Nupur Verma

ACR Appropriateness Criteria® Renovascular Hypertension

Renovascular hypertension is the most common type of secondary hypertension and is estimated to have a prevalence between 0.5% and 5% of the general hypertensive population, and an even higher prevalence among patients with severe hypertension and end-stage renal disease, approaching 25% in elderly dialysis patients. Investigation for renal artery stenosis is appropriate when clinical presentation suggests secondary hypertension rather than primary hypertension, when there is not another known cause of secondary hypertension, and when intervention would be carried out if a significant renal artery stenosis were identified. The primary imaging modalities used to screen for renal artery stenosis are CT, MRI, and ultrasound, with the selection of imaging dependent in part on renal function. 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® Thoracic Aorta Interventional Planning and Follow-Up

Thoracic endovascular aortic repair (TEVAR) has undergone rapid evolution and is now applied to a range of aortic pathologies. Imaging plays a vital role in the pre- and postintervention assessment of TEVAR patients. Accurate characterization of pathology and evaluation for high-risk anatomic features are necessary in the planning phase, and careful assessment for graft stability, aortic lumen diameter, and presence of endoleak are paramount in the follow-up period. CTA is the imaging modality of choice for pre- and postintervention assessment, and MRA is an acceptable alternative depending on patient stability and graft composition. Lifelong imaging follow-up is necessary in TEVAR patients because endoleaks may develop at any time. The exact surveillance interval is unclear and may be procedure and patient specific. 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.

Granulomatous-Lymphocytic Interstitial Lung Disease in a Patient With Common Variable Immunodeficiency

Common variable immunodeficiency is the most common primary immunodeficiency and consists of impaired immunoglobulin production causing recurrent sinopulmonary infections. The most common cause of mortality for this disorder, however, is from the development of malignancy and autoimmune disorders. One common entity that develops is a systemic granulomatous and lymphoproliferative disorder that can cause an interstitial lung disease more formally referred to as granulomatous-lymphocytic interstitial lung disease (GL-ILD). We discuss a case of a 25-year-old woman with common variable immunodeficiency and GL-ILD and review the literature to summarize the most common radiological findings to raise the suspicion for GL-ILD on high-resolution computed tomography and delineate this from infection and other mimickers. We will also review key histopathological characteristics for diagnosis and the clinical approach and treatment options for this rare disease.

Giving, Taking, and Matching: Leveraging the Power of Diverse Collaborative Behaviors to Build a Successful Radiology Team

Within a radiology team, members individually lean toward being givers or takers. Radiology leadership must recognize this characteristic and leverage the strengths of givers and takers to best assist the team and to provide effective motivation. Understanding the importance of balancing these qualities within a team improves productivity and morale and reduces burnout.

ACR Appropriateness Criteria® Suspected Thoracic Aortic Aneurysm

Although the incidence of thoracic aortic aneurysm is on the rise, initial imaging diagnosis can present a challenge for many clinicians. Providers are faced with many imaging choices as part of the initial workup. Considering level of invasiveness, relative radiation level, and quality of associated diagnostic data, CT angiography and MR angiography are believed to be the most appropriate options for radiological diagnosis of suspected thoracic aortic aneurysm. 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.

Gender disparity in academic emergency radiology

ObjectiveThis study is intended to better understand how academic productivity and career advancement differs between men and women emergency radiologists in academic practices.Materials and methodsParameters of academic achievement were measured, including number of citations, number of publications, and h-index, while also collecting information on academic and leadership ranking among emergency radiologists in North America.ResultsIn emergency radiology, there are significantly fewer women than men (22.2% vs 77.8%). Of these women, the greatest proportion of women held the lower academic rank of assistant professor (95.4%). Female assistant professors had a higher h-index than men at the same rank (4 vs 2), but it was not statistically significantly higher. There was no significant difference between gender and academic (p = 0.089) or leadership (p = 0.586) rankings.ConclusionThis study provides further evidence that gender disparity persists in emergency radiology, with women achieving less upward academic career mobility than men, despite better academic productivity in the earlier stages of their careers. The academic productivity of emergency radiologists at the rank of assistant professor is significantly higher for women than men.

Pulmonary Lymphangitic Carcinomatosis From Renal Cell Carcinoma

Lymphangitic carcinomatosis, the presence of tumor within the pulmonary lymphatics, occurs in the setting of malignant tumors and is associated with a poor prognosis. Here we describe a case of lymphangitic carcinomatosis in the setting of renal cell carcinoma and review the radiological manifestations of this disease.

Low-dose Lung Cancer Screening at an Academic Medical Center: Initial Experience and Dose Reduction Strategies

RATIONALE AND OBJECTIVES Implementation of low dose computed tomography (LDCT) lung cancer screening programs has followed the demonstration of reduced lung cancer mortality in the National Lung Screening Trial and subsequent consensus screening recommendations. Here we aim to assess the initial results of a screening program at an academic medical center, to discuss the challenges of implementing such a program, and suggest strategies for reducing patient dose. MATERIALS AND METHODS Retrospective review of all patients who underwent LDCT lung cancer screening at our institution between March 2015 and July 2016 was performed to assess the lung cancer detection rate, the spectrum of imaging findings (nodule or mass characteristics, degree of emphysema, etc.), and patient radiation dose indices. RESULTS A total of 272 patients were screened during the study period. Approximately 50% (n = 135) were women. The lung cancer detection rate was 2.2% (n = 6). One patient underwent chemoradiation therapy, whereas the remainder underwent uneventful thoracoscopic resection. Approximately, 80% of screened patients met United States Preventative Services Task Force criteria for LDCT screening. The median pack-years of smoking was 42 pack-years. The mean volume CT dose index for the screening CTs was 3.12 mGy. Utilizing tube current modulation and iterative reconstruction, where available, resulted in lower patient doses. CONCLUSION Initial LDCT lung cancer screening at our institution yielded results similar to those of the National Lung Screening Trial. Thorough prescreening evaluation, joint decision-making, centralized coordination of screening-related care, and patient size conscious scanning protocols are critical elements of a safe and successful lung cancer screening program.

ACR Appropriateness Criteria® Vascular Claudication—Assessment for Revascularization

Vascular claudication is a symptom complex characterized by reproducible pain and weakness in an active muscle group due to peripheral arterial disease. Noninvasive hemodynamic tests such as the ankle brachial index, toe brachial index, segmental pressures, and pulse volume recordings are considered the first imaging modalities necessary to reliably establish the presence and severity of arterial obstructions. Vascular imaging is consequently used for diagnosing individual lesions and triaging patients for medical, percutaneous, or surgical intervention. Catheter angiography remains the reference standard for imaging the peripheral arteries, providing a dynamic and accurate depiction of the peripheral arteries. It is particularly useful when endovascular intervention is anticipated. When combined with noninvasive hemodynamic tests, however, noninvasive imaging, including ultrasound, CT angiography, and MR angiography, can also reliably confirm or exclude the presence of peripheral arterial disease. All modalities, however, have their own technical limitations when classifying the location, extent, and severity of disease. 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.

Developing Your 360-Degree Leadership Potential

Radiologists serve in leadership roles throughout their career, making leadership education an integral part of their development. A maxim of leadership style is summarized by 360-Degree Leadership, which highlights the ability of a leader to lead from any position within the organization while relying on core characteristics to build confidence from within their team. The qualities of leadership discussed can be learned and applied by radiologists at any level. These traits can form a foundation for the leader when faced with unfavorable events, which themselves allow the leader an opportunity to build trust.