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To review response rates published in medical imaging journals, and to analyze potential factors which contributed to a low response rate.A literature search was performed in MEDLINE and Embase to identify and assess published medical imaging survey studies. Variables assessed were response rate, incentives such as reminders and remuneration, and rationales provided for a potential low response rate. Statistical significance was calculated using unpaired t tests, ANOVA, Mann-Whitney, and Kruskal-Wallis tests.Three hundred and fifty-six unique surveys were included for analysis. The mean survey response rate in the current age of predominately electronic surveys was 45%. Factors which statistically significantly demonstrated a difference in response rate were survey location (European countries: 52%, Canada: 47%, United States: 42%; p0.05), survey topic (musculoskeletal: 69%, nuclear medicine: 64%, and education: 47%; p0.05), survey delivery method (telephone: 76%, email: 41%; p0.0001), and survey question type (short answer: 62%, multiple choice: 43%; p0.01). Statistically significant linear correlations were observed between the response rate compared to the number of reminders sent (r = 0.27; p0.01) and the number of participants (r = -0.26; p0.0001).The survey response rate serves as a surrogate marker for nonresponse bias. Survey response controlled for intrinsic nonadjustable characteristics offer achievable research goals. Adjustable factors to low response, including survey delivery method, question type, and number of reminders demonstrated statistical difference in response rate, and can be utilized by researchers to prospectively minimize nonresponse bias.

Radiological diagnosis in general and in emergency and trauma setting demands quick decision-making under conditions of often substantial uncertainty, in which the availability of clinical information, and/or of prior imaging examinations, and/or the use of proper techniques, is often highly variable. Therefore, all such decisions have inherent error rates. While diagnostic errors are responsible for only approximately 10–15% of potentially preventable deaths in trauma center audits, as selective non-operative management has become increasingly feasible after abdominopelvic trauma, the accurate diagnosis of injuries requiring surgical or interventional management has become more imperative. As such, injuries missed on multi-detector computed tomography (MDCT) have the potential to result in more dire consequences. Radiologists are key members of the multidisciplinary trauma team, and play a critical role in not only diagnosing acute, potentially life-threatening injuries, but also in directing the clinical decision-making process toward appropriate surgical, interventional, or conservative management. Radiological errors in the emergency setting follow predictable patterns, including satisfaction of search errors and cognitive biases. By analyzing these patterns, individual and system-wide measures may be enacted to help prevent similar errors from being made in the future.

Genital and gynecologic infections are common medical problems, affecting millions of women worldwide. The spectrum of these infections extends from the labia, including processes such as necrotizing fasciitis and anogenital warts, to the upper reproductive tracts in conditions including endometritis and pelvic inflammatory disease. Although often a clinical diagnosis, the radiologist plays an important role in determining the etiology of acute abdominal and pelvic pain as well as facilitating the diagnosis for cases which are not clinically straightforward. Imaging also plays an important role in assessing the complications and sequelae of these conditions, including infertility, chronic abdominal and pelvic pain, and pelvic adhesions. Familiarity with the appearances of these infections, their complications, and their potential mimics on sonography, computed tomography, magnetic resonance imaging, and hysterosalpingography is important for timely diagnosis and optimal clinical outcomes.

Positive oral contrast agents, including barium suspensions and water-soluble iodinated solutions, have traditionally been used in conjunction with the CT evaluation of patients with abdominal and pelvic pain. Due to continued advancements in CT technology, and due to increasing obesity and correspondingly a general increase in the intra-abdominal and intra-pelvic fat separating bowel loops in North American patients and in patients in other parts of the world over the past few decades, the ability of radiologists to accurately evaluate the cause of acute symptoms has substantially improved. Recent research and evolving imaging society guidelines/systematic reviews increasingly support performing CT scans of the abdomen and pelvis without the need for positive oral contrast in these types of adult patient populations, in most clinical situations. Increased patient throughput, patient preference, patient safety, and most importantly, retention of high diagnostic accuracy, are reasons for this recent change in practice to routinely omit the use of enteric contrast agents for the majority of patients presenting with acute abdominal and pelvic pain whom are undergoing emergency CT.

The relative value unit (RVU) is an important measuring tool for the work performed by physicians, and is currently used in the United States to calculate physician reimbursement. An understanding of radiology RVUs and current procedural terminology codes is important for radiologists, trainees, radiology managers, and administrators, as this knowledge would help them to understand better their current productivity and reimbursement, as well as controversies regarding reimbursement, and permit them to adapt to reimbursement changes that may occur in the future. This article reviews the components of the RVU and how radiology payment is calculated, highlights trends in RVUs and resultant payment for diagnostic and therapeutic imaging and examinations, and discusses current issues involving RVU and current procedural terminology codes.

While pelvic congestion syndrome and chronic pelvic pain are relatively common in women, no large- or medium-sized studies have been conducted to our knowledge to evaluate the frequency and severity of ovarian vein dilatation (OVD) on computed tomography (CT). The purpose of our study was therefore to analyze a large number of consecutive abdominal and pelvic CT scans in adult women to determine OVD frequency and severity.An IRB-approved, single-institution retrospective analysis of 1042 consecutive abdominal and pelvic CT scans in women ages 25-65 was performed. Scans were evaluated for the presence and severity of OVD and association with "nutcracker anatomy." A gradation scheme was developed based on quartile analysis.143 of the CT scans had OVD (13.7%). Of the positive scans, 96 were bilateral, 29 were left-side only, 18 were right-side only, and 18 had nutcracker-type compression of the left renal vein (14.4% of scans with left or bilateral OVD). In positive scans, the mean and median left OVD were 7.5 and 7 mm, respectively, and right-side were 7.2 and 7 mm, respectively. Based on quartile analysis, OVD grading was mild ( 6 mm), moderate (6-8 mm), or severe ( 8 mm), with moderate including the middle 50% of patients.OVD was found on 13.7% of 1042 consecutive female abdominal and pelvic CT scans, with "nutcracker anatomy" present in 14.4% of the scans with left OVD. Moderate dilatation was defined as an OVD of 6-8 mm at the iliac crests.

Obesity is a growing problem around the world, and radiology departments frequently encounter difficulties related to large patient size. Diagnosis and management of suspected venous thromboembolism, in particular deep venous thrombosis (DVT) and pulmonary embolism (PE), are challenging even in some lean patients, and can become even more complicated in the setting of obesity. Many obstacles must be overcome to obtain imaging examinations in obese patients with suspected PE and/or DVT, and to ensure that these examinations are of sufficient quality to diagnose or exclude thromboembolic disease, or to establish an alternative diagnosis. Equipment limitations and technical issues both need to be acknowledged and addressed. Table weight limits and scanner sizes that readily accommodate obese and even morbidly obese patients are not in place at many clinical sites. There are also issues with image quality, which can be substantially compromised. We discuss current understanding of the effects of patient size on imaging in general and, more specifically, on the imaging modalities used for the diagnosis and treatment of DVT and PE. Emphasis will be placed on the technical parameters and protocol nuances, including contrast dosing, which are necessary to refine and optimize images for the diagnosis of DVT and PE in obese patients, while remaining cognizant of radiation exposure. More research is necessary to develop consistent high-level evidence regarding protocols to guide radiologists, and to help them effectively utilize emerging technology.

There has been a substantial increase in the utilization of imaging, particularly of multi-detector computed tomography (MDCT), for the evaluation of patients with suspected urolithiasis over the past 2 decades. While the diagnostic accuracy of computed tomography (CT) for urolithiasis is excellent, it has also resulted in substantial medical expenditures and increased ionizing radiation exposure. This is especially concerning in patients with known nephrolithiasis and in younger patients. This pictorial review will focus on recent trends and controversies in imaging of patients with suspected urolithiasis, including the current roles of ultrasound (US), MDCT, and magnetic resonance imaging, the estimated radiation dose from MDCT and dose reduction strategies, as well as imaging of suspected renal colic in pregnant patients. The current epidemiological, clinical, and practice management literature will be appraised.

The chapter will present recent evidence and controversies in diagnosis of acute abdominal pain due to pancreatitis and diverticulitis. Multidetector computed tomography (MDCT) has established indications and time frames for staging severity of pancreatitis in the acute phase. Currently, the role of MRI in diagnosis of acute pancreatitis had been increasing. MRI is the modality of choice for detection of CBD stones. MDCT has high accuracy for the depiction of colonic diverticulitis, but the effect on patient management and outcome has not been well established to our knowledge.

A very large range of disorders, from benign, self-limited conditions, to processes requiring emergency surgery, can present with acute abdominal and pelvic pain. The radiologist plays a substantial role in the routine diagnosis and management of patients with these disorders. Similarly, the radiologist plays a major role in the routine evaluation of patients with abdominal and pelvic trauma, whether blunt or penetrating. Computed tomography (CT) remains the mainstay of the evaluation of such patients, although protocols have evolved along with technological advancements. Ultrasound (US) has a continued important role, particularly for evaluation of right upper quadrant pain, for evaluation of suspected gynecologic disorders, and for evaluation of pediatric and pregnant patients with an acute abdomen. Magnetic resonance imaging (MRI) has a growing role for initial evaluation as well as follow-up of selected patients with a variety of acute abdominal and pelvic conditions (usually non-traumatic). Although it is not possible to cover every aspect of imaging of acute non-traumatic and traumatic conditions of the abdomen and pelvis in a single chapter, an overview is presented, with key concepts and teaching points.

To determine the yield of non-contrast multi-detector computed tomography (MDCT) of the abdomen and pelvis in diagnosing ureteral calculi as well as other alternative acute conditions in male vs in female adult patients presenting to the emergency department with new onset of symptoms.Our institutional review board approved a retrospective review of the official reports of the non-contrast MDCT examinations of the abdomen and pelvis performed on adults (18 years and older) presenting to our emergency department with a suspected ureteral calculus from October 1, 2011 to October 30, 2013. Patients with recently documented ureteral calculi, known urinary tract infection, malignancy, and trauma were excluded from the study. From a total of 1097 non-contrast MDCT examinations of the abdomen and pelvis over the 2-year period, 400 randomly selected examinations were reviewed (approximately one-third of all the examinations). We compared the prevalence of ureteral calculi between the male and female population. P values and confidence intervals were determined using software Stata 14. Other acute intra-abdominal and intra-pelvic findings amenable to prompt medical care were also documented and analyzed separately.The mean patient age was 55.2 years, with a range of 19-90 years. This included 170 female (mean age 56.8 years) and 230 male patients (mean age 54.2 years). Ureteral calculi were detected in 170 (42.5%) of the patients [111 males (48%) and 59 females (34.7%)] with a prevalence which was statistically significantly higher in the male patients compared to in the female patients (P0.01, confidence level of 95% and CI of 13.2-13.4). An alternative diagnosis was made based on the MDCT findings in 49 patient cases (12.25 %), including 26 females (15.29%) and 23 males (10.00%). There was no statistically significant difference in alternative acute findings in male compared to in female patients (P0.05). This was with the exception of acute pyelonephritis, which was statistically significantly higher in the female patients (P0.01).The likelihood of making the diagnosis of a ureteral calculus on non-contrast MDCT of the abdomen and pelvis was statistically significantly higher in male patients compared with female patients presenting to our emergency department. However, there was no statistically significant difference in the alternative diagnoses, with the exception of pyelonephritis, which was more common in women.

Pregnancy results in substantial hemodynamic and prothrombotic changes that form the foundation for downstream vascular complications, both during pregnancy and in the postpartum period. In addition, several important risk factors, including older patient age, diabetes, and smoking, can increase the risk for vascular-related pregnancy complications. Because radiologists often play an important role in evaluation of the pregnant patient, understanding the pathophysiology of vascular-related complications in pregnancy and their imaging appearances is essential for diagnostic accuracy. The authors review relevant normal physiologic changes of pregnancy, pathophysiologic changes, and imaging features of vascular conditions that can manifest in conjunction with pregnancy. Particular attention is given to pertinent imaging information that radiologists should provide to referring clinicians to optimally affect the management of pregnant patients as well as women in the peripartum and postpartum stages. Among the complications discussed are preeclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; spontaneous coronary artery dissection; placental abruption; amniotic fluid embolism and acute pulmonary embolism; dural venous sinus thrombosis; ovarian vein thrombophlebitis; vasa previa; uterine arteriovenous malformations; heritable aortopathies; and hereditary hemorrhagic telangiectasia. To help radiologists avoid the use of unnecessary ionizing radiation in pregnancy, imaging examination selection and optimization are also reviewed. Radiologists should be familiar with the physiologic changes of pregnancy, radiation risks during gestation, and pregnancy-related vascular complications to improve imaging examination selection, diagnosis, and clinical management.

Mentoring is an extremely important component of academic medicine, including radiology, yet it is not specifically emphasized in radiology training, and many academic radiology departments in the United States, Canada, and elsewhere do not have formal mentoring programs for medical students, residents, fellows, or junior faculty. The purpose of this article is to overview the current status of mentorship in radiology, to discuss the importance of mentorship at multiple levels and its potential benefits in particular, as well as how to conduct a successful mentor-mentee relationship. The literature on mentorship in radiology and in academic medicine in general is reviewed.

OBJECTIVE. The full spectrum of organized radiology consists of numerous organizations with varied missions targeting their respective members. CONCLUSION. This article highlights many of these organizations, discusses the benefits they can provide to radiology trainees and junior faculty, and provides a road map for progressive participation among trainees to junior faculty as they advance through training.

Being mindful of potential diagnostic pitfalls in trauma imaging; having a thorough, efficient, and informed search strategy; and developing a working knowledge of commonly missed traumatic injuries can help radiologists improve the care of patients with abdominopelvic trauma.

The failure to diagnose acute appendicitis (AA) is the third most common medical malpractice allegation related to gastrointestinal disease. There is a paucity of detailed data on this topic; however, publications by Whang et al and by Berlin and Berlin, which analyzed all types of malpractice suits against radiologists, have shown that the incidence of litigation has increased over time in the United States. This is likely true for cases of AA as well. The misinterpretation of cross-sectional imaging in patients with suspected appendicitis may be caused by suboptimal technique, errors of omission, i.e, missing key findings, failure to review a portion of the examination, and satisfaction of search error. This article summarizes the published legal, clinical, and imaging literature regarding litigation in cases of missed AA, and reviews optimized multidetector computed tomography and magnetic resonance imaging protocols for the diagnosis of AA, with examples shown of challenging cases.

Imaging examinations are often performed in patients with Legionnaires' disease. The literature to date has documented that the imaging findings in this disorder are relatively nonspecific, and it is therefore difficult to prospectively differentiate legionella pneumonia from other forms of pneumonia, and from other noninfectious thoracic processes. Through a review of clinical cases and the literature, our objective is for the reader to gain a better understanding of the spectrum of radiographic manifestations of Legionnaires' disease.

Aim To describe perigastric appendagitis (PA) on CT as a new and distinct clinical entity to enable recognition and prevent additional unnecessary investigation or intervention. Materials and methods Institutional review board approval was obtained and informed consent was waived. Retrospective review of the clinical data and CT findings in eight patients with PA encountered over 10 years at one institution was performed. The English literature was reviewed and summarized. Two experienced abdominal radiologists reviewed the CT images by consensus. Results Seven of eight patients had moderate to severe epigastric pain for 1–7 days. All eight patients (four men, four women; mean age 44 years, range 33–81 years) had no fever or leukocytosis. All underwent abdominal CT which showed ovoid fat inflammation along the course of the perigastric ligaments (gastrohepatic, gastrosplenic, and falciform). Two had gastric wall thickening. Although the inflammation was correctly described, the specific diagnosis was not made on initial interpretation in five patients. Subsequently, they underwent further diagnostic testing [an upper gastrointestinal examination and hepatobiliary iminodiacetic acid (HIDA) cholescintigraphy, an upper endoscopy and MRI examination, HIDA cholescintigraphy, another CT, and an MRI examination, respectively]. The HIDA cholescintigraphy, upper GI examination, and upper endoscopy examinations were normal. No repeated examination was performed on the other three patients. Pain resolved spontaneously in all within two days. Conclusion Perigastric appendagitis can present with an acute abdomen, which is safely managed conservatively if diagnosed correctly. Radiologists should be aware of the entity to avoid unnecessary intervention, and recognize the CT findings of ovoid fat inflammation in the distribution of the perigastric ligaments.

The subserous space is a large, anatomically continuous potential space that interconnects the chest, abdomen, and pelvis. The subserous space is formed from areolar and adipose tissue, and contains branches of the vascular, lymphatic, and nervous systems. As such, it provides one large continuous space in which many disease processes can spread between the chest, abdomen, and the pelvis.

The development of colorectal cancer screening programs in many countries has led to increasingly large numbers of patients undergoing optical colonoscopy. Although acute complications from screening optical colonoscopy are uncommon, they may occur in up to 5% or more of patients where biopsies or therapeutic procedures are performed. Abdominal radiographs are of value only for the detection of intraperitoneal perforation. There is a wide spectrum of other important associated complications. Such complications are most reliably identified using abdominal and pelvic CT, which also can guide appropriate conservative, interventional, or surgical management.

The field of diagnostic and therapeutic radiology has always been characterized by constant innovation and creativity to evolve to its current form. There are numerous imaging techniques that were once prevalent but have become outdated and were replaced by the current examinations and modalities, which improve diagnostic accuracy and patient outcomes. Many of these outdated examinations were first described in the journal Radiology during its first 100 years of existence and were subsequently able to be disseminated across its vast readership to become the standard of care across the nation and the world. These earlier techniques, such as pneumoencephalography as it applies to neuroimaging and neurosurgery; kymography, a predecessor of cardiac imaging; contrast agents such as Thorotrast; and miscellaneous cultural tools, such as the shoe-fitting fluoroscope, left lasting impressions on the current practice of radiology and reflect a small subset of the imaging examinations of our predecessors. Knowledge of historic radiologic examinations and procedures is important to understand how we have arrived at the current practice of radiology we embrace today and how our field can continue to evolve to improve our diagnostic and therapeutic abilities to fit the changing needs of our patients.

Primary peritoneal mesothelioma is a rare neoplasm which carries a dismal prognosis. These highly aggressive tumors arise from mesothelial cells lining the peritoneum and are rapidly fatal. The neoplasm is typically associated with crocidolite asbestos exposure. We present the case of a 75-year-old man with primary peritoneal mesothelioma, with invasion into the right hepatic lobe.

There are a variety of advanced gastrointestinal endoscopic procedures, many of which are guided by endosonography, which are performed by interventional gastroenterologists or minimally-invasive surgeons. The purpose of this pictorial review is to briefly describe several advanced gastrointestinal endoscopically guided procedures, to review the implications for radiologists interpreting the associated imaging examinations, and to demonstrate the expected preprocedural imaging findings, as well as the expected and the unexpected postprocedural findings, in patients undergoing these procedures.

A fundamental consideration in the workup of a jaundiced patient is the pretest probability of mechanical obstruction. Ultrasound is the first-line modality to exclude biliary tract obstruction. When mechanical obstruction is present, additional imaging with CT or MRI can clarify etiology, define level of obstruction, stage disease, and guide intervention. When mechanical obstruction is absent, additional imaging can evaluate liver parenchyma for fat and iron deposition and help direct biopsy in cases where underlying parenchymal disease or mass is found. Imaging techniques are reviewed for the following clinical scenarios: (1) the patient with painful jaundice, (2) the patient with painless jaundice, and (3) the patient with a nonmechanical cause for jaundice. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Sonography is the primary imaging modality for the evaluation of pelvic pain in female patients, especially if gynaecological pathology is suspected. However, computed tomography (CT) is frequently used in patients who present to emergency departments (and elsewhere) with otherwise nonspecific abdominal and pelvic pain and may be the first imaging modality to demonstrate an acute gynaecological abnormality. Computed tomography can also be used prospectively in selected patients to further evaluate findings initially identified on sonography, although to reduce radiation exposure, magnetic resonance imaging is being used more frequently in this situation. The purpose of this article is to discuss the spectrum of gynaecological findings of the acute female pelvis that may be identified on CT by the emergency radiologist and by the general radiologist, with a brief review of the imaging literature of each specific diagnosis.

The purpose of this article is to familiarize radiologists and clinicians with a subset of common and uncommon incidental findings on abdominal and pelvic computed tomography examinations, including hepatic, splenic, renal, adrenal, pancreatic, aortic/iliac arterial, gynecological, and a few other miscellaneous findings, with an emphasis on "incidentalomas" discovered in the emergency setting. In addition, we will review the complex problem of diagnosing such entities, and provide current management recommendations. Representative case examples, which we have encountered in our clinical practices, will be demonstrated.

The purpose of our study was to assess trends in the imaging of suspected appendicitis in adult patients in emergency departments of academic centers in Canada. A questionnaire was sent to all 17 academic centers in Canada to be completed by a radiologist who works in emergency radiology. The questionnaires were sent and collected over a period of 4 months from October 2015 to February 2016. Sixteen centers (94%) responded to the questionnaire. Eleven respondents (73%) use IV contrast–enhanced computed tomography (CT) as the imaging modality of choice for all patients with suspected appendicitis. Thirteen respondents (81%) use ultrasound as the first modality of choice in imaging pregnant patients with suspected appendicitis. Eleven respondents (69%) use ultrasound (US) as the first modality of choice in patients younger than 40 years of age. Ten respondents (67%) use ultrasound as the first imaging modality in female patients younger than 40 years of age. When CT is used, 81% use non-focused CT of the abdomen and pelvis, and 44% of centers use oral contrast. Thirteen centers (81%) have ultrasound available 24 h a day/7 days a week. At 12 centers (75%), ultrasound is performed by ultrasound technologists. Four centers (40%) perform magnetic resonance imaging (MRI) in suspected appendicitis in adult patients at the discretion of the attending radiologist. Eleven centers (69%) have MRI available 24/7. All 16 centers (100%) use unenhanced MRI. Various imaging modalities are available for the work-up of suspected appendicitis. Although there are North American societal guidelines and recommendations regarding the appropriateness of the multiple imaging modalities, significant heterogeneity in the first-line modalities exist, which vary depending on the patient demographics and resource availability. Imaging trends in the use of the first-line modalities should be considered in order to plan for the availability of the imaging examinations and to consider plans for an imaging algorithm to permit standardization across multiple centers. While this study examined the imaging trends specifically in Canada, there are implications to other countries seeking to streamline imaging protocols and determining appropriateness of the first-line imaging modalities.

We highlight what we believe are 2 major areas of weakness in current Canadian radiology training programs: insufficient community radiology training and limited preparation of residents for the job market. Although focusing on Canadian radiology programs, we suspect that these are also 2 areas of substantial concern for radiology training programs in the United States and other countries. We offer suggestions to address these deficiencies, particularly by using pre-existing hybrid radiology practices and by making relatively small changes to the current curricula of radiology residency programs.

OBJECTIVE. Although some research and publication practices are clearly unethical, including fraud and plagiarism, other areas of research and publication, such as informed consent and conflicts of interest, fall into grayer areas. CONCLUSION. The purposes of this article are, therefore, to review a variety of relevant ethical issues in radiology-related journalism, peer review, and research; to review the radiology literature to date that has addressed these issues; and to present position statements and potential solutions to these problems.

Objective The purpose of our study was to determine the current practice patterns of U.S. radiologists in imaging pregnant or potentially pregnant patients with acute abdominal and pelvic conditions. Materials and methods After obtaining an Institutional Review Board waiver, all members of the Association of University Radiologists, the Association of Program Directors in Radiology, and the Society of Radiologists in Ultrasound were invited via e-mail to take a 23-question online survey on radiology practices and clinical scenarios about acute abdominal and pelvic imaging of pregnant patients. Results Comparisons were made with previously published surveys. A total of 225 responses were received. Areas of high consensus included pregnancy assessment (97%) and obtaining informed consent (87%) before imaging, having a written policy on imaging pregnant patients (79%), modification of computed tomography (CT) protocols (74%), avoiding gadolinium contrast in magnetic resonance imaging (MRI) (74%), using ultrasound for initial imaging in some scenarios, and using CT in trauma cases after inconclusive ultrasound. Areas of emerging consensus compared to 2007 included the use of serum or urine testing to confirm pregnancy status (59.4%; previously 14%) and the use of MRI in suspected appendicitis after an inconclusive ultrasound (73% in first trimester and 67% in third trimester; previously 46% and 29%, respectively). Areas without clear consensus included policy development, additional modifications to MRI protocols, choice of imaging modality, radiation dose, and the use of contrast agents in some scenarios. Conclusion In conclusion, high or increasing consensus exists in some areas of imaging pregnant patients with acute abdominal and pelvic conditions, but has yet to emerge in other areas.

OBJECTIVE. Paramedics and hospital-based providers occasionally need to place intraosseous devices to obtain vascular access in critically ill patients. Diagnostic radiologists must be prepared for the emergent administration of iodinated contrast media via the intraosseous route, and interventional radiologists should be familiar with the potential clinical uses of such access. CONCLUSION. We present a protocol for the administration of iodinated contrast media through the intraosseous route. We also highlight the clinical and radiologic aspects of intraosseous access.

The utility of MR imaging in evaluating abdominal and pelvic pain in the pregnant patient is discussed. Details regarding the indications, technical aspects, and imaging findings of various common abdominal and pelvic abnormalities in pregnancy are reviewed.

Hepatocellular carcinoma (HCC) is the second largest cause of cancer mortality in the world, with vascular invasion being one of the most important prognostic factors. HCC with tumor thrombus was traditionally considered to have very limited treatment options. However, multiple promising treatment strategies have emerged in recent years, with diagnostic and interventional radiologists playing a major role in patient management. We provide a comprehensive update on the diagnosis and management of HCC with vascular invasion and the role of the radiologist in this condition.

We detail the association of sedentary behavior with a variety of health problems and provide the radiologist with a number of simple activities and techniques that can improve overall health while still meeting the productivity demands of a high-volume practice. Although these techniques are well known and recognized in the fitness and nutrition literature, they are not widely used in the radiology reading room. The computer- and workstation-based work routinely performed by diagnostic radiologists typically occurs in the seated position, leading to more than 8 hours per day of sitting. Studies have found that even for those who exercise regularly, spending increased time sitting can negate the healthful effects of exercise. Time spent in a seated or sedentary position leads to slowing of one's metabolism, with negative resultant effects.The concept of nonexercise activity thermogenesis (NEAT) will be described, with examples given of how to burn more calories while at work and, therefore, improve the health of the diagnostic radiologist. NEAT refers to the energy expended during activities of daily living, excluding sportlike or intentional exercise. The concept of NEAT must be understood by radiologists, because it allows the development of multiple strategies to combat the ill effects of sitting while working. Adding intermittent movement and stretching exercises throughout the day can stimulate metabolism. An understanding of the association of sedentary work behavior with a number of health risks is crucial for radiologists so that they can implement basic changes into their work routine, allowing them to increase activity to address and avoid these potential health hazards.

The placenta has a fundamental role in fetal health and functions as an important bridge to normal fetal development throughout pregnancy. A complete fetal ultrasound (US) survey should include full assessment of the placenta for any possible abnormalities. Placental diseases range from abnormal morphology, size, location, extent, and degree of placentation, to abruption and the presence of rare placental neoplasms of benign or malignant nature. Some of these conditions are associated with other diseases including aneuploidies, and their discovery should alert the radiologist to perform a very thorough fetal US examination. At times, a fetal karyotype may be needed to provide additional information. Timely detection of placental abnormalities can alert the clinician regarding the need to make important management decisions to reduce fetal and maternal morbidity and mortality. Familiarity with the normal and abnormal imaging appearance of the placenta is therefore necessary for the radiologist. Ultrasound with Doppler is the initial imaging modality of choice for placental assessment. Magnetic resonance imaging serves as a problem-solving examination in instances where the US findings are equivocal or where additional information is needed. Computed tomography has a limited role in the evaluation of placental disease because of its relatively limited tissue characterization and in particular because of the resultant direct radiation exposure of the fetus. However, in specific instances, particularly after trauma, computed tomography can provide invaluable information for patient management.

Because virtually all patients with colonic cancer will undergo some form of surgical therapy, the role of preoperative imaging is directed at determining the presence or absence of synchronous carcinomas or adenomas and local or distant metastases. In contrast, preoperative staging for rectal carcinoma has significant therapeutic implications and will direct the use of radiation therapy, surgical excision, or chemotherapy. CT of the chest, abdomen, and pelvis is recommended for the initial evaluation for the preoperative assessment of patients with colorectal carcinoma. Although the overall accuracy of CT varies directly with the stage of colorectal carcinoma, CT can accurately assess the presence of metastatic disease. MRI using endorectal coils can accurately assess the depth of bowel wall penetration of rectal carcinomas. Phased-array coils provide additional information about lymph node involvement. Adding diffusion-weighted imaging to conventional MRI yields better diagnostic accuracy than conventional MRI alone. Transrectal ultrasound can distinguish layers within the rectal wall and provides accurate assessment of the depth of tumor penetration and perirectal spread, and PET and PET/CT have been shown to alter therapy in almost one-third of patients with advanced primary rectal cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Implantation of an endometriotic lesion within a pelvic or abdominal wall scar is an uncommon but well-described condition that may be the underlying cause of acute or chronic recurrent abdominal or pelvic pain, especially after cesarean section. Radiologists may not consider scar endometriosis when it is encountered at cross-sectional imaging. Cesarean section scars are the most common site of extraovarian or extrauterine endometriosis. The condition also has been identified in other uterine surgery-related scars and in the skin, subcutaneous tissues, and abdominal and pelvic wall musculature adjacent to these scars. The most plausible cause of scar endometriosis is implantation of endometrial stem cells at the surgical site at the time of uterine surgery. Patients with scar endometriosis may be asymptomatic or present with cyclical pain corresponding to the menstrual cycle. Cross-sectional imaging findings vary from the nonspecific to those suggestive of the diagnosis when combined with clinical history. In particular, the presence of blood products in an anterior abdominal wall mass at magnetic resonance (MR) imaging with no other explanation is strongly suggestive of scar endometriosis. Ultrasonography, computed tomography, and MR imaging may be used to depict an endometriotic lesion, exclude endometriosis, or provide evidence for an alternative diagnosis.