ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update.

Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Renal Failure.

Renal failure can be divided into acute kidney injury and chronic kidney disease. Both are common and result in increased patient morbidity and mortality. The etiology is multifactorial and differentiation of acute kidney injury from chronic kidney disease includes clinical evaluation, laboratory tests, and imaging. The main role of imaging is to detect treatable causes of renal failure such as ureteral obstruction or renovascular disease and to evaluate renal size and morphology. Ultrasound is the modality of choice for initial imaging, with duplex Doppler reserved for suspected renal artery stenosis or thrombosis. CT and MRI may be appropriate, particularly for urinary tract obstruction. However, the use of iodinated and gadolinium-based contrast should be evaluated critically depending on specific patient factors and cost-benefit ratio. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR appropriateness criteria renal failure

Renal failure can be divided into acute kidney injury and chronic kidney disease. Both are common and result in increased patient morbidity and mortality. The etiology is multifactorial and differentiation of acute kidney injury from chronic kidney disease includes clinical evaluation, laboratory tests, and imaging. The main role of imaging is to detect treatable causes of renal failure such as ureteral obstruction or renovascular disease and to evaluate renal size and morphology. Ultrasound is the modality of choice for initial imaging, with duplex Doppler reserved for suspected renal artery stenosis or thrombosis. CT and MRI may be appropriate, particularly for urinary tract obstruction. However, the use of iodinated and gadolinium-based contrast should be evaluated critically depending on specific patient factors and cost-benefit ratio. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Foot Pain.

Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

FASpecT/CT, A New SPECT/CT Acquisition With Higher Sensitivity and Efficiency in Radioiodine Thyroid Cancer Imaging.

PURPOSE: This article demonstrates the use of a new SPECT/CT acquisition protocol in patients with differentiated thyroid cancer (DTC). METHODS: SPECT/CT scans (FASpecT/CT) with fewer angle acquisitions were retrospectively reviewed in 30 DTC patients treated with radioiodine at University Hospital, San Antonio, Tex, from July 2017 to March 2019. This FASpecT/CT of 12 versus 60 to 64 sampled views for convention SPECT was made possible by iterative reconstruction. RESULTS: The FASpecT/CT protocol was judged to increase lesion detection in patients with low count rates. Furthermore, in patients with higher count rates, this technique reduced the acquisition time. FASpecT/CT patient images are shown as case examples in 4 of the 30 patients reviewed. CONCLUSIONS: This FASpecT/CT acquisition in radioiodine-treated DTC offers the potential of higher sensitivity for metastatic lymph node detection in low count rates and a significant decrease in imaging time in high count rates. These advantages make SPECT/CT imaging more acceptable for patients who have difficulty with longer imaging times, to include the pediatric population.

ACR Appropriateness Criteria® Cervical Neck Pain or Cervical Radiculopathy.

Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms. Radiographs are appropriate as initial imaging for cervical or neck pain in the absence of "red flag" symptoms or if there are unchanging chronic symptoms; however, spondylotic changes are commonly identified and may result in both false-positive and false-negative findings. Noncontrast CT can be complementary to radiographs for evaluation of new or changing symptoms in the setting of prior cervical spine surgery or in the assessment of extent of ossification in the posterior longitudinal ligament. Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. MRI without and with contrast is usually appropriate in patients with new or increasing cervical or neck pain or radiculopathy in the setting of suspected infection or known malignancy. Imaging may be appropriate; however, it is not always indicated for evaluation of cervicogenic headache without neurologic deficit. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Knee Pain.

Chronic knee pain is a condition that is frequently encountered. Imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. The ACR Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations. The following narrative and accompanying tables should serve as useful guides to any clinician. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic.

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

To Use or Not to Use 131I in Thyroid Cancer.

PURPOSE: The purpose of the following commentary is to discuss recent controversies in the use of radioactive iodine for differentiated thyroid cancer (DTC). METHODS: R. M. Tuttle (Thyroid 2010; 20:257-263), at Memorial Sloan Kettering Cancer Center, has enumerated the well-accepted goals of radioactive iodine therapy (RAIT) in DTC: (1) ablate residual thyroid to facilitate future surveillance, (2) "adjuvant therapy" for residual radioactive iodine-avid disease, and (3) a post-RAIT scan may reveal unknown local and/or distant metastases. Using these goals as a guide, the authors have critically reviewed a recent movement to decrease the use of RAIT in DTC that is being advocated by some investigators. RESULTS: As a result, a recent article has highlighted this new treatment philosophy. A 2017 publication in the Journal of Clinical Oncology (Molenaar et al, 2017 0:JCO.2017.75.0232) recommends that RAIT not be used in low- or intermediate-risk DTC. In this article, the authors claim that the RAIT risks in DTC, particularly leukemia, outweigh its potential benefits. This change, if adopted, in our opinion will have profound deleterious consequences on patient outcomes. We also have identified a major problem with the article of Molenaar et al. The authors use the American Thyroid Association's criteria for staging thyroid cancer. In our opinion, this method of staging is severely flawed. We also quantitatively compare the article's alleged risk of RAIT-induced leukemia with the benefits of RAIT for DTC. CONCLUSIONS: In summary, this matter must be debated before eliminating RAIT in low- or intermediate-risk DTC. If RAIT is eliminated for these patients, many such patients will no longer benefit from the RAIT goals listed by R. M. Tuttle, including the critical advantage of potentially improved overall and event-free survival.

ACR Appropriateness Criteria® Chronic Ankle Pain.

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Wrist Pain.

Radiographs are indicated as the first imaging test in all patients with chronic wrist pain, regardless of the suspected diagnosis. When radiographs are normal or equivocal, advanced imaging with MRI (without or without intravenous contrast or following arthrography), CT (usually without contrast), and ultrasound each has a role in establishing a diagnosis. Furthermore, these examinations may contribute to staging disease, treatment planning, and prognostication, even when radiographs are diagnostic of a specific condition. Which examination or examinations are best depends on the specific location of pain and the clinically suspected conditions. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Simultaneous Blood Glucose Monitoring During Gastric-Emptying Scintigraphy May Identify Unsuspected Abnormalities.

PURPOSE: A retrospective study of 197 patients was performed to evaluate utility of simultaneous fingerstick glucose monitoring during standardized solid meal gastric-emptying scintigraphy (GES). We hypothesized the unlabeled carbohydrate components of the standardized meal often empty at different rates than the labeled egg protein component and that simultaneous glucose monitoring may identify rapid carbohydrate gastric emptying. METHODS: Patients were classified as normal, rapid, or delayed gastric emptying from the standardized solid egg meal GES criteria. Further subcategorization was made based on postprandial glycemic excursions above baseline at 30/60 minutes and was delineated as elevated (>75 mg/>85 mg/dL), normal, or diminished (<30 mg/dL) glucose excursion. RESULTS: Of the 197 patients, solid gastric-emptying rates for 105 were normal, delayed in 54, and rapid in 25 patients, and 13 patients had initially delayed emptying 1 or 2 hours with normal emptying by 4 hours. Of the 105 patients with normal gastric emptying, 58 had elevated, 47 normal, and none had diminished glucose excursions. Of the 54 patients with delayed gastric emptying, 26 had elevated, 16 had normal, and 12 had diminished glucose excursions. Nine patients with normal or delayed gastric emptying but elevated glycemic excursions returned for a liquid glucose GES. In contrast to their standardized GES results, all 9 had rapid emptying with elevated glycemic excursions. CONCLUSIONS: Simultaneous blood glucose monitoring with standardized GES protocols may provide a marker for contradictory findings of rapid gastric emptying of the unlabeled carbohydrate component in the standardized meal and may contribute to unexplained postprandial gastrointestinal symptoms. The additional insights provided by fingerstick glucose monitoring are inexpensive, easy to perform and may provide for new approaches to management of patient's gastrointestinal symptoms.

ACR Appropriateness Criteria® Imaging After Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is the most commonly performed joint replacement procedure in the United States and annual demand for primary TKA is expected to grow by 673% by 2030. The first part provides an overview of imaging modalities (radiographs, CT, MRI, ultrasound, and various nuclear medicine studies) and discusses their usefulness in the imaging evaluation of TKA. The second part focuses on evidence-based imaging and imaging-guided intervention algorithms for the workup of TKA and its complications, including routine follow-up, component wear, periprosthetic infection, aseptic loosening, granulomas/osteolysis, conventional and rotational instability, periprosthetic fracture, patellar complications, and a variety of periprosthetic soft tissue abnormalities. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

VARIABILITY IN THYROID CANCER MANAGEMENT AND PROGNOSIS AMONG HISPANIC VERSUS NON-HISPANIC PATIENTS : 17 YEARS DATA FROM UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AND UNIVERSITY HEALTH SYSTEM AT SAN ANTONIO.

Abstracts: Objective : Given the increase in the incidence of thyroid cancer in the United States, and it's potential public health implications, patient studies assessing ethnic, disparity and health care access are important. In this study, we retrospectively examined the variability in stage of thyroid cancer at presentation and final outcome among Hispanic vs non-Hispanic patients. METHOD: After obtaining IRB approval, we retrospectively reviewed the medical records of 220 adult patients with papillary thyroid carcinoma(PTC) who were treated at UT Health Science Center San Antonio between1996 and 2013. At disease presentation, patients were staged and risk stratified according to the 2009 American Thyroid Association (ATA) and TNM staging system. Clinical data obtained during the first 6-18 months was used to identify the initial response to therapy and clinical data from the last follow up visit was used to identify the "final" outcome. We examined the effect of insurance and ethnicity on initial response to therapy and final outcome using Chi-square test and one way ANOVA. RESULT: Our patient population's ATA risk at diagnosis, initial response to therapy and final outcome did not differ by ethnicity (P=0.5, 0.3 &0.4) and insurance coverage(P=0.7, 0.3 & 0.4) . CONCLUSION: Insurance coverage and ethnicity may not be independent factors since ethnic minority individuals are more likely to be uninsured.

ACR Appropriateness Criteria® Chronic Hip Pain.

Chronic hip pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic hip pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. 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 include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR 2016 Open-Microphone Session: ACR Membership 3.0-Moving From Member Volume to Value.

This report of the 2016 ACR Council Open Microphone session reviews the discussion around interests and concerns of council members and state chapter leaders as to the perceived and real value of their ACR membership, and how the ACR might further enhance membership value and meaningful engagement with members.

Current Status of Ventilation-Perfusion Scintigraphy for Suspected Pulmonary Embolism.

OBJECTIVE: The purpose of this article is to outline recent progress made in ventilation-perfusion (V/Q) scintigraphy imaging techniques and the interpretation systems used for the diagnosis of pulmonary embolism (PE). Various state-of-the-art approaches that can be selected according to the needs dictated by the medical practice environment and specific patient groups are presented. CONCLUSION: Although advances in tomographic imaging have certainly improved the sensitivity of V/Q scans for the diagnosis of PE, they may lead to overdiagnosis by revealing small and clinically insignificant PEs.

Adult Gamma Camera Myocardial Perfusion Imaging: Diagnostic Reference Levels and Achievable Administered Activities Derived From ACR Accreditation Data.

PURPOSE: The aim of this study was to glean from accreditation surveys of US nuclear medicine facilities the in-practice radiopharmaceutical diagnostic reference levels (DRLs) and achievable administered activities (AAAs) for adult gamma camera myocardial perfusion imaging (MPI). METHODS: Data were collected from the ACR Nuclear Medicine Accreditation Program during one three-year accreditation cycle from May 1, 2012, to April 30, 2015. Data elements included radiopharmaceutical, administered activity, examination protocol, interpreting physician specialty, practice type, and facility annual examination volume. Facility demographics, DRLs, and AAAs were tabulated for analysis. RESULTS: The calculated DRLs and AAAs are consistent with previously published surveys, and they adhere to national societal guidelines. Facilities seeking ACR accreditation are nearly evenly split between hospital based with multiple gamma cameras and office based with single gamma cameras. The majority of facilities use single-day, low-dosage/high-dosage (99m)Tc-based protocols; a small minority use (201)TlCl protocols. Administered activities show a consistency across facilities, likely reflecting adoption of standard MPI protocols. CONCLUSIONS: This practice-based analysis provides DRL and AAA benchmarks that nuclear medicine facilities may use to refine gamma camera MPI protocols. In general, the protocols submitted for ACR accreditation are consistent with national societal guidelines. The results suggest that there may be opportunities to further reduce patient radiation exposure by using modified examination protocols and newer gamma camera software and hardware technologies.

2015 AMCLC Open-Microphone Session: Improving the IQ (Information Quality) of What We Do.

Each year an open-microphone session is hosted by the Council Steering Committee. The committee invited an expert panel to discuss the use of effective communication in appropriate procedure selection and methods and resources to communicate the results of procedures performed in an actionable and clear manner to referring clinicians and patients, as well as downstream data systems. The ACR is actively encouraging radiologists to leverage existing and new technologies to increase their visibility in the health care system. Key features in Imaging 3.0 are results reporting through actionable reports, decision support for results reporting, guidelines for recommendations, tools for actionable reports, and tracking a radiologist's recommendations. The final radiology report is an essential product of our service, but it is increasingly clear that the noninterpretive components of our profession will add the most value to patient care. The radiology report is not the only evidence of our work. Nonetheless, the information quality and content of the radiology report can and must be improved so that it can add value and clinical usefulness toward excellent patient care. We must use appropriate tools and "best knowledge" to deliver actionable and value-added high-quality reports.