBJECTIVES: Given the immense time and energy radiologists dedicate to their profession, the experience at work should be a major contributor to a meaningful and fulfilling life. In pursuit of this vision, our department launched a novel faculty development workshop entitled "Thriving In and Out of the Reading Room: What They Didn't Teach Us in Training." We report on the design, implementation and initial outcomes of this faculty development workshop. MATERIALS AND METHODS: The workshop drew upon positive psychology research and the PERMA model of well-being, which encompasses five key elements: Positive emotion, Engagement, Relationships, Meaning, and Achievement. These elements have been shown to enhance work satisfaction and foster resilience. Using interactive, small group exercises, the workshop provided strategies for incorporating PERMA elements into daily life. At the conclusion of each workshop, an anonymous voluntary electronic survey was distributed to participants. RESULTS: The final version of the workshop was offered to 58 faculty over eight sessions between September 2022 and May 2023. Survey results indicate that participants found the workshop to be highly valuable and practical. They also found the workshop to promote camaraderie and peer learning. Developing the workshop internally allowed us to customize it to our faculty's unique experiences and engage a large number of participants. CONCLUSION: The workshop shows promise in improving job satisfaction and addressing burnout among academic radiologists.

Superb Microvascular Imaging-Based Vascular Index to Assess Adult Hepatic Steatosis: A Feasibility Study.

The aim of the study was to assess the feasibility of using a superb microvascular imaging-based vascular index (SMI-VI) for evaluating adult hepatic steatosis. We prospectively compared liver parenchyma SMI-VI (color pixels/total pixels in the region of interest), portal vein velocity, hepatic artery Doppler parameters (peak systolic velocity, end diastolic velocity, resistive index) and serum lipid and alanine aminotransferase (ALT) levels between 16 normal livers and 34 steatotic livers using magnetic resonance imaging-proton density fat fraction (MRI-PDFF) as the reference. On the basis of a two-tailed t-test, differences in SMI-VI, portal vein velocity, MRI-PDFF and ALT between normal (MRI-PDFF <5%) and steatotic (MRI-PDFF ≥5%) livers were statistically significant (p < 0.02), whereas hepatic artery Doppler parameters and triglyceride levels were not (p > 0.05). We observed an inverse correlation of SMI-VI with MRI-PDFF (r = -0.88). With 0.19 as the best cutoff value, the area under the receiver operating characteristic curve, sensitivity and specificity of SMI-VI for determining ≥mild (MRI-PDFF ≥5%) non-alcoholic fatty liver disease (NAFLD) were 0.95, 96% and 94%, respectively. Our results indicate the feasibility of using SMI-VI to assess adult hepatic steatosis. SMI-VI is a potential surrogate marker in the screening for NAFLD.

State of the Art MR Enterography Technique.

ABSTRACT: Magnetic resonance enterography (MRE) is a well-established imaging technique that is commonly used for evaluating a variety of bowel diseases, most commonly inflammatory bowel disease which is increasing in prevalence. Inflammatory bowel disease is composed of 2 related, but distinct disease entities: Crohn disease (CD) and ulcerative colitis. In ulcerative colitis, inflammation is generally limited to the mucosa and invariably involves the rectum, and often the more proximal colon. CD is typified by transmural inflammation with skip lesions occurring anywhere from the mouth to anus, but characteristically involves the terminal ileum. The transmural involvement of CD may lead to debilitating ulceration and, ultimately, development of sinus tracts, which can be associated with abscesses and fistulae as extraenteric manifestations of the disease. Because much of the small bowel and extraenteric disease cannot be adequately assessed with conventional endoscopy, imaging plays a crucial role in initial diagnosis and follow-up. MRE does not use ionizing radiation which is important for these patients, many of which present earlier in life and may require multiple imaging examinations. In this article, we review the clinical indications, patient preparation, and optimal technique for MRE. We also discuss the role and proper selection of intravenous gadolinium-based contrast material, oral contrast material, and antiperistaltic agents, including pediatric considerations. Finally, we review the recommended and optional pulse sequence selection, including discussion of a "time-efficient" protocol, reviewing their utility, advantages, and limitations. Our hope is to aid the radiologist seeking to develop a robust MRE imaging program for the evaluation of bowel disease.

Computed tomography and magnetic resonance enterography protocols and techniques: survey of the Society of Abdominal Radiology Crohn's Disease Disease-Focused Panel.

PURPOSE: To survey Society of Abdominal Radiology Crohn's Disease (CD) Disease-Focused Panel (DFP) members to understand state-of-the-art CT/MR enterography (CTE/MRE) protocols and variability between institutions. METHODS: This study was determined by an institutional review board to be "exempt" research. The survey consisted of 70 questions about CTE/MRE patient preparation, administration of contrast materials, imaging techniques, and other protocol details. The survey was administered to DFP members using SurveyMonkey® (Surveymonkey.com). Descriptive statistical analyses were performed. RESULTS: Responses were received from 16 DFP institutions (3 non-USA, 2 pediatric); 15 (94%) were academic/university-based. 10 (63%) Institutions image most CD patients with MRE; 4 (25%) use CTE and MRE equally. Hypoperistaltic medication is given for MRE at 13 (81%) institutions versus only 2 (13%) institutions for CTE. Most institutions have a technologist or nurse monitor oral contrast material drinking (n = 12 for CTE, 75%; n = 11 for MRE, 69%). 2 (13%) institutions use only dual-energy capable scanners for CTE, while 9 (56%) use either a single-energy or dual-energy scanner based on availability. Axial CTE images are reconstructed at 2-3 mm thickness at 8 (50%) institutions, > 3 mm at 5 (31%), and < 2 mm at 3 (19%) institutions. 13 (81%) institutions perform MRE on either 1.5 or 3T scanners without preference. All institutions perform MRE multiphase postcontrast imaging (median = 4 phases), ranging from 20 to 600 s after contrast material injection. CONCLUSION: CTE and MRE protocol knowledge from DFP institutions can help radiology practices optimize/standardize protocols, potentially improving image quality and patient outcomes, permitting objective comparisons between examinations, and facilitating research.

Small Bowel Crohn Disease at CT and MR Enterography: Imaging Atlas and Glossary of Terms.

Representatives from the Society of Abdominal Radiology Crohn's Disease-Focused Panel, the Society for Pediatric Radiology, the American Gastroenterological Association, and other international experts recently reported consensus recommendations for standardized nomenclature for the interpretation and reporting of CT enterography and MR enterography findings of small bowel Crohn disease. The consensus recommendations included CT enterography and MR enterography bowel wall findings that are associated with Crohn disease, findings that occur with penetrating Crohn disease, and changes that occur in the mesentery related to Crohn disease. Also included were recommended radiology report impression statements that summarize the findings of small bowel Crohn disease at CT enterography and MR enterography. This article, authored by the Society of Abdominal Radiology Crohn's Disease-Focused Panel, illustrates the imaging findings and recommended radiology report impression statements described in the consensus recommendations with examples of CT enterography and MR enterography images. Additional interpretation guidelines for reporting CT enterography and MR enterography examinations are also presented. The recommended standardized nomenclature can be used to generate radiology report dictations that will help guide medical and surgical management for patients with small bowel Crohn disease. Online supplemental material is available for this article. ©RSNA, 2020See discussion on this article by Heverhagen.

Hepatocellular carcinoma detection in liver cirrhosis: diagnostic performance of contrast-enhanced CT vs. MRI with extracellular contrast vs. gadoxetic acid.

OBJECTIVES: To evaluate the diagnostic performance of contrast-enhanced CT vs. MRI with extracellular contrast agents (EC-MRI) vs. MRI with gadoxetic acid (EOB-MRI) for HCC detection in patients with liver cirrhosis using liver explant as the reference. The additional value of hepatobiliary phase (HBP) post Gadoxetic acid was also assessed. METHODS: Two-hundred seventy-seven consecutive patients who underwent liver transplantation over a 9 year period and imaging within 90 days of were retrospectively included. Imaging consisted in CT (n = 100), EC-MRI (n = 77) and EOB-MRI (n = 100), the latter subdivided into dynamic EOB-MRI and full EOB-MRI (dynamic+HBP). Three radiologists retrospectively categorized lesions ≥ 1 cm using the LI-RADSv2017 algorithm. Dynamic EOB-MRI was re-evaluated with the addition of HBP. Results were correlated with explant pathology. RESULTS: Pathology demonstrated 265 HCCs (mean size 2.1 ± 1.4 cm) in 177 patients. Per-patient sensitivities were 86.3% for CT, 89.5% for EC-MRI, 92.8% for dynamic EOB-MRI and 95.2% for full EOB-MRI (pooled reader data), with a significant difference between CT and dynamic/full EOB-MRI (p = 0.032/0.002), and between EC-MRI and full EOB-MRI (p = 0.047). Per-lesion sensitivities for CT, EC-MRI, dynamic EOB-MRI and full EOB-MRI were 59.5%,78.5%,69.7% and 76.8%, respectively, with a significant difference between MRI groups and CT (p-range:0.001-0.04), and no difference between EC-MRI and dynamic EOB-MRI (p = 0.949). For HCCs 1-1.9 cm, sensitivities were 34.4%, 64.6%, 57.3% and 67.3%, respectively, with all MRI groups significantly superior to CT (p ≤ 0.01) and full EOB-MRI superior to dynamic EOB-MRI (p = 0.002). CONCLUSIONS: EOB-MRI outperforms CT and EC-MRI for per-patient HCC detection sensitivity, and is equivalent to EC-MRI for per-lesion sensitivity. MRI methods outperform CT for detection of HCCs 1-1.9 cm. KEY POINTS: • MRI is superior to CT for HCC detection in patients with liver cirrhosis. • EOB-MRI outperforms CT and MRI using extracellular contrast agents (EC-MRI) for per-patient HCC detection sensitivity, and is equivalent to EC-MRI for per-lesion sensitivity. • The addition of hepatobiliary phase images improves HCC detection when using gadoxetic acid.

Earlier Anti-Tumor Necrosis Factor Therapy of Crohn's Disease Correlates with Slower Progression of Bowel Damage.

INTRODUCTION: Crohn's disease (CD) follows a relapsing and remitting course incurring cumulative bowel damage over time. The question of whether or not the timing of the initiating biologic therapy affects long-term disease progression remains unanswered. Herein, we calculated rates of change in the Lémann index-which quantifies accumulated bowel damage-as a function of the time between the disease onset and initiation of biologic therapy. We aimed to explore the impact of the earlier introduction of biologics on the rate of progression of long-term cumulative bowel damage. METHODS: Medical records of CD patients treated during 2009-2014 at The Mount Sinai Hospital were queried. Inclusion criteria were two comprehensive assessments allowing calculation of the index at t1 and t2: two time-points ≥ 1 year apart. Patients with biologics introduced before or within 3 months at inclusion (t1) were defined as Bio-pre-t1 and those who did not as Bio-post-t1. The rate of disease progression was calculated as the change in the index per year during t1-t2. RESULTS: A total of 88 patients were studied: 58 Bio-pre-t1 and 30 Bio-post-t1. Among the 58 Bio-pre-t1 cases, damage progressed in 29 (50%), regressed in 20 (34.5%), and stabilized in 9 (15.5%). Median time to initiation of biologics among patients whose index improved was nominally shorter compared to that in patients whose index progressed (8 vs. 15 years). Earlier introduction of biologics tended to correlate with the slower rate of progression (ρ = 0.241; p = 0.069). CONCLUSIONS: Earlier introduction of biologics tended to correlate with the slower progression of bowel damage in CD, reflected by the reduced rate of Lémann index progression.

Magnetic Resonance Imaging Predicts Histopathological Composition of Ileal Crohn's Disease.

BACKGROUND AND AIMS: Recently, smooth muscle hypertrophy has been suggested to be a contributor to small bowel lesions secondary to Crohn's disease [CD], in addition to inflammation and fibrosis. Here, we assess the value of magnetic resonance imaging [MRI] for the characterisation of histopathological tissue composition of small bowel CD, including inflammation, fibrosis, and smooth muscle hypertrophy. METHODS: A total of 35 consecutive patients [male/female 17/18, mean age 33 years] with ileal CD, who underwent small bowel resection and a preoperative contrast-enhanced MRI examination within 1 month before surgery, were retrospectively included. Image assessment included qualitative [pattern/degree of enhancement, presence of ulcerations/fistulas/abscesses] and quantitative parameters [wall thickness on T2/T1-weighted images [WI], enhancement ratios, apparent diffusion coefficient [ADC], Clermont and Magnetic Resonance Index of Activity [MaRIA] scores). MRI parameters were compared with histopathological findings including active inflammation, collagen deposition, and muscle hypertrophy using chi square/Fisher or Mann-Whitney tests and univariate/multivariate logistic/linear regression analyses. RESULTS: Forty ileal segments were analysed in 35 patients. Layered pattern at early-post-contrast phase was more prevalent (odds ratio [OR] = 8; p = 0.008), ADC was significantly lower [OR = 0.005; p = 0.022], and MaRIA score was significantly higher [OR = 1.125; p = 0.022] in inflammation grades 2-3 compared with grade 1. Wall thickness on T2WI was significantly increased [OR = 1.688; p = 0.043], and fistulas [OR = 14.5; p = 0.017] were more prevalent in segments with disproportionately increased muscle hypertrophy versus those with disproportionately increased fibrosis. MaRIA/Clermont scores, wall thickness on T1WI and T2WI, and ADC were all significantly correlated with degree of muscular hypertrophy. CONCLUSIONS: MRI predicts the degree of inflammation, and can distinguish prominent muscle hypertrophy from prominent fibrosis in ileal CD with reasonable accuracy (area under receiver operating characteristic curve [AUROC] > 0.7).

Detection of liver fibrosis using qualitative and quantitative MR elastography compared to liver surface nodularity measurement, gadoxetic acid uptake, and serum markers.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) combining different techniques such as MR elastography (MRE) has emerged as a noninvasive approach to diagnose and stage liver fibrosis with high accuracy allowing for anatomical and functional information. PURPOSE: To assess the diagnostic performance of mpMRI including qualitative and quantitative assessment of MRE, liver surface nodularity (LSN) measurement, hepatic enhancement ratios postgadoxetic acid, and serum markers (APRI, FIB-4) for the detection of liver fibrosis. STUDY TYPE: IRB-approved retrospective. SUBJECTS: Eighty-three adult patients. FIELD STRENGTH/SEQUENCE: 1.5T and 3.0T MR systems. MRE and T1 -weighted postgadoxetic acid sequences. ASSESSMENT: Two independent observers analyzed qualitative color-coded MRE maps on a scale of 0-3. Regions of interest were drawn to measure liver stiffness on MRE stiffness maps and on pre- and postcontrast T1 -weighted images to measure hepatic enhancement ratios. Software was used to generate LSN measurements. Histopathology was used as the reference standard for diagnosis of liver fibrosis in all patients. STATISTICAL TESTS: A multivariable logistic analysis was performed to identify independent predictors of liver fibrosis. Receiver operating characteristic (ROC) analysis evaluated the performance of each imaging technique for detection of fibrosis, in comparison with serum markers. RESULTS: Liver stiffness measured with MRE provided the strongest correlation with histopathologic fibrosis stage (r = 0.74, P < 0.001), and the highest diagnostic performance for detection of stages F2-F4, F3-F4, and F4 (areas under the curve [AUCs] of 0.87, 0.91, and 0.89, respectively, P < 0.001) compared to other methods. Qualitative assessment of MRE maps showed fair to good accuracy for detection of fibrosis (AUC range 0.76-0.84). Multivariable logistic analysis identified liver stiffness and FIB-4 as independent predictors of fibrosis with AUCs of 0.90 (F2-F4), 0.93 (F3-F4) and 0.92 (F4) when combined. DATA CONCLUSION: Liver stiffness measured with MRE showed the best performance for detection of liver fibrosis compared to LSN and gadoxetic acid uptake, with slight improvement when combined with FIB-4. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1552-1561.

Imaging of Hepatocellular Carcinoma Response After 90Y Radioembolization.

OBJECTIVE: The purpose of this study is to discuss the imaging modalities and response criteria used for assessing hepatocellular carcinoma (HCC) response to 90Y radioembolization, as well as the imaging appearances of treated tumors. CONCLUSION: An understanding of the appearance of HCC after 90Y radioembolization is crucial for accurate evaluation of treatment response. Residual tumor necrosis and enhancement are essential for assessing response. Multiparametric MRI, including DWI and perfusion imaging, plays an emerging role in response assessment and outcome prediction.

Comparison of gadoxetic acid to gadobenate dimeglumine for assessment of biliary anatomy of potential liver donors.

PURPOSE: To compare MRI using gadobenate dimeglumine (Gd-BOPTA) vs. gadoxetic acid disodium (Gd-EOB-DTPA) for the assessment of biliary anatomy of potential liver donors. METHODS: 76 potential liver donors (39 M/37 F, mean 38 years) who underwent 1.5T MRI using Gd-BOPTA (n = 37) or Gd-EOB-DTPA (n = 39) were retrospectively evaluated. T2 cholangiogram (T2 MRC) and delayed hepatobiliary phase (HBP) T1 cholangiogram (T1 MRC) (performed during HBP 20 min after injection of Gd-EOB-DTPA and 1-2 h after Gd-BOPTA injection) were obtained in addition to MR angiogram/venogram. Two independent observers evaluated image quality (IQ) and conspicuity scores (CS) of the biliary system. Biliary anatomy was assessed in 3 reading sessions (T2 MRC, T1 MRC, and combined T2/T1 MRC). Reference standard consisted of consensus reading of two separate observers of all image sets, clinical/surgical information and intraoperative cholangiogram when available. Datasets were compared using the Mann-Whitney U test or Chi-squared test. RESULTS: There was no difference in IQ for T1 MRC using either contrast agent or T2 MRC vs. T1 MRC for both observers (all p values >0.07). There was superior CS for T2 MRC vs. Gd-BOPTA T1 MRC for both observers and T2 MRC vs. Gd-EOB for one observer (p < 0.001). No difference was found for biliary variant detection for T1 MRC (with either contrast agent) vs. T2 MRC. Combined T2/T1 MRC demonstrated improved sensitivity for biliary variant detection using Gd-BOPTA for both observers (p < 0.004) and Gd-EOB-DTPA for one observer (p < 0.001). CONCLUSION: Equivalent image quality was found for T1 MRC obtained with Gd-BOPTA or Gd-EOB-DTPA and T2 MRC. T1 MRC is equivalent to T2 MRC for detection of variant biliary anatomy, and the combination of sequences may have added value.

Diffusion-weighted imaging of the liver in patients with chronic liver disease: comparison of monopolar and bipolar diffusion gradients for image quality and lesion detection.

OBJECTIVE: The objective of our study was to compare diffusion-weighted imaging (DWI) sequences using a bipolar versus a monopolar single-shot echo-planar imaging (EPI) gradient design for image quality and for lesion detection and characterization in patients with liver disease. MATERIALS AND METHODS: In this retrospective study, 77 patients with chronic liver disease who underwent MRI including bipolar and monopolar DWI at 1.5 T were assessed. Two independent observers reviewed the DWI studies for image quality and the detection and characterization of liver lesions. The reference standard for diagnosis was established by consensus review of two different observers using imaging characteristics on conventional MRI sequences, lesion stability over time, pathologic correlation, or a combination of these findings. The estimated signal-to-noise ratio (SNR) of liver parenchyma and apparent diffusion coefficients (ADCs) of the liver and lesions were calculated for both sequences. ROC analysis was conducted to evaluate the performance of ADC for the diagnosis of hepatocellular carcinoma (HCC). RESULTS: Eighty-five lesions, 50 HCCs and 35 benign lesions, were detected with the reference standard in 38 patients. There was equivalent image quality for the bipolar and monopolar sequences (p = 0.24-0.42). The HCC detection rate for observers 1 and 2 was slightly better with bipolar DWI (50.0% and 52.0%, respectively) compared with monopolar DWI (44.0% and 46.0%); however, this difference did not reach statistical significance. The estimated SNR was higher with the monopolar sequence than with the bipolar sequence (p ≤ 0.001). The AUC for the ROC curve was 0.691 for bipolar DWI and 0.649 for monopolar DWI when ADC was used for the characterization of HCC, which is not a statistically significant difference (p = 0.59). CONCLUSION: The higher estimated SNR yielded by the monopolar DWI sequence did not translate into better HCC detection compared with the bipolar DWI sequence. ADC has a limited role for HCC characterization in patients with liver disease.

DCE-MRI of the liver: effect of linear and nonlinear conversions on hepatic perfusion quantification and reproducibility.

PURPOSE: To evaluate the effect of different methods to convert magnetic resonance (MR) signal intensity (SI) to gadolinium concentration ([Gd]) on estimation and reproducibility of model-free and modeled hepatic perfusion parameters measured with dynamic contrast-enhanced (DCE)-MRI. MATERIALS AND METHODS: In this Institutional Review Board (IRB)-approved prospective study, 23 DCE-MRI examinations of the liver were performed on 17 patients. SI was converted to [Gd] using linearity vs. nonlinearity assumptions (using spoiled gradient recalled echo [SPGR] signal equations). The [Gd] vs. time curves were analyzed using model-free parameters and a dual-input single compartment model. Perfusion parameters obtained with the two conversion methods were compared using paired Wilcoxon test. Test-retest and interobserver reproducibility of perfusion parameters were assessed in six patients. RESULTS: There were significant differences between the two conversion methods for the following parameters: AUC60 (area under the curve at 60 s, P < 0.001), peak gadolinium concentration (Cpeak, P < 0.001), upslope (P < 0.001), Fp (portal flow, P = 0.04), total hepatic flow (Ft, P = 0.007), and MTT (mean transit time, P < 0.001). Our preliminary results showed acceptable to good reproducibility for all model-free parameters for both methods (mean coefficient of variation [CV] range, 11.87-23.7%), except for upslope (CV = 37%). Among modeled parameters, DV (distribution volume) had CV <22% with both methods, PV and MTT showed CV <21% and <29% using SPGR equations, respectively. Other modeled parameters had CV >30% with both methods. CONCLUSION: Linearity assumption is acceptable for quantification of model-free hepatic perfusion parameters while the use of SPGR equations and T1 mapping may be recommended for the quantification of modeled hepatic perfusion parameters.

Comparison of nonenhanced MR angiographic subtraction techniques for infragenual arteries at 1.5 T: a preliminary study.

PURPOSE: To evaluate diagnostic performance of three nonenhanced methods: variable-refocusing-flip angle (FA) fast spin-echo (SE)-based magnetic resonance (MR) angiography (variable FA MR) and constant-refocusing-FA fast SE-based MR angiography (constant-FA MR) and flow-sensitive dephasing (FSD)-prepared steady-state free precession MR angiography (FSD MR) for calf arteries, with dual-injection three-station contrast material-enhanced MR angiography (gadolinium-enhanced MR) as reference. MATERIALS AND METHODS: This prospective study was institutional review board approved and HIPAA compliant, with informed consent. Twenty-one patients (13 men, eight women; mean age, 62.6 years) underwent calf-station variable-FA MR, constant-FA MR, and FSD MR at 1.5 T, with gadolinium-enhanced MR as reference. Image quality and stenosis severity were assessed in 13 segments per leg by two radiologists blinded to clinical data. Combined constant-FA MR and FSD MR reading was also performed. Methods were compared (logistic regression for correlated data) for diagnostic accuracy. RESULTS: Of 546 arterial segments, 148 (27.1%) had a hemodynamically significant (≥ 50%) stenosis. Image quality was satisfactory for all nonenhanced MR sequences. FSD MR was significantly superior to both other sequences (P < .0001), with 5-cm smaller field of view; 9.6% variable-FA MR, 9.6% constant-FA MR, and 0% FSD MR segmental evaluations had nondiagnostic image quality scores, mainly from high diastolic flow (variable-FA MR) and motion artifact (constant-FA MR). Stenosis sensitivity and specificity were highest for FSD MR (80.3% and 81.7%, respectively), compared with those for constant-FA MR (72.3%, P = .086; and 81.8%, P = .96) and variable-FA MR (75.9%, P = .54; and 75.6%, P = .22). Combined constant-FA MR and FSD MR had superior sensitivity (81.8%) and specificity (88.3%) compared with constant-FA MR (P = .0076), variable-FA MR (P = .0044), and FSD MR (P = .0013). All sequences had an excellent negative predictive value (NPV): 93.2%, constant-FA MR; 94.7%, variable-FA MR; 91.7%, FSD MR; and 92.9%, combined constant-FA MR and FSD MR. CONCLUSION: At 1.5 T, all evaluated nonenhanced MR angiographic methods demonstrated satisfactory image quality and excellent NPV for hemodynamically significant stenosis. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120859/-/DC1.

When does a radiologist's recommendation for follow-up result in high-cost imaging?

PURPOSE: To measure the proportion of high-cost imaging generated by a radiologist's recommendation and to identify the imaging findings resulting in follow-up. MATERIALS AND METHODS: This retrospective HIPAA-compliant study had institutional review board approval, with waiver of informed consent. A recommended examination was defined as one performed within a single episode of care (defined as fewer than 60 days after the initial imaging) following a radiologist's recommendation in a prior examination report. Chest and abdominal computed tomography (CT), brain and lumbar spine magnetic resonance (MR) imaging, and body positron emission tomography were included for analysis. From a database of all radiology examinations (approximately 200,000) at one institution over a 6-month period, a computerized search identified all high-cost examinations that were preceded by an examination containing a radiologist recommendation. Medical records were reviewed to verify accuracy of the recommending-recommended examination pairs and to determine the reason for the radiologist's recommendation. For proportions, 95% confidence intervals were calculated. RESULTS: Overall, 1558 of 29,232 (5.3%) high-cost examinations followed a radiologist's recommendation. Chest CT was the high-cost examination most often resulting from a radiologist's recommendation (878 of 9331, 9.4%), followed by abdominal CT (390 of 10,258, 3.8%) and brain MR imaging (222 of 6436, 3.4%). The examination types with the highest numbers of follow-up examinations were chest radiography (n=431), chest CT (n=410), abdominal CT (n=214), and abdominal ultrasonography (n=120). The most common findings resulting in follow-up were pulmonary nodules or masses (559 of 1558, 35.9%), other pulmonary abnormalities (150 of 1558, 9.6%), adenopathy (103 of 1558, 6.6%), renal lesions (101 of 1558, 6.5%), and negative examination findings (101 of 1558, 6.5%). CONCLUSION: Radiologists' recommendations account for only a small proportion of outpatient high-cost imaging examinations. Pulmonary nodule follow-up is the most common cause for radiologist-generated examinations.

Optimizing 1.5-Tesla and 3-Tesla dynamic contrast-enhanced magnetic resonance imaging of the breasts.

The technical requirements for magnetic resonance imaging (MRI) of the breasts are challenging because high temporal and high spatial resolution are necessary. This article describes the necessary equipment and pulse sequences for performing a high-quality study. Although imaging at 3-Tesla (T) has a higher signal-to-noise ratio, the protocol needs to be modified from the 1.5-T system to provide optimal imaging. The article presents the requirements for performing breast MRI and discusses techniques to ensure high-quality examinations on 1.5-T and 3-T systems.

Infection-induced modulation of m1 and m2 phenotypes in circulating monocytes: role in immune monitoring and early prognosis of sepsis.

To monitor and better understand the immunoinflammatory sequelae in sepsis and septic shock, systemic and monocyte-related cytokine responses were evaluated in baboons with experimental peritonitis induced by an E. coli-laden fibrin clot. Despite similar bacterial inocula, considerable interindividual variability in clinical manifestation and outcome of infection was observed. Because monocytes and macrophages are a key component of innate immunity, we hypothesized that early polarization of distinct activation programs in circulating monocytes that culminates in the emergence of either classically (M1) or alternatively (M2) activated monocytes may underlie the observed susceptibility or resistance to infection. To test our hypothesis, we analyzed infection-induced expression of cytokine mRNAs in monocytes isolated from surviving and dead animals. Our data show that resistance to E. coli sepsis may well be associated with a mixed M1/M2 activation state of circulating monocytes, whereas M1 phenotype appeared to be prevailing in monocytes from animals that died. Together with data on systemic cytokine responses, the latter findings indicate that morbidity and mortality of animals with gram-negative sepsis may well result from an overwhelming proinflammatory response. Collectively, our data contribute to a better understanding of cytokine networking in the immunoinflammatory response to microbial infection and suggest M1/M2 immunophenotypic profiling of readily available circulatory monocytes for early prognosis of severe infections.