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Another terrorist attack on our nation is virtually inevitable. Most believe that it is not a question of if but when. The form of the terrorism, the time, and the place will not be of our choosing. Radiology professionals (radiologists, technologists, radiologists' assistants, and nurses) will be involved in caring for the victims of the attack, whether the method employed is chemical, biological, radiological, or nuclear. If chemical or biological weapons are used, we must be ready to help with the diagnoses and follow-up care of these patients. Probably the greatest challenges to the radiology community will arise if the terrorist act involves a radiological or a nuclear explosive device. Understanding terrorists' goals of creating pandemonium and causing economic disruption is important. Radiology professionals need to be prepared to be resources for the medical community in providing patient care and for the community at large, especially if the terrorist attack involves detonation of a nuclear device, an attack on a nuclear power plant, or the use of a simple radiation dispersal device in a highly populated area.

The results of a survey sent to practice leaders in the ACR Practice of Radiology Environment Database show that the majority of responding groups will continue to hire recently trained residents and fellows even though they have been unable to take the final ABR diagnostic radiology certifying examination. However, a significant minority of private practice groups will not hire these individuals. The majority of private practices expect the timing change for the ABR certifying examinations to affect their groups' function. In contrast, the majority of academic medical school practices expect little or no impact. Residents and fellows should not expect work time off or protected time to study for the certifying examination or for their maintenance of certification examinations in the future.

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

John E. Aruny, MD, Curtis A. Lewis, MD, John F. Cardella, MD, Patricia E. Cole, PhD, MD, Andrew Davis, MD, Alain T. Drooz, MD, Clement J. Grassi, MD, Richard J. Gray, MD, James W. Husted, MD, Michael Todd Jones, MD, Timothy C. McCowan, MD, Steven G. Meranze, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Steven B. Oglevie, MD, Reed A. Omary, MD, Nilesh H. Patel, MD, Kenneth S. Rholl, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Mark I. Silverstein, MD, Harjit Singh, MD, Timothy L. Swan, MD, Richard B. Towbin, MD, Scott O. Trerotola, MD, Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee

Alain T. Drooz, MD, Curtis A. Lewis, MD, Timothy E. Allen, MD, Steven J. Citron, MD, Patricia E. Cole, PhD, MD, Neil J. Freeman, MD, James W. Husted, MD, Patrick C. Malloy, MD, Louis G. Martin, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Anthony C. Venbrux, MD, Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee

PERCUTANEOUS transhepatic cholangiography is a safe and effective technique for evaluating biliary abnormalities. It reliably demonstrates the level of abnormalities and sometimes can help diagnose their etiologies. Percutaneous transhepatic biliary drainage is an effective method for the primary or palliative treatment of many biliary abnormalities demonstrated with cholangiography. Participation by the radiologist in patient follow-up is an integral part of percutaneous transhepatic biliary drainage and will increase the effectiveness of the procedure. Close follow-up, with monitoring and management of the patients’ drainage-related problems, is appropriate for the interventional radiologist. These guidelines are written to be used in quality improvement programs to assess percutaneous biliary procedures. The most important processes of care are (a) patient selection, (b) performing the procedure, and (c) monitoring the patient. The outcome measures or indicators for these processes are indications, success rates, and complication rates. Outcome measures are assigned threshold levels.

Curtis A. Lewis, MD, Timothy E. Allen, MD, Dana R. Burke, MD, John F. Cardella, MD, Steven J. Citron, MD, Patricia E. Cole, MD, PhD, Alain T. Drooz, MD, Elizabeth A. Drucker, MD, JD, Ziv J. Haskal, MD, Louis G. Martin, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Steven B. Oglevie, MD, Kenneth S. Rholl, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Anthony Venbrux, MD, Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice Committee

The universe of medical practice is changing at an ever increasing rate, an exponentially increasing rate. In examining Earth's history from the beginning of time, it is not necessarily change per se that has threatened countless species but the rate of change that has challenged species survival. Darwin's thesis indicates that those who are most able to adapt to change will be more likely to survive. Medical technology, especially imaging technology, has been on a exponential growth curve for the past 2 decades, dramatically changing not only the field of medical imaging but the environment of all of medicine. Change in our practice environment represents both threats and opportunities to medical specialties to adapt and survive in the context of radiology and remain relevant to the future practice of medicine. Can we as radiologists survive and remain relevant in the future practice of medicine? What is the path to survival? The approach to survival will be multifactorial. We must continue to put our patients first, maintaining high-quality patient care in our adaptation strategy. We must do a better job of developing and investing in leaders, not only within radiology, but within all of medicine. We will need to hypersubspecialize within our profession and with that hypersubspecialization develop an integrated team concept, working together like a well-oiled Swiss watch. Last, we must as a profession invest in ourselves vigorously, supporting imaging research in a number of arenas, searching for the next imaging breakthrough, and exploring and adapting nanotechnology applications in both imaging and therapy.

Telemedicine is becoming an increasingly important tool in the practice of medicine throughout the world. For radiologists, telemedicine translates to teleradiology. Because an increasing amount of imaging is now archived in a digital format, and with the application of more powerful computers in radiology, digital image transmission between display stations is becoming commonplace. The ability to move large diagnostic image data sets to display stations anywhere in the world using the Internet and other high-speed data links is solving some problems and creating others. Medicine and radiology will be challenged in many ways by the issues created from the application of this burgeoning technology. Our task force was charged with investigating the evolving practice of international teleradiology and with developing a pubic statement to be adopted by the ACR Council (http://www.acr.org). This white paper is our effort to define those issues we believe to be most pertinent to international teleradiology as we know them today. Will these issues be changing? Certainly. For some facets of the issue, there are currently more questions than answers. We describe several scenarios that we believe are acceptable practices of international teleradiology as well as some that are not. We believe that much will be written about international teleradiology in the future as the issues of credentialing, quality assurance, licensure, American Board of Radiology certification, the maintenance of certification, jurisdictional and medical liability issues, patient privacy, fraud and medical ethics are more precisely defined and shaped by state and federal legislation and medical jurisprudence. This white paper is our assessment of what we believe to be the major challenges that exist as of this writing.

ContextContrast-induced nephropathy remains a common complication of radiographic procedures. Pretreatment with sodium bicarbonate is more protective than sodium chloride in animal models of acute ischemic renal failure. Acute renal failure from both ischemia and contrast are postulated to occur from free-radical injury. However, no studies in humans or animals have evaluated the efficacy of sodium bicarbonate for prophylaxis against contrast-induced nephropathy.ObjectiveTo examine the efficacy of sodium bicarbonate compared with sodium chloride for preventive hydration before and after radiographic contrast.Design, Setting, and PatientsA prospective, single-center, randomized trial conducted from September 16, 2002, to June 17, 2003, of 119 patients with stable serum creatinine levels of at least 1.1 mg/dL (≥97.2 µmol/L) who were randomized to receive a 154-mEq/L infusion of either sodium chloride (n = 59) or sodium bicarbonate (n = 60) before and after iopamidol administration (370 mg iodine/mL). Serum creatinine levels were measured at baseline and 1 and 2 days after contrast.InterventionsPatients received 154 mEq/L of either sodium chloride or sodium bicarbonate, as a bolus of 3 mL/kg per hour for 1 hour before iopamidol contrast, followed by an infusion of 1 mL/kg per hour for 6 hours after the procedure.Main Outcome MeasureContrast-induced nephropathy, defined as an increase of 25% or more in serum creatinine within 2 days of contrast.ResultsThere were no significant group differences in age, sex, incidence of diabetes mellitus, ethnicity, or contrast volume. Baseline serum creatinine was slightly higher but not statistically different in patients receiving sodium bicarbonate treatment (mean [SD], 1.71 [0.42] mg/dL [151.2 {37.1} µmol/L] for sodium chloride and 1.89 [0.69] mg/dL [167.1 {61.0} µmol/L] for sodium bicarbonate; P = .09). The primary end point of contrast-induced nephropathy occurred in 8 patients (13.6%) infused with sodium chloride but in only 1 (1.7%) of those receiving sodium bicarbonate(mean difference, 11.9%; 95% confidence interval [CI], 2.6%-21.2%; P = .02). A follow-up registry of 191 consecutive patients receiving prophylactic sodium bicarbonate and meeting the same inclusion criteria as the study resulted in 3 cases of contrast-induced nephropathy (1.6%; 95% CI, 0%-3.4%).ConclusionHydration with sodium bicarbonate before contrast exposure is more effective than hydration with sodium chloride for prophylaxis of contrast-induced renal failure.

Curtis W. Bakal, MD, MPH, Chairman, David Sacks, MD, Dana R. Burke, MD, John F. Cardella, MD, Paramjit S. Chopra, MD, Steven L. Dawson, MD, Alain T. Drooz, MD, Neil Freeman, MD, Steven G. Meranze, MD, A. Van Moore, Jr, MD, Aubrey M. Palestrant, MD, Anne C. Roberts, MD, James B. Spies, MD, Eric J. Stein, MD, Richard Towbin, MD, for the Society of Interventional Radiology Standards of Practice Committee