Update on Interstitial Pneumonias.

The American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Asociación Latinoamericana de Tórax 2018 clinical practice guideline and 2022 update provide recommendations to define and diagnose idiopathic pulmonary fibrosis (IPF) in patients with newly diagnosed interstitial lung disease. The guideline emphasizes recognition of usual interstitial pneumonia (UIP) and probable UIP patterns of fibrosis on high-resolution CT, which can obviate the need for surgical lung biopsy and allow timely initiation of antifibrotic pharmacotherapy citing a high correlation with UIP on histopathology. This article reviews the recent 2022 IPF clinical practice guideline with a focus on the imaging updates.

Patient, Provider, and Practice Characteristics Predicting Use of Diagnostic Imaging in Primary Care: Cross-Sectional Data From the National Ambulatory Medical Care Survey.

OBJECTIVE: To determine imaging utilization rates in outpatient primary care visits and factors influencing likelihood of imaging use. METHODS: We used 2013 to 2018 National Ambulatory Medical Care Survey cross-sectional data. All visits to primary care clinics during the study period were included in the sample. Descriptive statistics on visit characteristics including imaging utilization were calculated. Logistic regression analyses evaluated the influence of a variety of patient-, provider-, and practice-level variables on the odds of obtaining diagnostic imaging, further subdivided by modality (radiographs, CT, MRI, and ultrasound). The data's survey weighting was accounted for to produce valid national-level estimates of imaging use for US office-based primary care visits. RESULTS: Using survey weights, approximately 2.8 billion patient visits were included. Diagnostic imaging was ordered at 12.5% of visits with radiographs the most common (4.3%) and MRI the least common (0.8%). Imaging utilization was similar or greater among minority patients compared with White, non-Hispanic patients. Physician assistants used imaging at higher rates than physicians, in particular CT at 6.5% of visits compared with 0.7% for doctors of medicine and doctors of osteopathic medicine (odds ratio 5.67, 95% confidence interval 4.07-7.88). CONCLUSION: Disparities in rates of imaging utilization for minorities seen in other health care settings were not present in this sample of primary care visits, supporting that access to primary care is a path to promote health equity. Higher rates of imaging utilization among advanced-level practitioners highlight an opportunity to evaluate imaging appropriateness and promote equitable, high-value imaging among all practitioners.

Community-based Participatory Research: A Practical Guide for Radiologists.

Community-based participatory research (CBPR) is defined by the Kellogg Community Health Scholars Program as a collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each community member brings. The CBPR process begins with a research topic of importance to the community, with the goal of combining knowledge and action with social change to improve community health and eliminate health disparities. CBPR engages and empowers affected communities to collaborate in defining the research question; sharing the study design process; collecting, analyzing, and disseminating the data; and implementing solutions. A CBPR approach in radiology has several potential applications, including removing limitations to high-quality imaging, improving secondary prevention, identifying barriers to technology access, and increasing diversity in the research participation for clinical trials. The authors provide an overview with the definitions of CBPR, explain how to conduct CBPR, and illustrate its applications in radiology. Finally, the challenges of CBPR and useful resources are discussed in detail. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Routes of Transdiaphragmatic Migration from the Abdomen to the Chest.

The diaphragm serves as an anatomic border between the abdominal and thoracic cavities. Pathologic conditions traversing the diaphragm are often incompletely described and may be overlooked, resulting in diagnostic delays. Several routes allow abdominal contents or pathologic processes to spread into the thorax, including along normal transphrenic structures, through congenital defects in the diaphragm, through inherent areas of weakness between muscle groups, or by pathways created by tissue destruction, trauma, or iatrogenic injuries. A thorough knowledge of the anatomy of the diaphragm can inform an accurate differential diagnosis. Often, intraperitoneal pathologic conditions crossing the diaphragm may be overlooked if axial imaging is the only approach to this complex region because of the horizontal orientation of much of the diaphragm. Multiplanar capabilities of volumetric CT and MRI provide insight into the pathways where pathologic conditions may traverse this border. Knowledge of these characteristic routes and use of multiplanar imaging are critical for depiction of specific transdiaphragmatic pathologic conditions.©RSNA, 2020.

Imaging Early Postoperative Complications of Cardiothoracic Surgery.

Imaging plays a central role in the evaluation of patients following cardiothoracic surgery, both for monitoring in the early postoperative period and for assessing for suspected complications. Patients with postsurgical complications can develop a range of signs and symptoms, from hypotension and tachycardia, as the result of severe bleeding, to fever and leukocytosis because of infection. The radiologist is an important member of the care team in the postoperative period, helping identify and manage complications of cardiothoracic surgery. This article reviews the common complications of cardiothoracic surgery focusing on the role of imaging and clues to diagnosis.

Incidence, clinical manifestations, and course of water and electrolyte metabolism disturbances following transsphenoidal pituitary adenoma surgery: a prospective observational study.

OBJECT: The authors prospectively studied the incidence, spectrum of clinical manifestations, course, and risk factors of water and electrolyte disturbances (WEDs) following transsphenoidal pituitary adenoma surgery. METHODS: From the preoperative day to the 14th postoperative day, 57 successive patients undergoing transsphenoidal adenomectomy were monitored daily for body weight, balance of fluids, serum electrolytes, plasma osmolality, plasma antidiuretic hormone (ADH) levels, urinary sodium excretion, urinary osmolality, and subjective sensation of thirst. The type of adenoma operated on and the intraoperative manipulation of the neurohypophysis were also recorded. RESULTS: Fifty-seven patients (mean age 55 years, 61.4% females) harbored 30 clinically hormone-inactive and 27 hormone-secreting pituitary adenomas. Postoperative WED occurred in 75.4% of the patients: in 38.5% as isolated diabetes insipidus (DI); in 21% as isolated hyponatremia; and in 15.7% as combined DI-hyponatremia. The maximum of medians of diuresis (5.750 L) in patients with isolated DI occurred on postoperative Day 2. Nadir of medians of hyponatremia (132 mmol/L) in patients with isolated hyponatremia occurred on postoperative Day 9. In patients with combined DI-hyponatremia, maximum of medians of diuresis (5.775 L) occurred on the 2nd day and nadir of medians of hyponatremia (130 mmol/L) on the 10th postoperative day. Altogether, 8.7% of the patients had to be treated with desmopressin because of DI persisting for >3 months. Of all the patients with hyponatremia, 42.8% were treated by transient fluid-intake restriction due to an IH of <130 mmol/L with or without clinical symptomatology. Transient acute renal failure occurred in one of these patients. Generally, the occurrence of postoperative WEDs was linked to the intraoperative manipulation of the neurohypophysis. Increased thirst correlated significantly with DI (p=0.001 and 0.02, respectively) and decreased thirst with the hyponatremic episode in patients with combined DI-hyponatremia (p=0.003). Decreased urine osmolality correlated significantly with the presence of DI (p=0.023). Electrolyte-free water clearance and urinary Na+ excretion were not correlated with DI and hyponatremia. Antidiuretic hormone was not suppressed during hyponatremia. CONCLUSIONS: Water and electrolyte disturbances occurred in the majority of patients undergoing transsphenoidal adenomectomy and were usually transient. Diabetes insipidus is more frequent than hyponatremia. Diabetes insipidus usually occurs during the 1st postoperative day and resolves in the majority of cases within 10 days. In few patients, DI may persist and require therapy with ADH analogs. Hyponatremia usually occurs at the end of the 1st postoperative week and resolves in most cases within 5 days. Very few patients will need treatment other than fluid-intake restriction to avoid serious complications. Thus, careful monitoring of the WEDs in patients undergoing transsphenoidal pituitary adenoma surgery is mandatory for the first 10 postoperative days.

Adrenal steroids in adrenomyeloneuropathy. Dehydroepiandrosterone sulfate, androstenedione and 17alpha-hydroxyprogesterone.

Adrenoleukodystrophy (ALD) and its adult variant adrenomyeloneuropathy (AMN) are X-linked diseases associated with a deficiency in the peroxisomal degradation of saturated very long chain fatty acids (VLCFA) resulting in an accumulation of VLCFA in the central and peripheral myelin, the adrenal cortex and the testis. Adrenal insufficiency with clinical hypocortisolism occurs in approximately two thirds of the patients with AMN. We studied the circulating adrenal hormones 17alpha-hydroxyprogesterone (17alpha-OHP), androstenedione and dehydroepiandrosterone sulphate (DHEAS) in 63 male AMN patients (age 17-65 years) and the DHEAS serum levels in 95 healthy male controls (age 30-65 years). 34 of the patients presented with the phenotype of only spinal cord and peripheral nerve disability without hypocortisolism, 29 of the patients presented with the phenotype of either additional hypocortisolism or Addison's syndrome only. Normal 17alpha-OHP concentrations were found in all patients with no significant difference between patients without and with hypocortisolism (6.07 +/- 0.61 nmol/l and 4.76 +/- 0.37 nmol/l). Androstenedione concentration was significantly (p < 0.01) lower in patients with hypocortisolism (2.99 +/- 0.65 pmol/l versus 5.71 +/- 0.68 pmol/l). As serum levels of DHEAS are agedependent we divided the two groups into two subgroups each (subgroup one: age 17-40 years, subgroup two: age 41-65 years). The DHEAS concentration of patients without and with hypocortisolism was significantly (p < 0.01) lower in both subgroups (1. 4.35 +/- 0.84 micromol/l, n = 15, 2. 15 +/- 0.28 micromol/l, n = 19; 1. 1.90 +/- 0.57 micromol/, n = 21, 2. 0.96 +/- 0.29 micromol/l, n = 8) compared to controls (1. 9.0 +/- 0.96 micromol/l; 2. 5.21 +/- 0.25 micromol/l). In conclusion, androstenedione and DHEAS serum concentrations are subnormal in all AMN patients and may therefore serve as sensitive markers of the adrenal function in adrenomyeloneuropathy.